Benign prostatic hyperplasia

Last reviewed: June 2018

Last updated: November 2017

Summary

Multi-factorial involving smooth muscle hyperplasia, prostatic enlargement, and bladder dysfunction, as well as input from the CNS.

Presents with both storage symptoms (frequency, urgency, nocturia, and incontinence) and voiding symptoms (weak stream, dribbling, dysuria, straining).

Physical examination may demonstrate prostate volume ≥30 g, nodules or tenderness suspicious of prostate cancer or prostatitis.

Evaluation includes history and examination including an abdominal examination for a palpable bladder, a digital rectal exam, and a neurological assessment.

Urinalysis, PSA level, and International Prostate Symptom Score (IPSS) are first-line tests of powerful diagnostic impact in the appropriate patient groups. Given the debate regarding the morbidity and mortality reduction of prostate cancer with PSA testing, the implications of such testing should be discussed with the patient prior to testing.

If symptoms or disease severity warrant, therapy can be initiated with an alpha-blocker and 5-alpha-reductase inhibitors.

Common complications are disease progression and urinary retention, which may require invasive therapy.

Definition

Lower urinary tract symptoms consequent upon bladder outlet obstruction due to benign prostatic hyperplasia (BPH), also known as benign prostatic enlargement (BPE), are predominantly due to 2 components: a static component related to an increase in benign prostatic tissue narrowing the urethral lumen and a dynamic component related to an increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors. Symptoms related to bladder outlet obstruction may also be contributed by bladder over-activity. [1]

History and exam

Key diagnostic factors

presence of risk factors
storage symptoms
voiding symptoms

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Other diagnostic factors

fever with dysuria
urinary retention

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Risk factors

age over 50 years
family history
non-Asian race
cigarette smoking
male pattern baldness
metabolic syndrome

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Diagnostic investigations

1st investigations to order

urinalysis
PSA
International Prostate Symptom Score (IPSS)
global bother score
volume charting

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Investigations to consider

ultrasound
CT abdomen/pelvis
cystoscopy
uroflowmetry
urodynamic study

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Treatment algorithm

ACUTE

mild disease (IPSS score 0-7) with no significant bother

mild disease (IPSS score 0-7) with significant bother

moderate and severe disease (IPSS score 8-35)

ONGOING

abnormal rectal examination and/or elevated PSA or PSA velocities and/or progressive BPH and/or with complications

Contributors

Authors VIEW ALL 

Michael T. Flannery, MD

Professor and Program Director

Internal Medicine Residency

University of South Florida College of Medicine

Department of Internal Medicine

Tampa

Disclosures

MTF declares that he has no competing interests.

Erika Abel, MD

Assistant Professor and Program Director

Internal Medicine-Pediatrics Residency

University of South Florida College of Medicine

Department of Internal Medicine

Tampa

Disclosures

EA declares that she has no competing interests.

Peer reviewers VIEW ALL 

Christopher R. Chapple, BSc, MD, FRCS (Urol), FEBU

Consultant Urological Surgeon

Royal Hallamshire Hospital

Honorary Senior Lecturer of Urology

University of Sheffield

Newcastle University

Visiting Professor of Urology

Sheffield Hallam University

Adjunct Secretary responsible for Education

European Association of Urology

Sheffield

Disclosures

CRC is Chairman of NICE Male LUTS Guidelines Development Group.

Robert Pickard, MD, FRCS (Urol)

Professor of Urology

Institute of Cellular Medicine

Newcastle University

Newcastle upon Tyne

Disclosures

RP has received funding from the UK NHS (NIHR) to undertake commissioned reviews of treatment for benign prostatic enlargement.

Steven K. Brooks, MD

Chief

Department of Surgery

South Seminole Hospital

Longwood

Disclosures

SKB is a member of the National Speakers Bureau for Boehringer Ingelheim, Astellas Pharmaceutics, and Glaxo Pharmaceuticals and has served as a consultant for these companies.

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Benign prostatic hyperplasia

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

mild disease (IPSS score 0-7) with no significant bother

mild disease (IPSS score 0-7) with significant bother

moderate and severe disease (IPSS score 8-35)

abnormal rectal examination and/or elevated PSA or PSA velocities and/or progressive BPH and/or with complications

Contributors

Authors VIEW ALL 

Michael T. Flannery, MD

Disclosures

Erika Abel, MD

Disclosures

Peer reviewers VIEW ALL 

Christopher R. Chapple, BSc, MD, FRCS (Urol), FEBU

Disclosures

Robert Pickard, MD, FRCS (Urol)

Disclosures

Steven K. Brooks, MD

Disclosures

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