Benign prostatic hyperplasia

The etiology of benign prostatic hyperplasia (BPH) is multifactorial involving smooth muscle hyperplasia, prostatic enlargement, and bladder dysfunction, as well as input from the central nervous system.

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

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

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

Urinalysis, prostate-specific antigen (PSA) level, and International Prostate Symptom Score 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, discuss the implications with the patient before testing.

Use shared decision-making based on understanding the patient’s desires and risks associated with specific therapies to guide treatment strategies.

If symptoms or disease severity warrant, initiate therapy with an alpha-blocker, 5-alpha-reductase inhibitor, combination therapy, or other agents depending on symptom profile.

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

Failure or intolerance of medical management or renal complications are indications for surgical intervention. There are a host of procedural treatments, which have unique risk/benefit profiles for consideration.

Lower urinary tract symptoms (LUTS) caused by bladder outlet obstruction due to BPH, also known as benign prostatic enlargement, 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 overactivity. LUTS are further defined as storage symptoms (frequency, urgency, nocturia, and incontinence) and voiding symptoms (weak stream, dribbling, dysuria, straining).[1]D'Ancona C, Haylen B, Oelke M, et al. The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction. Neurourol Urodyn. 2019 Feb;38(2):433-77. http://www.ncbi.nlm.nih.gov/pubmed/30681183?tool=bestpractice.com