Benign prostatic hyperplasia

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 9 Apr 2025

Last updated: 03 Oct 2024

Benign prostatic hyperplasia (BPH) 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.

Definition

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]

History and exam

Key diagnostic factors

storage symptoms
voiding symptoms

Full details

Other diagnostic factors

fever with dysuria
urinary retention

Full details

Risk factors

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

Full details

Diagnostic tests

1st tests to order

urinalysis
prostate-specific antigen (PSA)
symptom score questionnaire
frequency/volume chart and voiding diary

Full details

Tests to consider

ultrasound
CT or MRI abdomen/pelvis
cystoscopy
Postvoid residual (PVR) assessment
uroflowmetry
pressure flow urodynamic studies
assessment of renal function

Full details

Treatment algorithm

ACUTE

non-bothersome symptoms

bothersome symptoms with no indications for surgery

bothersome symptoms with indication for surgery: prostate volume ≤30 g

bothersome symptoms with indication for surgery: prostate volume 30-80 g

bothersome symptoms with indication for surgery: prostate volume ≥80 g

Contributors

Authors

Claus Roehrborn, MD

Professor

Urology

University of Texas Southwestern Medical Center

Dallas

Disclosures

CR is on an ad board for Teleflex; consults for Teleflex, Zenflow, and Medeon; and has done research with Zenflow and Teleflex. CR is an author of several references cited in this topic.

Ramy Goueli, MD

Assistant Professor

Urology

University of Texas Southwestern Medical Center

Dallas

Disclosures

RG declares that he has no competing interests.

Acknowledgements

Professor Claus Roehrborn and Dr Ramy Goueli would like to gratefully acknowledge Professor Michael T. Flannery and Dr Erika Abel, the previous contributors to this topic. Regretfully, Professor Flannery died in December 2020.

Disclosures

EA declares that she has no competing interests.

Peer reviewers

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 Pharmaceuticals, and Glaxo Pharmaceuticals and has served as a consultant for these companies.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA guideline amendment 2023. J Urol. 2024 Jan;211(1):11-9.Full text Abstract

European Association of Urology. Management of non-neurogenic male LUTS. 2024 [internet publication].Full text

Elterman D, Aubé-Peterkin M, Evans H, et al. Update - Canadian Urological Association guideline: male lower urinary tract symptoms/benign prostatic hyperplasia. Can Urol Assoc J. 2022 Aug;16(8):245-56.Full text Abstract

Expert Panel on Urological Imaging; Alexander LF, Oto A, Allen BC, et al. ACR Appropriateness Criteria® lower urinary tract symptoms - suspicion of benign prostatic hyperplasia. J Am Coll Radiol. 2019 Nov;16(11s):S378-83.Full text Abstract

McConnell JD, Roehrborn CG, Bautista O, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. 2003 Dec 18;349(25):2387-98. Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Overactive bladder
- Acute prostatitis
- Chronic prostatitis
More Differentials
Guidelines
- Management of non-neurogenic male LUTS
- Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia
More Guidelines
Patient information
Enlarged prostate: what is it?
Enlarged prostate: what treatments are there?
More Patient information
Calculators
International Prostatism Symptom Score (IPSS)
More Calculators
Videos
Male urethral catheterization: animated demonstration
More videos
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Benign prostatic hyperplasia

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

non-bothersome symptoms

bothersome symptoms with no indications for surgery

bothersome symptoms with indication for surgery: prostate volume ≤30 g

bothersome symptoms with indication for surgery: prostate volume 30-80 g

bothersome symptoms with indication for surgery: prostate volume ≥80 g

Contributors

Authors

Claus Roehrborn, MD

Disclosures

Ramy Goueli, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

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

Disclosures

Robert Pickard, MD, FRCS (Urol)

Disclosures

Steven K. Brooks, MD

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Calculators

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice