• Clinical science

Benign prostatic hyperplasia


Benign prostatic hyperplasia (BPH) is a non-neoplastic glandular and stromal hyperplasia of the transition zone of the prostate. It is a common disorder affecting ∼ 40% of the male population by the age of 50 years. Although the etiology has not been conclusively established, sex hormones (androgens, estrogens, and androgen-estrogen imbalance) have been implicated as a key factor in the development of prostatic hyperplasia. Patients present with symptoms of bladder irritation (urinary frequency, urgency, urge incontinence), bladder outlet obstruction (urinary hesitancy, straining to urinate, sensation of incomplete voiding), and/or hematuria. Digital rectal examination reveals a smoothly enlarged, non-tender, and firm prostate. Diagnosis can be confirmed on abdominal ultrasound which demonstrates an enlarged prostate and increased post-void residual urine in the bladder. Bladder outlet obstruction can be quantitatively measured on uroflowmetry which shows a decreased maximal urinary flow rate. BPH is graded as mild, moderate and severe based on the frequency and severity of the symptoms. Behavioral modifications (night-time fluid restriction, urinating in a sitting position, etc.) are advised in all patients who are managed conservatively. Patients with mild/moderate BPH respond well to medical management with alpha-blockers (tamsulosin, doxazosin), 5-alpha-reductase inhibitors (finasteride), and parasympatholytics (oxybutynin). Severe BPH, unsuccessful medical therapy, and complications due to BPH are indications for surgery (e.g., transurethral resection of prostate, TURP). Complications of BPH include recurrent urinary tract infections (UTIs), urinary retention, bladder calculi, hydroureteronephrosis, and chronic kidney disease. BPH can recur after TURP in ∼15% of men. Prostate cancer can occur in patients with BPH, including in those who have undergone TURP. Normal prostate specific antigen (PSA) screening protocol is followed in these patients.




  • Age: Prevalence of BPH increases with age (∼ 70 % of males > 60 years).
  • Race: BPH is equally prevalent in white, Asian, and black men. However, black men with BPH typically have more severe symptoms and greater total and transitional zone prostate volume.


Epidemiological data refers to the US, unless otherwise specified.


BPH is not a risk factor for the development of prostate cancer.




Clinical features

To remember the symptoms of BPH, think “FUNWISE”: Frequency, Urgency, Nocturia, Weak stream /hesitancy, Intermittent stream, Straining to urinate, and Emptying (not emptying completely, terminal dribbling).




Differential diagnoses

The differential diagnoses listed here are not exhaustive.


Conservative management

Surgical intervention

Since the peripheral zone (in which prostate cancer can develop) is left intact in TURP, the risk of developing prostate cancer after TURP is the same as that of the general male population. Normal PSA screening protocol should be followed.

Almost all surgical interventions lead to retrograde ejaculation into the bladder because of anatomical changes!




We list the most important complications. The selection is not exhaustive.