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Benign prostatic hyperplasia

Last updated: September 16, 2020

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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 (e.g., night-time fluid restriction, urinating in a sitting position) 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.

Prevalence of BPH increases with age (present in ∼ 50% of men > 50 years and more than 80% of men > 80 years). [1]

Epidemiological data refers to the US, unless otherwise specified.

The etiology is not fully understood. The following factors play a role in prostatic hyperplasia and growth:

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

  • Lower urinary tract symptoms (LUTS): the irritative and obstructive symptoms of BPH, grouped together [7]
  • Often gross hematuria [8][9]
  • Digital rectal examination (DRE) findings: symmetrically enlarged, smooth (no nodules), firm, nontender prostate with rubbery or elastic texture
  • International prostate symptom score (IPSS): a scoring system based on the presence and severity of seven BPH symptoms in the past 30 days [10]
    • Based on the final scores, BPH is graded as follows:
      • 0–7 points: mild symptoms
      • 8–19 points: moderate symptoms
      • 20–35 points: severe symptoms
    • IPSS is also useful as a prognostic marker of disease progression and response to treatment.

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).

The differential diagnoses listed here are not exhaustive.

Conservative management

Surgical intervention [22]

  • Indications
    • Severe BPH symptoms with/without complications
    • Moderate BPH with complications (see “Complications” below)
  • Transurethral resection of the prostate (TURP)
    • Procedure: resection of the hyperplastic prostatic tissue under cystoscopic guidance, using a cautery resectoscope
    • Complications [23]
      • Retrograde ejaculation: most common complication (∼ 75% of patients)
      • TUR-syndrome: dilutional hypotonic hyponatremia due to the absorption of the irrigant by the open prostatic blood vessels
      • Urinary incontinence
      • Erectile dysfunction (∼ 10%): may be temporary or permanent
      • Urethral strictures (∼ 10%)
      • Recurrent BPH: ∼ 15% of men need to have a TURP again within 10 years.
  • Transurethral incision of the prostate (TUIP): indicated in patients with small prostates with obstructive symptoms or those at high risk for surgical complications [24]
  • Open/laparoscopic/robotic prostatectomy: the laparotomic/laparoscropic removal of the entire prostate gland or a part of it
  • Other procedures: Laser ablation, radiofrequency ablation, and microwave thermotherapy are the newest techniques used for prostate tissue resection.

Since the peripheral zone (in which prostate cancer most commonly develops) is left intact in TURP, the risk of developing prostate cancer after TURP is the same as that in 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.

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