Benign prostatic hyperplasia (BPH) is a nonneoplastic 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 underlying etiology of BPH has not been conclusively established, sex hormones likely play a key role. BPH typically manifests as lower urinary tract symptoms (LUTS), which includes features of bladder irritation (urinary frequency, urgency, urge incontinence), features of bladder outlet obstruction (urinary hesitancy, straining to urinate, sensation of incomplete voiding), and hematuria. The initial workup comprises standardized questionnaires to assess symptom severity, physical examination including digital rectal examination (DRE), urinalysis, a voiding diary, and, in select patients, serum prostate-specific antigen (PSA) analysis. DRE may reveal a smooth, enlarged, nontender, and firm prostate. Imaging and urodynamic studies are indicated in patients with and to guide management. Behavioral modifications (e.g., fluid restriction at night, bladder training) are advised in all patients with LUTS caused by BPH and may be the only management required in patients with minimal symptoms. Pharmacotherapy, such as alpha blockers, 5-alpha reductase inhibitors (5-ARIs), and parasympatholytics, for BPH is indicated in patients with bothersome symptoms; the choice of agent depends on the size of the prostate and the predominant symptoms. Surgery, e.g., transurethral resection of the prostate (TURP), is indicated in patients with severely symptomatic BPH, those with complications due to BPH (e.g., urinary retention, recurrent UTIs, hydroureteronephrosis), and those who experience intolerable adverse effects with pharmacotherapy. In patients with BPH, the risk of developing prostate cancer is not higher than that of the general male population; therefore, standard PSA screening protocol can be followed. TURP does not reduce the risk of developing prostate cancer and, following the procedure, BPH recurs in ∼ 7% of men.
- Benign prostatic hyperplasia (BPH): benign glandular and stromal hyperplasia of the transitional zone of the prostate
- Benign prostatic syndrome (BPS): caused by benign hyperplasia of the transitional zone of the prostate
- BOO): any obstruction to urinary outflow from the bladder which presents with and is confirmed on urodynamic testing (see “ ” for causes of BOO) (
- Benign prostatic obstruction (BPO): BOO caused by BPH
Prevalence of BPH increases with age (present in ∼ 50% of men > 50 years and more than 80% of men > 80 years). 
Epidemiological data refers to the US, unless otherwise specified.
- Estrogens: Estrogens (mainly estradiol) are potent stimulators of prostatic hyperplasia. 
- Androgen-estrogen imbalance: As men age, testosterone levels decline, but estrogen levels remain the same, which results in a higher estrogen/testosterone ratio.
- Stem cell proliferation and longevity: abnormal proliferation and longer prostatic stem cell life-span 
- Genetic susceptibility: Genes involved in the development of BPH include growth factor genes, androgen-regulator genes, apoptosis genes, and androgen-regulated genes. 
- The prostate consists of zones and lobes (see “ ” for more information).
- A combination of hormonal factors, stem cell proliferation and genetic susceptibility → glandular and stromal hyperplasia in the transition zone → formation of smooth, elastic, firm hyperplastic nodule → slit-like prostatic urethral compression → BOO → obstructive symptoms of BPH
- Detrusor overactivity (involuntary detrusor contractions during bladder filling) → irritative symptoms of BPH 
- Weakening of the bladder wall → incomplete voiding → urinary stasis → predisposition to urinary tract infections, acute/chronic urinary retention, and formation of bladder stones
- Increased intracystic pressure while voiding → detrusor muscle hypertrophy → bladder trabeculation and pseudodiverticula formation
- Irritative symptoms (storage LUTS; LUTS associated with OAB) 
Obstructive symptoms (voiding LUTS; LUTS associated with BOO) 
- Straining to urinate
- Poor and/or intermittent stream (not continuous)
- Prolonged terminal dribbling
- Sensation of incomplete voiding
- Acute urinary retention
- Additional symptoms: gross hematuria 
- Digital rectal examination (DRE) findings: symmetrically enlarged, smooth (no nodules), firm, nontender prostate with rubbery or elastic texture
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).
- Initial assessment: Determine if LUTS is attributable to BPH.
Additional diagnostics: not routinely recommended
- Serum PSA level: to aid selection of pharmacotherapy for BPH or if detection of prostate cancer will alter management
- Renal function tests and imaging of the upper urinary tract: if there is clinical suspicion of renal impairment
- Postvoid residue and uroflowmetry: in patients with suspected BOO
- Imaging and additional urodynamic studies: Consider in the following instances.
- Uncertain etiology
- Persistent symptoms despite pharmacotherapy
- Prior to surgical treatment
Initial assessment 
History and examination
- A thorough medical history and examination are essential to evaluate for the likely cause of LUTS.
- Conduct DRE to identify prostatic enlargement.
- Physical examination should also include assessment for other causes of LUTS (see “Differential diagnoses of BPH”).
- All patients should be instructed to maintain a voiding diary.
- Includes a urinary frequency-volume chart and additional information
- Most useful for patients with predominantly storage symptoms, such as nocturia 
Assess for features of complicated LUTS 
- Suspected prostate cancer
- Suspected chronic urinary retention
Urology referral is advised for patients with clinical , as these can signify a primary bladder disorder and/or cancer.Suspect prostate cancer in patients with clinical features of complicated LUTS, those experiencing constitutional symptoms such as weight loss or bone pain (which may suggest bone metastases), and those with a family history of prostate cancer or BRCA2 mutation. 
Assess the severity of LUTS with a validated self-administered questionnaire to guide management and evaluate response to therapy. There are several symptom score questionnaires. The following are some of the most widely used.
- International prostate symptom score (IPSS)
- American urological association symptom index for BPH (AUA-SI): a similar questionnaire to IPSS but does not assess the impact of LUTS severity on quality of life 
Laboratory studies 
- Perform for all patients with LUTS. 
- Abnormal findings may warrant further evaluation, e.g., urine culture to rule out a UTI (see “ ”). 
Serum PSA level
- Indications (not routinely required)
- Free PSA levels and free PSA/total PSA ratio 
Renal function tests 
Indications (not routinely required)
- Clinical suspicion of renal impairment
- Baseline levels before surgical intervention for LUTS
- Findings: typically normal in patients with uncomplicated BPH
Urodynamic studies 
- Indications 
- > 50mL is usually considered abnormal 
- > 300 mL may indicate . 
- Consider in all patients with suspected BOO.
- Baseline reading before surgical or medical management to assess response to therapy
- Findings: Low maximum flow rate (Qmax) can be caused by BOO, detrusor underactivity, or an underfilled bladder. 
- Pressure-flow studies and/or video urodynamic studies: to confirm the presence of urodynamic obstruction and determine the level of obstruction 
- Cystometry: can indicate OAB 
Imaging in patients with LUTS attributable to BPH is indicated to assess prostate size and morphology, if the results may affect treatment selection. Imaging may also be considered to rule out differential diagnoses or to assess for complications.
- Indications 
- Supportive findings of BPH
Transrectal ultrasound (TRUS) 
- Supportive findings of BPH: heteroechoic enlargement of the periurethral (transition) zones of the prostate
- Commonly used for preprocedural assessment of prostate volume and localization of enlarged tissue
- MRI can potentially differentiate BPH from prostate cancer. 
- LUTS causing little to no bother: Consider nonpharmacological therapy (watchful waiting).
Bothersome LUTS attributable to BPH
- First line:
- Failure of initial pharmacotherapy : surgery
Patients with require urgent .
Nonpharmacological therapy 
Nonpharmacological measures should be advised to all patients with LUTS attributable to BPH. Watchful waiting (a nce) can be considered as the sole management of LUTS causing mild to moderate symptoms in a patient with no features of complicated LUTS.
- Review of medications 
- Dietary advice
Education about bladder emptying techniques, such as:
- Bladder retraining
- Double voiding techniques
- Urethral milking
Pharmacological therapy 
Transuretheral resection of the prostate (TURP) is the gold standard treatment of BPH. However, pharmacotherapy can delay or even prevent the need to undergo surgery and should be considered as a first-line option in all patients with uncomplicated bothersome LUTS attributable to BPH.
- Pharmacological therapy is indicated in patients with moderate to severe LUTS attributable to BPH.
- The choice of medication depends on the predominant symptoms, prostate size, and serum PSA levels (see “Preferred first-line options” below).
- Consider serum PSA level testing or a TRUS prior to initiation of pharmacotherapy if treatment selection is based on prostate size or volume. 
- Symptomatic relief can be expected within weeks (with alpha blockers) or months (with 5-ARIs) after treatment initiation. 
- Life-long medication is typically required unless intolerable adverse effects develop or the patient undergoes surgery for BPH.
Overview of medications for BPH
|Pharmacotherapy for BPH |
|Alpha blockers|| |
|5-alpha reductase inhibitors (5-ARIs)|| || |
|Phosphodiesterase type 5 inhibitors|
Adverse effects of alpha blockers include orthostatic hypotension (relevant for elderly patients who are prone to falls) and intraoperative floppy iris syndrome (relevant for patients who are due to undergo cataract surgery). 
Any elevation in serum PSA levels in patients receiving 5-ARI therapy should increase suspicion for prostate cancer.
Preferred first-line options 
|Small prostate (< 40 mL) and/or serum PSA < 1.5 ng/mL||Alpha blocker |
|Large prostate (> 40 mL) and/or serum PSA > 1.5 ng/mL||5-alpha reductase inhibitors (5-ARIs) |
|Severe symptoms or an inadequate response to monotherapy||Combination therapy: alpha blocker PLUS a 5-ARI|
|Antimuscarinic (see also “”)|
|LUTS caused by mixed BOO and OAB||An alpha blocker PLUS an antimuscarinic|
|LUTS associated with erectile dysfunction||Phosphodiesterase 5 inhibitor |
- Insufficient improvement with pharmacological therapy
- Development of intolerable complications on pharmacotherapy
- BPH that is causing complications (see “Complications of BPH”)
Transurethral resection of the prostate 
- Procedure 
- Perioperative complications 
Late complications (incidence rates are shown in parentheses)
- Sexual dysfunction: erectile dysfunction (up to 32%), retrograde ejaculation (53–75%) 
- LUTS: transient dysuria; (up to ∼ 8%), urge incontinence (up to 2%) 
- Urethral strictures (up to 4%) 
- Recurrent BPH: Up to ∼ 7% of patients may need another TURP within 8 years of the initial procedure. 
The risk of developing prostate cancer after TURP remains the same as that of the general male population, as the peripheral zone (where prostate cancer most commonly develops) is left intact. Normal PSA screening protocols should be followed.
Other surgical treatment options 
Large prostates (> 60 g)
- Prostatectomy (open, laparoscopic, or robotic); approaches include: 
- Laser enucleation of the prostate (LEP): holmium LEP (HoLEP) or thulium LEP (ThuLEP) 
- Average (31–60 g) and small (≤ 30 g) prostates: radiofrequency-generated water thermotherapy, aquablation, prostatic urethral lift, transurethral vaporization of the prostate
- Small prostates (≤ 30 g): transurethral incision of the prostate; (lower risk of postoperative complications compared with TURP)