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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]

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.

  1. Benign Prostatic Hyperplasia. . Accessed: June 18, 2020.
  2. Izumi K, Li L, Chang C. Androgen receptor and immune inflammation in benign prostatic hyperplasia and prostate cancer. Clinical Investigation. 2014; 4 (10): p.935-950. doi: 10.4155/cli.14.77 . | Open in Read by QxMD
  3. Nicholson TM, Ricke WA. Androgens and estrogens in benign prostatic hyperplasia: past, present and future. Differentiation. 2011; 82 (4-5): p.184-199. doi: 10.1016/j.diff.2011.04.006 . | Open in Read by QxMD
  4. Isaacs JT. Prostate Stem Cells and Benign Prostatic Hyperplasia. Prostate. 2008; 68 (9): p.1025-1034. doi: 10.1002/pros.20763 . | Open in Read by QxMD
  5. Prajapati A, Gupta S, Mistry B, Gupta S. Prostate Stem Cells in the Development of Benign Prostate Hyperplasia and Prostate Cancer: Emerging Role and Concepts. BioMed Research International. 2013 . doi: 10.1155/2013/107954 . | Open in Read by QxMD
  6. UpToDate. Epidemiology and pathogenesis of benign prostatic hyperplasia. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: August 11, 2015. Accessed: March 4, 2017.
  7. McVary KT, Saini R. Lower urinary tract symptoms in men. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: May 11, 2015. Accessed: March 11, 2017.
  8. Vasdev N, Kumar A, Veeratterapillay R, Thorpe AC. Hematuria Secondary to Benign Prostatic Hyperplasia: Retrospective Analysis of 166 Men Identified in a Single One Stop Hematuria Clinic. Curr Urol. . 2012; 6 (3): p.146-149. doi: 10.1159/000343529 . | Open in Read by QxMD
  9. Kashif KM, Foley SJ, Basketter V, Holmes SA. Haematuria associated with BPH-Natural history and a new treatment option.. Prostate Cancer Prostatic Dis. 1998; 1 (3): p.154-156. doi: 10.1038/sj.pcan.4500224 . | Open in Read by QxMD
  10. UpToDate. Calculator: International Prostatism Symptom Score (IPSS). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Accessed: March 11, 2017.
  11. Hoffman RM. Screening for prostate cancer. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: January 25, 2017. Accessed: February 15, 2017.
  12. Kotwal AA, Mohile SG, Dale W. Remaining Life Expectancy Measurement and PSA Screening of Older Men. J Geriatr Oncol. 2012; 3 (3): p.196-204. doi: 10.1016/j.jgo.2012.02.003 . | Open in Read by QxMD
  13. Aliasgari M, Soleimani M, Hosseini moghaddam SM. The effect of acute urinary retention on serum prostate-specific antigen level. Urol J. 2005; 2 (2): p.89-92.
  14. Cunningham GR, Kadmon D. Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: August 20, 2015. Accessed: February 15, 2017.
  15. Benign prostatic hyperplasia. . Accessed: September 16, 2020.
  16. Wasserman NF, Spilseth B, Golzarian J, Metzger GJ. Use of MRI for Lobar Classification of Benign Prostatic Hyperplasia: Potential Phenotypic Biomarkers for Research on Treatment Strategies. American Journal of Roentgenology. 2014; 205 (3): p.564-571. doi: 10.2214/ajr.14.13602 . | Open in Read by QxMD
  17. Guneyli S, Ward E, Thomas S, et al. Magnetic resonance imaging of benign prostatic hyperplasia. Diagnostic and Interventional Radiology. 2016; 22 (3): p.215-219. doi: 10.5152/dir.2015.15361 . | Open in Read by QxMD
  18. Christian JD, Lamm TC, Morrow JF, Bostwick DG. Corpora amylacea in adenocarcinoma of the prostate: incidence and histology within needle core biopsies. Modern Pathology. 2004; 18 (1): p.36-39. doi: 10.1038/modpathol.3800250 . | Open in Read by QxMD
  19. CIALIS (tadalafil). Updated: October 1, 2011. Accessed: September 10, 2020.
  20. McVary KT. A review of combination therapy in patients with benign prostatic hyperplasia. Clin Ther. 2007; 29 (3): p.387-398. doi: 10.1016/s0149-2918(07)80077-4 . | Open in Read by QxMD
  21. Barragán-Arteaga I, Reyes-Vallejo L. Combination therapy for the treatment of lower urinary tract symptoms in men. Rev Mex Urol. 2016; 76 (6): p.360-369. doi: 10.1016/j.uromx.2016.05.007 . | Open in Read by QxMD
  22. Edwards JL. Diagnosis and Management of Benign Prostatic Hyperplasia. Am Fam Physician. 2008; 77 (10): p.1403-1410.
  23. Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP): incidence, management, and prevention. Eur Urol. 2006; 50 (5): p.969-979. doi: 10.1016/j.eururo.2005.12.042 . | Open in Read by QxMD
  24. Cunningham GR, Kadmon D. Transurethral procedures for treating benign prostatic hyperplasia. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: August 9, 2016. Accessed: February 15, 2017.
  25. Benign Prostatic Hyperplasia: Surgical Management of Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms. Updated: January 1, 2018. Accessed: September 16, 2020.
  26. Urologie Online Lehrbuch. . Accessed: January 1, 2012.
  27. Agabegi SS, Agabegi ED. Step-Up To Medicine. Wolters Kluwer Health ; 2015