> Table of Contents > Prostatic Hyperplasia, Benign (BPH)
Prostatic Hyperplasia, Benign (BPH)
Sara M. DeSpain, MD
James E. Hougas III, MD, Maj, USAF, MC
image BASICS
  • Benign prostatic hyperplasia (BPH) is caused by a proliferation of both the smooth muscle and epithelial cell lines of the prostate which cause increased volume and can cause compression of the urethra and obstructive symptoms.
  • Clinically presents with storage and/or voiding symptoms commonly referred to as lower urinary tract symptoms (LUTS). These include difficulty initiating stream, frequency, or dysuria.
  • Symptoms do not directly correlate to prostate volume. Estimated that half of all men with histologic evidence of BPH experience moderate to severe LUTS.
  • Progression may result in upper and lower tract infections and may progress to direct bladder outlet obstruction and acute renal failure (ARF).
EPIDEMIOLOGY
Near universal development in men; age dependent
Incidence and Prevalence
Incidence increases with age; wide variety of estimates of prevalence ranging from 70% to 90% by the age of 80 (estimated at 8-20% by age 40).
ETIOLOGY AND PATHOPHYSIOLOGY
  • Develops in prostatic periurethral or transition zone.
  • Hyperplastic nodules of stromal and epithelial components increase glandular components.
  • Etiology is unknown but recently there is a theory that it is from a reawakening of the embryonic induction process because of the similarity between BPH and the embryonic morphogenesis.
COMMONLY ASSOCIATED CONDITIONS
  • LUTS
    • LUTS can be divided into two groups: filling/storage symptoms and voiding symptoms.
      • Filling/storage symptoms include frequency, nocturia, urgency, and urge incontinence.
      • Voiding symptoms include difficulty initiating stream, incomplete voiding, weak stream.
      • Can lead to acute or chronic obstructive symptoms
  • Sexual dysfunction, including erectile dysfunction and ejaculatory disorders
  • LUTS can also be secondary to cardiovascular, respiratory, or renal disease (1).
RISK FACTORS
  • Most significant risk factor is age.
  • Increased risk of BPH with higher free prostate-specific antigen (PSA) levels, heart disease, and use of &bgr;-blockers
  • Obesity and lack of exercise can cause LUTS to be more significant.
  • No evidence of increased or decreased risk with smoking, alcohol, or any dietary factors.
  • Low androgen levels from cirrhosis/chronic alcoholism can reduce the risk of BPH.
GENERAL PREVENTION
  • The disease appears to be part of the aging process.
  • Symptoms can be managed through weight loss, regulation of fluid intake, decreased intake of caffeine, and increased physical activity.
image DIAGNOSIS
PHYSICAL EXAM
  • Digital rectal exam (DRE) finding of symmetrically enlarged prostate, but size does not always correlate with symptoms.
  • Signs of renal failure due to obstructive uropathy (edema, pallor, pruritus, ecchymosis, nutritional deficiencies)
  • If DRE is suggestive of prostate cancer, there is hematuria, recurrent infections, concern for stricture, or evidence of neurologic disease, the patient should be referred to urology.
DIFFERENTIAL DIAGNOSIS
  • Obstructive
    • Prostate cancer
    • Urethral stricture or valves
    • Bladder neck contracture (usually secondary to prostate surgery)
    • Inability of bladder neck or external sphincter to relax appropriately during voiding
  • Neurologic
    • Spinal cord injury
    • Stroke
    • Parkinsonism
    • Multiple sclerosis
  • Medical
    • Poorly controlled diabetes mellitus
    • Congestive heart failure (CHF)
  • Pharmacologic
    • Diuretics
    • Decongestants
    • Anticholinergics
    • Opioids
    • Tricyclic antidepressants
  • Other:
    • Bladder carcinoma
    • Overactive bladder
    • Nocturnal polyuria (>33% of the 24-hour urine volume occurs at night)
    • Bladder calculi
    • UTI
    • Prostatitis
    • Urethritis/sexually transmitted infections
    • Obstructive sleep apnea (OSA) (nocturia)
    • Caffeine
    • Polyuria (either isolated nocturnal polyuria or 24-hour polyuria)
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Urinalysis (UA) in all patients presenting with LUTS, can help rule out other etiologies such as bladder stones, cancer, UTI, or urethral strictures
  • PSA should be offered to all men with a life expectancy of 10 years and who would be surgical candidates if prostate cancer was identified.
  • PSA levels also correlate with prostate volume which can help guide treatment choice.
  • With bladder cancer risk factors (smoking history or hematuria) obtain urine cytology
  • If nocturia is the main concern, consider using a frequency volume chart for urine output.
  • Sleep study if OSA or primary nocturnal polyuria is suspected.
  • Serum creatinine measurement is not recommended. (AUA recommendation).
Follow-Up Tests & Special Considerations
  • No further testing that is recommended in uncomplicated LUTS; further testing when symptoms that do not respond to medical management or if initial evaluation suggests underlying disease.
  • Uroflow: volume voided per unit time (peak flow <10 mL/s is abnormal)
  • Postvoid residual: either with catheterization or bladder ultrasound (>100 mL = incomplete emptying)
  • Transrectal ultrasound: assessment of gland size; not necessary in the routine evaluation
  • Abdominal ultrasound: can demonstrate increased postvoid residual or hydronephrosis; not necessary in the routine evaluation
Diagnostic Procedures/Other
  • Pressure-flow studies (urine flow vs. voiding pressures) to determine etiology of symptoms
    • Obstructive pattern shows high voiding pressures with low flow rate.
  • Cystoscopy
    • Demonstrates presence, configuration, cause (stricture, stone), and site of obstructive tissue
    • May help determine therapeutic option
    • Not recommended in initial evaluation unless other factors, such as hematuria, are present.
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image TREATMENT
GENERAL MEASURES
  • Treatment ranges from watchful waiting to lifestyle modifications, medications, or surgical management.
  • Mild symptoms (score of <7) or moderate symptoms (score 8 to 15) that are non-bothersome require no treatment. Reevaluate annually.
  • For moderate to severe symptoms, try lifestyle interventions regulation of fluid intake, avoidance of alcohol and caffeine, exercise, diet, and eliminating/reducing contributing medications.
  • Medical treatment requires interval follow-up of 2 to 4 weeks for &agr;-blockers and 3 months for 5-&agr;-reductase inhibitors until symptoms improved, then annually.
  • Patients with complications including obstruction and urinary retention require bladder drainage.
MEDICATION
  • Should be used as additive therapy, lifestyle modifications are still encouraged.
  • Two main classes of medications: &agr;-adrenergic antagonists and 5-&agr;-reductase inhibitors.
  • The combination of these two medication classes is effective for long-term management of BPH and demonstrated large prostates.
    • &agr;-Adrenergic antagonists
      • Are the first line option for moderate to severe bothersome LUTS. Affect contraction of smooth muscle in the prostatic urethra and bladder neck. Show benefit over placebo. Typically take 2 to 4 weeks to show improvement. May affect blood pressure; requires dose titration and blood pressure monitoring. AUA recommends alfuzosin (Uroxatral), doxazosin (Cardura), and tamsulosin (Flomax) as they are thought to be more selective and have less effect on blood pressure. Prazosin (Minipress) and phenoxybenzamine (Dibenzyline) have insufficient evidence and are not recommended. Most common adverse effect is dizziness. May cause orthostatic hypotension
        • Doxazosin (Cardura): 1 to 8 mg/day PO. May delay the occurrence of acute urinary retention but does not decrease incidence.
        • Tamsulosin (Flomax): 0.4 to 0.8 mg/day PO
        • Alfuzosin (Uroxatral): 10 mg/day PO
        • Terazosin (Hytrin): Start at 1 mg PO daily at bedtime, max 20 mg daily.
      • Contraindications:
        • Use caution in patients who are also using phosphodiesterase type 5 inhibitors for erectile dysfunction.
        • Do not use in men pursuing cataract surgery until they are postoperative due to the risk for perioperative floppy iris syndrome.
    • 5-&agr;-reductase inhibitors
      • Block conversion of testosterone to dihydrotestosterone, gradually reduce prostatic volume therefore are of most benefit when prostate volume exceeds 40 mL. Require 6 months to show clinical benefit. Two equally effective options:
        • Finasteride (Proscar): 5 mg/day PO
        • Dutasteride (Avodart): 0.5 mg/day PO
      • Used in patients with refractory hematuria after other causes have been ruled out
      • Should not be used in patients without evidence of enlarged prostates
      • Show reduced risk of acute urinary retention, less need for surgical intervention and less overall incidence of prostate cancer.
      • Side effects include decreased libido and erectile dysfunction.
  • A PSA value in a patient taking a 5-&agr;-reductase inhibitors will be artificially low.
  • Combination therapy of &agr;-blocker plus 5-&agr;-reductase inhibitor is equal to &agr;-blocker therapy, but superior to monotherapy among men with large prostates. Combination therapy is superior to monotherapy to prevent progression but increase risk of drug-related adverse events.
  • Anticholinergic agents are appropriate for irritative LUTS without an elevated postvoid residual (PVR). Options include Solifenacin (Vesicare), Tolterodine (Detrol LA), or Oxybutynin (Ditropan XL). Should be avoided in patients with PVR >250 mL
  • If patient also experiences erectile dysfunction phosphodiesterase-5 inhibitors have been shown to have mild improvement of LUTS. Can use Tadalafil (Cialis): 5 mg/day PO but avoid use in combination with &agr;-blockers or in those with CrCl <30 mL/min.
Geriatric Considerations
Drugs to use with caution: anticholinergics, antihistamines, sympathomimetics, tricyclic antidepressants, opioids
ISSUES FOR REFERRAL
  • Moderate or severe LUTS that does not respond to medical management.
  • BPH related complications such as recurrent UTIs or hematuria, renal insufficiency, and urinary retention.
  • Abnormal PSA or prostate exam
  • Any history of urethral trauma or stricture, or neurologic disease of the bladder/urinary system
SURGERY/OTHER PROCEDURES
  • Indications for surgery:
    • Urinary retention due to prostatic obstruction, recurrent, no improvement with medications
    • Intractable symptoms due to prostatic obstruction AUA score >8 and symptoms
    • Obstructive uropathy (renal insufficiency)
    • Recurrent or persistent UTIs due to prostatic obstruction
    • Recurrent gross hematuria due to enlarged prostate
    • Bladder calculi
  • Surgical procedures: TURP remains the gold standard of surgical procedures; however for select patient populations, there are other options available.
  • Common complications of TURP:
    • Bleeding can be significant.
    • TUR syndrome: hyponatremia secondary to absorption of hypotonic irrigation fluid
    • Retrograde ejaculation
    • Urinary incontinence
  • Other options include transurethral needle ablation (TUNA) and transurethral microwave thermo-therapy (TUMT), or transurethral incision of the prostate (TUIP). Open prostatectomy is more common when prostate exceeds 100 g. Transurethral laser ablation is an alternative option for patients on anticoagulants.
COMPLEMENTARY & ALTERNATIVE MEDICINE
Saw palmetto (Serenoa repens) has been thoroughly studied in a subject in Cochrane review, and did not improve LUTS. Other agents including pygeum, cernilton, and herbs with beta sitosterols have been studied less however no current evidence to support their use. Acupuncture failed to show improvement in LUTS in one clinical trial as well. There are no recommended complementary or alternative treatments for BPH.
image ONGOING CARE
Patient Monitoring
  • Symptom index (IPSS) monitored every 3 to 12 months.
  • DRE yearly
    • PSA yearly: should not be checked while patient is in retention, recently catheterized, or within a week of any surgical procedure to the prostate
    • Consider monitoring PVR, if elevated.
DIET
Avoid large boluses of oral or IV fluids or alcohol intake, caffeine may exacerbate symptoms as well.
PATIENT EDUCATION
National Kidney and Urologic Diseases Information Clearinghouse, Box NKUDIC, Bethesda, MD 20893; 301-468-6345
PROGNOSIS
  • Symptoms improve or stabilize in 70-80% of patients.
  • 25% of men with LUTS will have persistent storage symptoms after prostatectomy.
  • Of men with BPH, 11-33% have occult prostate cancer.
REFERENCES
1. McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol. 2011;185(5):1793-1803.
2. Pearson R, Williams PM. Common questions about the diagnosis and management of benign prostatic hyperplasia. Am Fam Physician. 2014; 90(11):769-774.
Additional Reading
&NA;
  • American Urological Association Guidelines: guideline on the management of benign prostatic hyperplasia (BPH). Updated 2010. www.auanet.org. Accessed 2015.
  • Edwards JL. Diagnosis and management of benign prostatic hyperplasia. Am Fam Physician. 2008;77(10):1403-1410.
Codes
&NA;
ICD10
  • N40.0 Enlarged prostate without lower urinary tract symptoms
  • N40.1 Enlarged prostate with lower urinary tract symptoms
Clinical Pearls
&NA;
  • Although medical therapy has changed the management of BPH, it has only delayed the need for TURP by 10 to 15 years, not eliminated it.
  • Urinary retention, obstructive uropathy, recurrent UTIs, elevated PSA, bladder calculi, hematuria, and failure of medical therapy are indications for surgical management of BPH.