II. Epidemiology
III. Pathophysiology
-
Prostate size increases with age
- Birth: few grams
- Age 20 to 55 years: 20-30 ml volume (normal)
- Age over 55 years: Increased growth (>40 ml volume is considered large)
- Prostatic Hyperplasia begins centrally (periurethral)
- Prostatic Hyperplasia compresses Urethra
- Results in urinary flow obstruction
-
Prostate growth is hormonally regulated
- Testosterone converted to Dihydrotestosterone
- Dihydrotestosterone stimulates Prostate growth
- Estrogen also stimulates Prostate growth
IV. Risk Factors: Provocative factors for Urinary Retention
- See Medication Causes of Urinary Retention
- Conditions that may mimic BPH symptoms
- Urinary Tract Infection
- Overhydration
- Caffeine and other Diuretics
- Comorbid conditions associated with neurogenic Bladder
- Post-operative pelvic floor Muscle spasm
- Herniorrhaphy
- Hydrocelectomy
- Perirectal Abscess
- Rectal Trauma or perineal Trauma
- Comorbid conditions predisposing to non-BPH related Urinary Retention
- Prior Urethral instrumentation
- Nephrolithiasis
V. Symptoms
- See International Prostate Symptom Score
- Obstructive uropathy symptoms
- Weak urine stream with decreased caliber
- Hesitancy starting urine stream
- Incomplete voiding Sensation
- Urinary Retention
- Double voiding (returning to urinate shortly after)
- Straining to empty Bladder
- Postvoid or terminal dribbling
- Irritative symptoms
- Dysuria
- Urinary Frequency
- Urinary urgency
- Increased urine Residual Volume symptoms
- Nocturia
- Overflow Incontinence
- Bladder palpable on exam
- Symptoms suggestive of alternative cause
VI. Signs
-
Digital Rectal Exam
- Findings suggestive of Prostate Cancer
- Asymmetry
- Induration
- Nodularity
- Diffuse firmness
- Findings suggestive of Benign Prostatic Hyperplasia
- Symmetric prostatic enlargement
- Smooth
- Firm but elastic
- Findings suggestive of Prostatitis
- Findings suggestive of Prostate Cancer
- Abdominal and genitourinary exam
- Suprapubic swelling of distended Bladder
- Signs of Urethral Stricture
- Penile induration
- Penile nodularity
- Balanoposthitis
- Meatal stenosis (Diabetes Mellitus)
-
Neurologic Exam (evaluate for neurogenic Bladder)
- Motor Exam of lower extremities
- Anal sphincter tone
- Sensory Exam of perineum
VII. Differential Diagnosis
VIII. Labs
- Urinalysis (Urine Dipstick with urine microscopy)
-
Prostate Specific Antigen (PSA)
- Prostate Cancer
- AUA recommends if Life Expectancy >10 years
- See Prostate Specific Antigen (PSA) for Informed Consent discussion in obtaining PSA
- Evaluate Prostate size (determines efficacy for 5a-Reductase Inhibitor)
- PSA >1.5 ng/ml is a proxy for an enlarged Prostate
- Prostate Cancer
- Urine cytology
- Consider if risk of Bladder Cancer
-
Renal Function Tests (Serum Creatinine and Blood Urea Nitrogen)
- No longer recommended since BPH does not affect baseline renal disease risk
- Previously recommended to assess for Postrenal Azotemia
IX. Diagnostics
- See Urodynamics
- Transabdominal Ultrasound
- Assess post-void residual
- Normal residual urine <100 ml
- Other studies to consider
- Transrectal Ultrasound (Prostate size evaluation)
- Intravenous pyelogram (assess urinary obstruction)
X. Management: Conservative Measures for mild symptoms
- Limit night-time water consumption
- Weight loss (if Overweight)
- Reduce Caffeine and Alcohol intake
- Avoid provocative medications
- See risk factors above
- Avoid Anticholinergics (e.g. Antihistamines, Oxybutynin)
- Manage Constipation
- Pelvic Floor Exercise (Kegel Exercise)
- Observe for complications with annual examination
- Alternative Medications (low efficacy)
- Saw Palmetto 160 mg orally twice daily
- Mixed results from studies regarding efficacy (see Saw Palmetto)
- Initial studies suggested benefit, but 2006 Placebo-controlled study did not
- Did not reduce Nocturia, Peak Urine Flow, Prostate size or AUA Symptom Index for BPH
- Soy products (Isoflavone Genistein)
- Tofu contains high concentrations of Genistein
- Trinovin (OTC Genistein derived from red clover)
- Reduced BPH symptoms at 40-80 mg daily (small trial)
- References
- Saw Palmetto 160 mg orally twice daily
XI. Management: Medications
- Indications
- Benign Prostatic Hyperplasia Symptom Index 8 or higher
- Protocol: Combination option
- Consider for large Prostate and moderate obstructive symptoms
- First 2-3 months (allows for delay in 5a-Reductase Inhibitor activity onset)
- Next
- Continue 5a-Reductase Inhibitor
- Taper or discontinue Alpha Adrenergic Antagonist
-
Alpha Adrenergic Antagonists (long-acting)
- Preferred over 5a-Reductase Inhibitors (Finasteride)
- Non-Selective agents (antihypertensives, risk of Dizziness, Orthostatic Hypotension, Fall Risk)
- Selective agents (no Blood Pressure effect)
-
5a-Reductase Inhibitor (Testosterone conversion inhibitor)
- Consider as adjunct to Alpha Adrenergic Antagonists (if not controlled after 4 to 12 weeks)
- Efficacy: See Finasteride
- Less effective than alpha blockade or surgery
- Maximum effect not reached until 6-12 months after starting
- Most effective in men with large Prostate (>40 ml)
- Digital Rectal Exam predicts size
- See PSA for estimating Prostate size
- Finasteride effective in reducing Gross Hematuria due to BPH (80%)
- Adverse effects
- Suicidal Ideation
- Gynecomastia
- Sexual Dysfunction (Finasteride)
- High grade Prostate Cancer (Finasteride, due to delayed diagnosis with lower PSA values)
- Agents
- Dutasteride (Avodart, Duagen) 0.5 mg orally daily
- Finasteride (Proscar) 5 mg orally daily
-
Anticholinergic Agents
- May be used as an adjunct in combination with other agents above
- May reduce Bladder contractions and improve irritative urinary symptoms (urgency, frequency)
- Increased risk of Urinary Retention, although risk of acute urinary obstruction <1%
- Preparations
- Oxybutynin ER (Ditropan XL) 10 mg orally daily (generic)
- Fesoterodine (Toviaz) 4-8 mg orally daily
- Solifenacin (Vesicare) 5 mg orally daily
- Tolterodine ER (Detrol LA) 4 mg orally daily
- Other agents: PDE5 Inhibitor
- Tadalafil (Cialis) 5 mg once daily
- Improves symptom scores but not post-Residual Volume or max urine flow in metaanalysis
- Avoid in combination with alpha blockers (risk of Hypotension)
- Hatzimouratidis (2014) Ther Adv Urol 6(4): 135-47 +PMID: 25083163 [PubMed]
- Tadalafil (Cialis) 5 mg once daily
XII. Management: Acute urinary obstruction
- Evaluation
- Consider recent medications predisposing to urinary obstruction (especially Anticholinergics such as Antihistamines)
- Consider alternative causes of urinary obstruction (e.g. pelvic mass, neurologic disorders such as cauda equina)
- Urinalysis
- Prostate exam
- Assess size
- Exquisite tenderness suggests Acute Prostatitis
- Urinary Catheterization
- Medications that decrease obstruction acutely
- Start agent with or without catheterization
- Alpha Adrenergic Antagonists (see above)
- Alfuzosin XL (Uroxatral) 10 mg daily for 2 days
- Medications - antibiotics
- Treat Acute Prostatitis if present
- References
- Henry (2013) Urology Rapid Assessment, EM Boot Camp, CEME
XIII. Management: Surgery
- Indications
- Benign Prostatic Hyperplasia Symptom Index 20 or higher
- Failed medical therapy
- Refractory Urinary Retention
- Recurrent Urinary Tract Infections
- Persistant Hematuria (gross or microscopic)
- Bladder stones
- Renal Insufficiency
- Bladder decompensation (decreased detrusor Muscle Contractions)
- Invasive Procedures
- Transurethral Resection of the Prostate (TURP)
- Open Prostatectomy (rarely used for BPH alone)
- Very large Prostate size
- Large median Prostate lobe protruding into Bladder
- Urethral Diverticulum
XIV. Management: Surgery with minimally invasive procedures
- Advantages
- Lower complication rates
- Disadvantages
- Typically no tissue samples for histopathology testing
- Some procedures are less effective or have higher failure rates than TURP
- Procedures inpatient (with good efficacy compared with TURP)
- Transurethral Incision of the Prostate (TUIP)
- Indicated for BPH in smaller Prostate size (<30 ml)
- Transurethral Laser Induced Prostatectomy (TULIP)
- Ultrasound-guided Nd-Yag laser (or Holmium: Yag Laser)
- Shorter procedure and fewer complications than TURP
- Similar efficacy for large Prostates (>60 grams) as TURP at 2 years
- Wilson (2006) Eur Urol 50(3):569-73 [PubMed]
- Transurethral Incision of the Prostate (TUIP)
- Procedures outpatient
- Transurethral Microwave Thermotherapy (TUMT)
- Microwave probe heats to over 45 C)
- Safe, effective method for Urinary Retention relief
- Transurethral Vaporization of the Prostate (TUVP)
- Transurethral Electrovaporization Prostate (TVP)
- Hot Water Ballon Thermoablation
- Experimental procedure with good outcomes
- Minimal discomfort
- Transurethral Microwave Thermotherapy (TUMT)
- Procedures falling out of favor due to low efficacy or higher risk
- Transurethral Needle Ablation of Prostate (TUNA)
- High failure rate (23% at 5 years, 83% at 10 years)
- Rosario (2007) J Urol 177(3): 1047-51 [PubMed]
- Urethral stent
- Risk of infection and re-blockage
- Indications
- BPH patients with high surgical risk
- Short Life Expectancy
- Transurethral Balloon Dilation
- Rarely used due to high rate of symptom recurrence
- Transurethral Needle Ablation of Prostate (TUNA)
XV. Complications
- BPH is not related to Prostate Cancer development
- Obstructive complications
- Postrenal Azotemia
- Hydronephrosis
- Bladder decompensation
- Overflow Incontinence
- Bladder hypertrophy
- Urosepsis
XVI. References
- (2022) Presc Lett 29(1): 2-3
- Cooner (1994) Prostate Disease, AAFP, p. 9-15
- Dornbland (1992) Adult Ambulatory Care, p. 249-52
- Macchia (Feb, 1997) Consultant, p.336-45
- Corica (2000) Urology 56:76-81 [PubMed]
- Donovan (2000) J Urol 164:65-70 [PubMed]
- Dull (2002) Am Fam Physician 66(1):77-84 [PubMed]
- Edwards (2008) Am Fam Physician 77(10): 1403-10 [PubMed]
- Guthrie (1997) Postgrad Med 101(5):141-62 [PubMed]
- Oesterling (1995) N Engl J Med 332(2):99-109 [PubMed]
- Pearson (2014) Am Fam Physician 90(11): 769-74 [PubMed]