Benign Prostatic Hyperplasia

Aka: Benign Prostatic Hyperplasia, Benign Prostatic Hypertrophy, Prostatic Hyperplasia, BPH

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II. Epidemiology

  1. Incidence of BPH increases with age
    1. Men aged 60 years: 50%
    2. Men aged 80 years: 88%
  2. Incidence of symptomatic onset is related to ethnicity
    1. African american men: onset at age 60 years
    2. Caucasian men: onset at age 65 years

III. Pathophysiology

  1. Prostate size increases with age
    1. Birth: few grams
    2. Age 20 to 55 years: 20-30 ml volume (normal)
    3. Age over 55 years: Increased growth (>40 ml volume is considered large)
  2. Prostatic Hyperplasia begins centrally (periurethral)
    1. Prostatic Hyperplasia compresses Urethra
    2. Results in urinary flow obstruction
  3. Prostate growth is hormonally regulated
    1. Testosterone converted to Dihydrotestosterone
    2. Dihydrotestosterone stimulates Prostate growth
    3. Estrogen also stimulates Prostate growth

IV. Risk Factors: Provocative factors for Urinary Retention

  1. See Medication Causes of Urinary Retention
  2. Conditions that may mimic BPH symptoms
    1. Urinary Tract Infection
    2. Overhydration
    3. Caffeine and other Diuretics
  3. Comorbid conditions associated with neurogenic Bladder
    1. Diabetes Mellitus
    2. Multiple Sclerosis
    3. Parkinson's Disease
    4. Sexual Dysfunction
  4. Post-operative pelvic floor Muscle spasm
    1. Herniorrhaphy
    2. Hydrocelectomy
    3. Perirectal Abscess
    4. Rectal Trauma or perineal Trauma
  5. Comorbid conditions predisposing to non-BPH related Urinary Retention
    1. Prior Urethral instrumentation
    2. Nephrolithiasis

V. Symptoms

  1. See International Prostate Symptom Score
  2. Obstructive uropathy symptoms
    1. Weak urine stream with decreased caliber
    2. Hesitancy starting urine stream
    3. Incomplete voiding Sensation
    4. Urinary Retention
      1. Double voiding (returning to urinate shortly after)
      2. Straining to empty Bladder
    5. Postvoid or terminal dribbling
  3. Irritative symptoms
    1. Dysuria
    2. Urinary Frequency
    3. Urinary urgency
  4. Increased urine Residual Volume symptoms
    1. Nocturia
    2. Overflow Incontinence
    3. Bladder palpable on exam
  5. Symptoms suggestive of alternative cause
    1. Fever
    2. Gross Hematuria

VI. Signs

  1. Digital Rectal Exam
    1. Findings suggestive of Prostate Cancer
      1. Asymmetry
      2. Induration
      3. Nodularity
      4. Diffuse firmness
    2. Findings suggestive of Benign Prostatic Hyperplasia
      1. Symmetric prostatic enlargement
      2. Smooth
      3. Firm but elastic
    3. Findings suggestive of Prostatitis
      1. Prostate tenderness
      2. Fever
  2. Abdominal and genitourinary exam
    1. Suprapubic swelling of distended Bladder
    2. Signs of Urethral Stricture
      1. Penile induration
      2. Penile nodularity
    3. Balanoposthitis
      1. Meatal stenosis (Diabetes Mellitus)
  3. Neurologic Exam (evaluate for neurogenic Bladder)
    1. Motor Exam of lower extremities
    2. Anal sphincter tone
    3. Sensory Exam of perineum

VII. Differential Diagnosis

  1. See Urinary Retention
  2. Medication Causes of Urinary Retention

VIII. Labs

  1. Urinalysis (Urine Dipstick with urine microscopy)
    1. Urinary Tract Infection
    2. Hematuria
  2. Prostate Specific Antigen (PSA)
    1. Prostate Cancer
      1. AUA recommends if Life Expectancy >10 years
      2. See Prostate Specific Antigen (PSA) for Informed Consent discussion in obtaining PSA
    2. Evaluate Prostate size (determines efficacy for 5a-Reductase Inhibitor)
      1. PSA >1.5 ng/ml is a proxy for an enlarged Prostate
  3. Urine cytology
    1. Consider if risk of Bladder Cancer
  4. Renal Function Tests (Serum Creatinine and Blood Urea Nitrogen)
    1. No longer recommended since BPH does not affect baseline renal disease risk
    2. Previously recommended to assess for Postrenal Azotemia

IX. Diagnostics

  1. See Urodynamics
  2. Transabdominal Ultrasound
    1. Assess post-void residual
    2. Normal residual urine <100 ml
  3. Other studies to consider
    1. Transrectal Ultrasound (Prostate size evaluation)
    2. Intravenous pyelogram (assess urinary obstruction)

X. Management: Conservative Measures for mild symptoms

  1. Limit night-time water consumption
  2. Weight loss (if Overweight)
  3. Reduce Caffeine and Alcohol intake
  4. Avoid provocative medications
    1. See risk factors above
    2. Avoid Anticholinergics (e.g. Antihistamines, Oxybutynin)
  5. Manage Constipation
  6. Pelvic Floor Exercise (Kegel Exercise)
  7. Observe for complications with annual examination
  8. Alternative Medications (low efficacy)
    1. Saw Palmetto 160 mg orally twice daily
      1. Mixed results from studies regarding efficacy (see Saw Palmetto)
      2. Initial studies suggested benefit, but 2006 Placebo-controlled study did not
        1. Bent (2006) N Engl J Med 354: 557-66 [PubMed]
      3. Did not reduce Nocturia, Peak Urine Flow, Prostate size or AUA Symptom Index for BPH
        1. Tacklind (2012) Cochrane Database Syst Rev (12): CD001423 [PubMed]
    2. Soy products (Isoflavone Genistein)
      1. Tofu contains high concentrations of Genistein
      2. Trinovin (OTC Genistein derived from red clover)
        1. Reduced BPH symptoms at 40-80 mg daily (small trial)
      3. References
        1. Lowe (2000) Patient Care 34:191-203 [PubMed]

XI. Management: Medications

  1. Indications
    1. Benign Prostatic Hyperplasia Symptom Index 8 or higher
  2. Protocol: Combination option
    1. Consider for large Prostate and moderate obstructive symptoms
    2. First 2-3 months (allows for delay in 5a-Reductase Inhibitor activity onset)
      1. Alpha Adrenergic Antagonist and
      2. 5a-Reductase Inhibitor
    3. Next
      1. Continue 5a-Reductase Inhibitor
      2. Taper or discontinue Alpha Adrenergic Antagonist
  3. Alpha Adrenergic Antagonists (long-acting)
    1. Preferred over 5a-Reductase Inhibitors (Finasteride)
    2. Non-Selective agents (antihypertensives, risk of Dizziness, Orthostatic Hypotension, fall risk)
      1. Terazosin (Hytrin)
      2. Doxazosin (Cardura)
      3. Prazosin (Minipress) is not recommended due to lack of evidence
    3. Selective agents (no Blood Pressure effect)
      1. Tamsulosin (Flomax) 0.4 mg (up to 0.8 mg) orally daily (generic)
      2. Silodosin (Rapaflo) 8 mg orally daily
      3. Alfuzosin (Uroxatral) 10 mg orally daily (generic)
        1. Alfuzosin ER is least likely to cause ejaculatory dysfunction of the selective alpha agents
  4. 5a-Reductase Inhibitor (Testosterone conversion inhibitor)
    1. Consider as adjunct to Alpha Adrenergic Antagonists (if not controlled after 4 to 12 weeks)
    2. Efficacy: See Finasteride
      1. Less effective than alpha blockade or surgery
      2. Maximum effect not reached until 6-12 months after starting
      3. Most effective in men with large Prostate (>40 ml)
        1. Digital Rectal Exam predicts size
        2. See PSA for estimating Prostate size
      4. Finasteride effective in reducing Gross Hematuria due to BPH (80%)
    3. Adverse effects
      1. Suicidal Ideation
      2. Gynecomastia
      3. Sexual Dysfunction (Finasteride)
      4. High grade Prostate Cancer (Finasteride, due to delayed diagnosis with lower PSA values)
    4. Agents
      1. Dutasteride (Avodart, Duagen) 0.5 mg orally daily
      2. Finasteride (Proscar) 5 mg orally daily
  5. Anticholinergic Agents
    1. May be used as an adjunct in combination with other agents above
    2. May reduce Bladder contractions and improve irritative urinary symptoms (urgency, frequency)
    3. Increased risk of Urinary Retention, although risk of acute urinary obstruction <1%
    4. Preparations
      1. Oxybutynin ER (Ditropan XL) 10 mg orally daily (generic)
      2. Fesoterodine (Toviaz) 4-8 mg orally daily
      3. Solifenacin (Vesicare) 5 mg orally daily
      4. Tolterodine ER (Detrol LA) 4 mg orally daily
  6. Other agents: PDE5 Inhibitor
    1. Tadalafil (Cialis) 5 mg once daily
      1. Improves symptom scores but not post-Residual Volume or max urine flow in metaanalysis
      2. Avoid in combination with alpha blockers (risk of Hypotension)
      3. Hatzimouratidis (2014) Ther Adv Urol 6(4): 135-47 +PMID: 25083163 [PubMed]

XII. Management: Acute urinary obstruction

  1. Evaluation
    1. Consider recent medications predisposing to urinary obstruction (especially Anticholinergics such as Antihistamines)
    2. Consider alternative causes of urinary obstruction (e.g. pelvic mass, neurologic disorders such as cauda equina)
    3. Urinalysis
    4. Prostate exam
      1. Assess size
      2. Exquisite tenderness suggests Acute Prostatitis
  2. Urinary Catheterization
    1. Indicated for complete obstruction with significant post-void residual
    2. Pre-anesthetize Urethra (e.g. Lidocaine jelly)
    3. Larger catheters may pass more easily than smaller catheters
    4. Plan follow-up with urology in following 7-10 days (earlier catheter removal may fail)
  3. Medications that decrease obstruction acutely
    1. Start agent with or without catheterization
    2. Alpha Adrenergic Antagonists (see above)
    3. Alfuzosin XL (Uroxatral) 10 mg daily for 2 days
  4. Medications - antibiotics
    1. Treat Acute Prostatitis if present
  5. References
    1. Henry (2013) Urology Rapid Assessment, EM Boot Camp, CEME

XIII. Management: Surgery

  1. Indications
    1. Benign Prostatic Hyperplasia Symptom Index 20 or higher
    2. Failed medical therapy
    3. Refractory Urinary Retention
    4. Recurrent Urinary Tract Infections
    5. Persistant Hematuria (gross or microscopic)
    6. Bladder stones
    7. Renal Insufficiency
    8. Bladder decompensation (decreased detrusor Muscle Contractions)
  2. Invasive Procedures
    1. Transurethral Resection of the Prostate (TURP)
    2. Open Prostatectomy (rarely used for BPH alone)
      1. Very large Prostate size
      2. Large median Prostate lobe protruding into Bladder
      3. Urethral diverticulum

XIV. Management: Surgery with minimally invasive procedures

  1. Advantages
    1. Lower complication rates
  2. Disadvantages
    1. Typically no tissue samples for histopathology testing
    2. Some procedures are less effective or have higher failure rates than TURP
  3. Procedures inpatient (with good efficacy compared with TURP)
    1. Transurethral Incision of the Prostate (TUIP)
      1. Indicated for BPH in smaller Prostate size (<30 ml)
    2. Transurethral Laser Induced Prostatectomy (TULIP)
      1. Ultrasound-guided Nd-Yag laser (or Holmium: Yag Laser)
      2. Shorter procedure and fewer complications than TURP
      3. Similar efficacy for large Prostates (>60 grams) as TURP at 2 years
      4. Wilson (2006) Eur Urol 50(3):569-73 [PubMed]
  4. Procedures outpatient
    1. Transurethral Microwave Thermotherapy (TUMT)
      1. Microwave probe heats to over 45 C)
      2. Safe, effective method for Urinary Retention relief
    2. Transurethral Vaporization of the Prostate (TUVP)
    3. Transurethral Electrovaporization Prostate (TVP)
    4. Hot Water Ballon Thermoablation
      1. Experimental procedure with good outcomes
      2. Minimal discomfort
  5. Procedures falling out of favor due to low efficacy or higher risk
    1. Transurethral Needle Ablation of Prostate (TUNA)
      1. High failure rate (23% at 5 years, 83% at 10 years)
      2. Rosario (2007) J Urol 177(3): 1047-51 [PubMed]
    2. Urethral stent
      1. Risk of infection and re-blockage
      2. Indications
        1. BPH patients with high surgical risk
        2. Short Life Expectancy
    3. Transurethral Balloon Dilation
      1. Rarely used due to high rate of symptom recurrence

XV. Complications

  1. BPH is not related to Prostate Cancer development
  2. Obstructive complications
    1. Postrenal Azotemia
    2. Hydronephrosis
    3. Bladder decompensation
      1. Overflow Incontinence
      2. Bladder hypertrophy
    4. Urosepsis

XVI. References

  1. (2022) Presc Lett 29(1): 2-3
  2. Cooner (1994) Prostate Disease, AAFP, p. 9-15
  3. Dornbland (1992) Adult Ambulatory Care, p. 249-52
  4. Macchia (Feb, 1997) Consultant, p.336-45
  5. Corica (2000) Urology 56:76-81 [PubMed]
  6. Donovan (2000) J Urol 164:65-70 [PubMed]
  7. Dull (2002) Am Fam Physician 66(1):77-84 [PubMed]
  8. Edwards (2008) Am Fam Physician 77(10): 1403-10 [PubMed]
  9. Guthrie (1997) Postgrad Med 101(5):141-62 [PubMed]
  10. Oesterling (1995) N Engl J Med 332(2):99-109 [PubMed]
  11. Pearson (2014) Am Fam Physician 90(11): 769-74 [PubMed]

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Related Studies

Ontology: Benign prostatic hypertrophy (C0005001)

Concepts Pathologic Function (T046)
MSH D011470
ICD9 600.0
ICD10 N40
SnomedCT 367483003, 197957005, 270536001, 155906003, 266569009, 61059009
English Hypertrophy, Benign Prostatic, BEP - Bengn enlargmnt prostate, BPH - Benign prost hypertrophy, benign prostatic hypertrophy (diagnosis), benign prostatic hypertrophy, BPH (benign prostatic hypertrophy), Enlarged prostate (benign), Prostatic hypertrophy (benign), Benign Prostatic Hyperplasia - BPH, prostate hypertrophy, benign prostatic hyperplasia, prostate hyperplasia, prostatic hyperplasia, prostatic hypertrophy, benign enlarged prostate, benign prostate hyperplasia, benign prostate enlargement, benign prostatic hyperplasia (BPH), benign prostate hypertrophy, benign hypertrophy of the prostate, Prostatic hyper -benign, Enlarged prostate - benign, BPH - benign prostatic hypertrophy, Hypertrophy-prost.ben., Benign prostatic hyper., BPH, BEP - Benign enlargement of prostate, BPH - Benign prostatic hypertrophy, Benign enlargement of prostate, Benign enlargement of prostate, NOS, Benign Prostatic Hypertrophy, Prostatic Hypertrophy, Benign, Hypertrophy (benign) of prostate, Benign hypertrophy of prostate NOS, Benign prostatic hypertrophy
Dutch BPH, benigne prostaathypertrofie, prostaathypertrofie (benigne), vergrote prostaat (benigne), Benigne prostaathypertrofie, Prostaathypertrofie, benigne, Benigne prostaathyperplasie, Prostaathyperplasie, benigne
French Hypertrophie de la prostate (bénigne), HPB, Hypertrophie prostatique bénigne, Augmentation de taille de la prostate (bénigne), Hypertrophie bénigne de la prostate
German BPH, gutartige Hypertrophie der Prostata, Prostatahypertrophie (gutartig), Benigne Prostatahypertrophie, gutartige Prostatahypertrophie, vergroesserte Prostata (gutartig), Prostatahypertrophie, gutartige
Italian BPH, Ipertrofia prostatica (benigna), Ingrossamento della prostata (benigno), Ipertrofia prostatica benigna
Portuguese Hipertrofia benigna da próstata, Hiperplasia benigna da próstata, Hipertrofia Prostática Benigna, Próstata aumentada de volume (benigno)
Spanish Hipertrofia prostática benigna, Hipertrofia prostática (benigna), Próstata dilatada (benigna), Hipertrofia Prostática Benigna, HPB, agrandamiento benigno de la próstata, hipertrofia prostática benigna
Japanese ＢＰＨ, 良性前立腺肥大, ﾘｮｳｾｲｾﾞﾝﾘﾂｾﾝﾋﾀﾞｲ, BPH, ｾﾞﾝﾘﾂｾﾝｼｭﾀﾞｲﾘｮｳｾｲ, 前立腺腫大（良性）, 前立腺肥大（良性）, ｾﾞﾝﾘﾂｾﾝﾋﾀﾞｲﾘｮｳｾｲ
Czech BPH (potenciál biologického rizika), Benigní hypertrofie prostaty, Zvětšení prostaty (benigní), Hypertrofie prostaty (benigní), prostata - hypertrofie benigní, benigní hypertrofie prostaty
Hungarian BPH, Prosztata megnagyobbodott (jóindulatú), Prostata hypertrophia (jóindulatú), jóindulatú prostata hypertrophia
Norwegian Prostatic hypertrophy, benign
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Benign Prostatic Hyperplasia (C1704272)

Definition (NCI_NCI-GLOSS) A benign (noncancerous) condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine.
Definition (NCI) A non-cancerous nodular enlargement of the prostate gland. It is characterized by the presence of epithelial cell nodules, and stromal nodules containing fibrous and smooth muscle elements. It is the most common urologic disorder in men, causing blockage of urine flow.
Definition (CSP) enlargement or overgrowth of the prostate gland as a result of an increase in the number of its constituent cells.
Definition (MSH) A disease caused by hyperplastic process of non-transformed prostatic cells.
Concepts Neoplastic Process (T191)
MSH D011470
SnomedCT 266569009, 367483003, 61059009
LNC LP90121-2
English benign prostate hyperplasia, PROSTATIC HYPERPLASIA BENIGN <PROSTATISM>, Prostatic Hyperplasia, Benign, Benign Prostatic Hyperplasia, benign prostatic hyperplasia, PROSTATIC HYPERPLASIA, BENIGN, BPH, Nodular hyperplasia of prostate gland, Benign prostatic hyperplasia, Benign prostatic hyperplasia (disorder), Benign prostatic hyperplasia, NOS, Benign Hyperplasia of Prostate, Benign Hyperplasia of the Prostate, Benign Prostate Hyperplasia
Portuguese Hiperplasia Prostática Benigna, Hiperplasia Benigna da Próstata, Hiperplasia benigna da próstata
Spanish Hiperplasia Benigna Prostática, Hiperplasia Prostática Benigna, hiperplasia prostática benigna (concepto no activo), hiperplasia prostática benigna (trastorno), hiperplasia prostática benigna, Hiperplasia benigna de próstata
German Gutartige Prostatahyperplasie, Benigne Prostatahyperplasie, gutartige Prostatahyperplasie
French Hyperplasie prostatique bénigne, Hyperplasie bénigne de la prostate, Hypertrophie bénigne de la prostate
Japanese 良性前立腺肥大症, ﾘｮｳｾｲｾﾞﾝﾘﾂｾﾝﾋﾀﾞｲｼｮｳ
Italian Iperplasia prostatica benigna
Czech Benigní hyperplazie prostaty, prostata - benigní hyperplazie, benigní hyperplazie prostaty
Hungarian Benignus prostata hyperplasia
Norwegian Godartet prostataforstørrelse, Godartet prostatahyperplasi
Dutch prostaathyperplasie, benigne
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Prostatic Hypertrophy (C1739363)

Concepts Disease or Syndrome (T047)
MSH D011470
ICD10 N40
SnomedCT 367483003, 266569009, 61059009
Dutch prostaathypertrofie, hypertrofie; prostaat, prostaat; hypertrofie
Italian Ipertrofia della prostata, Ipertrofia prostatica
Portuguese Hipertrofia prostática, Hipertrofia Prostática
Spanish Hipertrofia prostática, Hipertrofia Prostática, hipertrofia adenofibromatosa de próstata, hipertrofia prostática
French Hypertrophie prostatique, Hypertrophie de la prostate
Japanese 前立腺肥大, ｾﾞﾝﾘﾂｾﾝﾋﾀﾞｲ
German Prostatahypertrophie
English adenofibromatous hypertrophy of prostate (diagnosis), adenofibromatous hypertrophy of prostate, Prostatic Hypertrophy, Prostate--Hypertrophy, Prostatic hypertrophy, Prostatic area hypertrophy, hypertrophy; prostate, prostate; hypertrophy, Adenofibromatous hypertrophy of prostate, NOS, Adenofibromatous hypertrophy of prostate, Hypertrophy of prostate NOS
Czech Prostatická hypertrofie, hypertrofie prostaty, prostata - hypertrofie
Hungarian Prostata hypertrophia
Norwegian Prostatic hypertrophy
Derived from the NIH UMLS (Unified Medical Language System)

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