Benign Prostate Hyperplasia/Hypertrophy

Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate. Chronic bladder outlet obstruction (BOO) secondary to BPH may lead to urinary retention, renal insufficiency, recurrent urinary tract infections, gross hematuria, and bladder calculi. The image below illustrates normal prostate anatomy.

Normal prostate anatomy. The prostate is located at the apex of the bladder and surrounds the proximal urethra.

Signs and symptoms

When the prostate enlarges, it may constrict the flow of urine. Nerves within the prostate and bladder may also play a role in causing the following common symptoms:

• Urinary frequency
• Urinary urgency
• Nocturia- Needing to get up frequently at night to urinate
• Hesitancy – Difficulty initiating the urinary stream; interrupted, weak stream
• Incomplete bladder emptying – The feeling of persistent residual urine, regardless of the frequency of urination
• Straining – The need strain or push (Valsalva maneuver) to initiate and maintain urination in order to more fully evacuate the bladder
• Decreased force of stream – The subjective loss of force of the urinary stream over time
• Dribbling – The loss of small amounts of urine due to a poor urinary stream as well as weak urinary stream

Diagnosis

Digital rectal examination

The digital rectal examination (DRE) is an integral part of the evaluation in men with presumed BPH. During this portion of the examination, prostate size and contour can be assessed, nodules can be evaluated, and areas suggestive of malignancy can be detected.

Laboratory studies

• Urinalysis – Examine the urine using dipstick methods and/or via centrifuged sediment evaluation to assess for the presence of blood, leukocytes, bacteria, protein, or glucose
• Urine culture – This may be useful to exclude infectious causes of irritative voiding and is usually performed if the initial urinalysis findings indicate an abnormality
• Prostate-specific antigen – Although BPH does not cause prostate cancer, men at risk for BPH are also at risk for this disease and should be screened accordingly (although screening for prostate cancer remains controversial)
• Electrolytes, blood urea nitrogen (BUN), and creatinine – These evaluations are useful screening tools for chronic renal insufficiency in patients who have high postvoid residual (PVR) urine volumes; however, a routine serum creatinine measurement is not indicated in the initial evaluation of men with lower urinary tract symptoms (LUTS) secondary to BPH ^[1^]

Ultrasonography

Ultrasonography (abdominal, renal, transrectal) is useful for helping to determine bladder and prostate size and the degree of hydronephrosis (if any) in patients with urinary retention or signs of renal insufficiency. Generally, they are not indicated for the initial evaluation of uncomplicated LUTS.

Endoscopy of the lower urinary tract

Cystoscopy may be indicated in patients scheduled for invasive treatment or in whom a foreign body or malignancy is suspected. In addition, endoscopy may be indicated in patients with a history of sexually transmitted disease (eg, gonococcal urethritis), prolonged catheterization, or trauma.

IPSS/AUA-SI

The severity of BPH can be determined with the International Prostate Symptom Score (IPSS)/American Urological Association Symptom Index (AUA-SI) plus a disease-specific quality of life (QOL) question. Questions on the AUA-SI for BPH concern the following:

• Incomplete emptying
• Frequency
• Intermittency
• Urgency
• Weak stream
• Straining
• Nocturia

Other tests

• Flow rate – Useful in the initial assessment and to help determine the patient’s response to treatment
• PVR urine volume – Used to gauge the severity of bladder decompensation; it can be obtained invasively with a catheter or noninvasively with a transabdominal ultrasonic scanner
• Pressure flow studies – Findings may prove useful for evaluating for BOO
• Urodynamic studies – To help distinguish poor bladder contraction ability (detrusor underactivity) from BOO
• Cytologic examination of the urine – May be considered in patients with predominantly irritative voiding symptoms

Management

Pharmacologic treatment

Agents used in the treatment of BPH include the following:

• Alpha-1–receptor blockers
• Alpha-adrenergic receptor blockers
• Phosphodiesterase-5 enzyme inhibitors
• 5-alpha reductase inhibitors
• Anticholinergic agents

Surgery

• Transurethral resection of the prostate (TURP) – The criterion standard for relieving BOO secondary to BPH
• Open prostatectomy – Reserved for patients with very large prostates (>75 g), patients with concomitant bladder stones or bladder diverticula, and patients who cannot be positioned for transurethral surgery

Minimally invasive treatment

• Transurethral incision of the prostate (TUIP)
• Laser treatment – Used to cut or destroy prostate tissue; multiple laser types are available, including green light, holmium, and thulium, and each has its own strengths and weaknesses
• Transurethral microwave therapy (TUMT) – Generates heat that causes cell death in the prostate, leading to prostatic contraction and volume reduction
• Transurethral needle ablation of the prostate (TUNA)
• High-intensity ultrasonographic energy therapy – Currently in the clinical trial stage
• Prostatic stents – Flexible devices that expand when put in place to improve the flow of urine past the prostate
• Laparoscopic prostatectomy