Benign prostatic hyperplasia

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I now have comprehensive, high-quality information from multiple authoritative textbooks. Here is a complete overview of BPH:

Benign Prostatic Hyperplasia (BPH)

Definition & Epidemiology

BPH is a benign proliferation of stromal and epithelial cells within the prostate gland, centered in the transition zone (periurethral region). It is the most common benign prostatic disease in men over 50.

Histologic BPH develops in ~50% of men over 50 years, rising to ~90% by the 8th decade
Of those with histologic BPH, approximately 50% develop notable lower urinary tract symptoms (LUTS)
Normal prostate volume: ~20 mL in young men; BPH is defined as volume >30 mL
Average volume increases from ~24 mL to ~38 mL between ages 50-80
Goldman-Cecil Medicine, p. 1316
Robbins & Kumar Basic Pathology, p. 659

Pathogenesis

The central driver is androgen-dependent overgrowth of stromal and glandular elements:

Dihydrotestosterone (DHT) is the key mediator - it is 10 times more potent than testosterone
Testosterone is converted to DHT in the prostate by 5α-reductase type 2
DHT binds nuclear androgen receptors, upregulating genes that support cell growth and survival
DHT-induced growth factors increase stromal cell proliferation and decrease epithelial cell apoptosis
With aging, testosterone declines but estrogen levels remain elevated (due to peripheral conversion); estrogens act synergistically with DHT via estrogen receptors on both epithelial and stromal cells
BPH does NOT occur in men castrated before puberty or in those with genetic defects in androgen activity

Obstruction occurs via two mechanisms:

Static component: physical compression of the urethra by enlarged gland
Dynamic component: increased smooth muscle tone in prostate stroma (alpha-1 adrenergic mediated)
Robbins & Kumar Basic Pathology, p. 659
Goldman-Cecil Medicine, p. 1316

Morphology

Prostate weight increases 3- to 5-fold (60-100 g or more)
BPH affects the transition zone, compressing the urethra to a slit-like orifice
Cut section shows hyperplastic nodules (variable in color/consistency)
Nodules may be solid or contain cystic spaces (dilated glands)
Microscopically: variable proportions of glandular elements and fibromuscular stroma
Hyperplastic glands lined by two cell layers: tall columnar inner cells + flattened basal cells (this two-layer pattern distinguishes BPH from carcinoma)
Glandular lumina may contain corpora amylacea (laminated proteinaceous secretions)

Cystoscopic and gross appearance of BPH (Sabiston Textbook of Surgery):

BPH cystoscopy and gross specimen: (A) Normal prostatic urethra, (B) Moderate BPH with lateral lobe enlargement, (C) Prostatic adenoma after open prostatectomy

Clinical Features / LUTS

LUTS from BPH are categorized into three groups:

Category	Symptoms
Voiding (obstructive)	Hesitancy, weak/intermittent stream, straining, prolonged voiding
Storage (irritative)	Frequency, urgency, nocturia, urge incontinence
Post-void	Incomplete emptying, dribbling, high post-void residual

Important: There is little correlation between prostate volume and symptom severity, and bladder outlet obstruction severity does not necessarily correlate with LUTS severity.

Chronic obstruction can lead to:

Recurrent UTIs
Bladder calculi
Hydronephrosis / azotemia (renal impairment)
Acute urinary retention
Bladder detrusor dysfunction (overactive or underactive bladder)

Diagnosis / Evaluation

Test	Purpose
History + IPSS (International Prostate Symptom Score)	Quantify symptom burden
Digital rectal examination (DRE)	Estimate prostate size; assess for nodules (to rule out cancer)
Urinalysis	Rule out infection, hematuria
PSA	If life expectancy >10 years (controversial for screening)
Post-void residual (PVR)	Assess bladder emptying
Uroflowmetry	Measure flow rate
Cystoscopy / urodynamic studies	Selected cases with diagnostic uncertainty

Management

Behavioral & Dietary Modifications (First-line for all patients)

Reduce evening fluid intake, caffeine, alcohol
Timed voiding, bladder training
Treat contributing medications (e.g., anticholinergics, diuretics)

Medical Therapy

Drug Class	Mechanism	Examples	Key Side Effects
Alpha-1 blockers	Relax smooth muscle in bladder neck and prostate; reduce outflow resistance	Tamsulosin, silodosin, alfuzosin, terazosin	Orthostatic hypotension, retrograde ejaculation, rhinitis
5α-reductase inhibitors (5-ARIs)	Block testosterone → DHT conversion; reduce prostate volume (~20-30% reduction)	Finasteride, dutasteride	Reduced libido, erectile dysfunction; reduce serum PSA ~50%
Combination therapy	Alpha-blocker + 5-ARI	Tamsulosin + dutasteride	Superior outcomes vs. monotherapy; greater side effects
Anticholinergics / Beta-3 agonists	Target overactive bladder component	Solifenacin, mirabegron	Used when storage symptoms predominate
PDE-5 inhibitors	Also relax prostate smooth muscle	Tadalafil	Erectile dysfunction concurrently treated

Note on 5-ARIs and PSA: These drugs reduce serum PSA by approximately 50%, which must be accounted for when using PSA to screen for prostate cancer (double the measured PSA value as a correction).

Surgical Indications (Absolute / Objective)

Surgery is indicated when medical therapy fails OR when the following arise:

Acute urinary retention
Bladder calculi
Azotemia (obstructive renal failure)
Recurrent UTIs
Recurrent hematuria

Surgical Options

Procedure	Notes
TURP (transurethral resection of the prostate)	Gold standard; bipolar/laser versions reduce risk of dilutional hyponatremia and bleeding
HoLEP (Holmium Laser Enucleation)	Effective for large glands; excellent long-term outcomes
ThuLEP (Thulium Laser Enucleation)	Similar to HoLEP
PVP (Photoselective Vaporization)	Laser vaporization; good for anticoagulated patients
Open simple prostatectomy	For very large adenomas (>80-100 g); enucleation of adenoma
Minimally invasive (microwave thermotherapy, radiofrequency ablation)	Office-based; inferior long-term outcomes vs. TURP

TURP complications: Persistent bleeding, dilutional hyponatremia (from glycine irrigation - eliminated with bipolar/laser), UTI, urinary incontinence, urethral stricture.

Sabiston Textbook of Surgery, p. 2824-2825
Goldman-Cecil Medicine, p. 1316

Key Distinguishing Points

Feature	BPH	Prostate Carcinoma
Zone of origin	Transition zone	Peripheral zone
Gland histology	Two cell layers (columnar + basal)	Single cell layer (no basal layer)
Obstruction	Common (periurethral location)	Less likely unless advanced
Palpation (DRE)	Smooth, firm enlargement	Hard, irregular nodule
Metastasis	Never	Common (bone, lymph nodes)

Sources: Robbins & Kumar Basic Pathology (Robbins Pathology), p. 659; Goldman-Cecil Medicine, p. 1316; Sabiston Textbook of Surgery, p. 2824-2825

Simple language

Benign Prostatic Hyperplasia (BPH) - Simple Explanation

What is it?

BPH means the prostate gland gets bigger as men age. It is not cancer - just extra cells growing in the gland.

The prostate sits just below the bladder and wraps around the urine tube (urethra). When it grows, it squeezes that tube and makes urination difficult.

Who gets it?

Very common in older men
1 in 2 men over age 50 have it
9 in 10 men in their 80s have it

Why does it happen?

As men age, a hormone called DHT (made from testosterone) builds up in the prostate and makes cells grow too much. Estrogen levels also rise with age and add to this growth.

Think of it like a donut squeezing a straw - the bigger the donut, the harder it is for urine to flow through.

Symptoms

Trouble urinating (voiding):

Weak urine stream
Difficulty starting to urinate
Stream that stops and starts

Bladder irritation (storage):

Needing to urinate frequently
Waking up at night to urinate (nocturia)
Sudden, urgent need to go

After urinating:

Feeling like the bladder is never fully empty
Dribbling at the end

Complications (if untreated)

Bladder infections (recurring UTIs)
Bladder stones
Complete inability to urinate (urinary retention)
Kidney damage over time

Diagnosis

Test	Why it's done
Symptom score (IPSS questionnaire)	Measures how bad symptoms are
Rectal exam (DRE)	Doctor feels the prostate size
Urine test	Rules out infection
PSA blood test	Rules out prostate cancer
Urine flow test	Measures how fast urine flows
Post-void residual scan	Checks how much urine is left after urinating

Treatment

Step 1 - Lifestyle changes (always first)

Drink less fluid in the evening
Cut down on coffee and alcohol
Go to the toilet on a schedule
Avoid medications that worsen symptoms

Step 2 - Medicines

Medicine Type	What it does	Common Examples
Alpha-blockers	Relax the muscle around the prostate - urine flows more easily	Tamsulosin, Alfuzosin
5-alpha reductase inhibitors	Shrink the prostate over several months	Finasteride, Dutasteride
Combination	Both medicines together - works better for large prostates	Tamsulosin + Dutasteride

Step 3 - Surgery (when medicines don't work)

Surgery is also done urgently if the man cannot urinate at all, has repeated infections, or kidney damage.

Procedure	Simple Explanation
TURP (most common)	A telescope is passed through the urine tube; excess prostate tissue is shaved away
Laser surgery (HoLEP)	Same idea but uses a laser - less bleeding, good for very large glands
Open surgery	Only for very large prostates; gland is removed through a cut in the abdomen

Key Point to Remember

BPH is not cancer and does not turn into cancer. But both BPH and prostate cancer can exist at the same time, which is why the doctor checks for cancer separately.

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