Bengin prostatic hyperplasia
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"benign prostatic hyperplasia"[MeSH Terms] AND treatment
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benign prostatic hyperplasia pathophysiology diagnosis management guidelines 2024
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Here is a complete overview of Benign Prostatic Hyperplasia (BPH):
Benign Prostatic Hyperplasia (BPH)
Definition
BPH is a non-malignant adenomatous overgrowth of the periurethral (transitional zone) prostate gland. It is the most common benign neoplasm in men, increasing in prevalence with age.
Epidemiology
- Prevalence by autopsy: 8% in men aged 31-40 years, rising to 40-50% in men aged 51-60, and >80% in men over 80.
- Clinically significant BPH (prostate volume >35 mL + moderate/high IPSS score) affects ~19% of men aged 55-74 without prostate cancer.
Pathophysiology
BPH results from hyperplasia of both stromal and glandular epithelial elements in the periurethral transitional zone.
Mechanisms:
- Hormonal: Dihydrotestosterone (DHT) - converted from testosterone by 5-alpha reductase in the prostate - drives cell proliferation. Estrogen may also sensitize cells to DHT.
- Static component: Enlarged gland physically compresses the urethra.
- Dynamic component: Increased alpha-1 adrenergic smooth muscle tone in the prostate stroma and bladder neck further obstructs outflow.
- Long-standing bladder outlet obstruction (BOO) causes detrusor hypertrophy followed by detrusor instability and eventually decompensation, leading to overflow incontinence and retention.
Clinical Features (LUTS)
Symptoms are scored using the International Prostate Symptom Score (IPSS) / AUA Symptom Score (7 questions, 0-35 points):
- Mild: 0-7
- Moderate: 8-19
- Severe: 20-35
Storage (Irritative) Symptoms
- Urinary frequency
- Urgency (urge incontinence)
- Nocturia
Voiding (Obstructive) Symptoms
- Weak/slow urinary stream
- Hesitancy (difficulty initiating urination)
- Intermittency (stop-start stream)
- Straining to void
- Terminal dribbling
- Sensation of incomplete emptying
Complications
- Acute urinary retention (AUR) - precipitated by cold, alcohol, anticholinergics, opioids, immobilization, UTI
- Chronic urinary retention - leads to overflow incontinence
- Recurrent UTIs
- Bladder calculi
- Bilateral hydronephrosis / renal failure (late)
- Hematuria (due to prostatic venous engorgement)
Diagnosis
Mandatory Workup
| Investigation | Purpose |
|---|---|
| IPSS score | Quantify symptom severity |
| Urinalysis + culture | Rule out UTI, hematuria |
| Serum PSA | Rule out prostate cancer (age-specific reference ranges) |
| Digital Rectal Examination (DRE) | Assess prostate size, consistency, symmetry |
| Serum creatinine | Assess renal function |
| Post-void residual (PVR) volume (ultrasound) | Assess incomplete emptying (>50 mL significant) |
Additional Studies (when indicated)
- Uroflowmetry: Max flow rate (Qmax) <10 mL/sec suggests significant obstruction
- Transrectal ultrasound (TRUS): Precise prostate volume measurement
- Cystoscopy: Evaluate bladder, rule out stricture or tumor
- Urodynamics: Differentiate BOO from detrusor underactivity
Note: BPH and prostate cancer can coexist. If PSA is elevated or DRE is abnormal, biopsy is warranted.
Treatment
Treatment is guided by symptom severity (IPSS), prostate volume, flow rate, and patient preference.
1. Watchful Waiting (Active Surveillance)
- For mild symptoms (IPSS ≤7) or moderate symptoms not bothering the patient
- Lifestyle advice: limit fluids before bed, reduce caffeine/alcohol, double voiding, timed voiding
2. Medical Management
Alpha-1 Blockers (first-line for moderate-severe LUTS)
Relax smooth muscle in prostate and bladder neck (dynamic component).
- Tamsulosin (0.4 mg OD) - uroselective, preferred
- Alfuzosin, Silodosin, Doxazosin, Terazosin
- Onset within days; do not shrink the prostate
- Side effects: orthostatic hypotension, retrograde ejaculation (especially tamsulosin/silodosin)
- Floppy iris syndrome - important to warn patients before cataract surgery
5-Alpha Reductase Inhibitors (5-ARIs)
Reduce prostate size by ~25% over 6-12 months; best for large prostates (>40 mL) or elevated PSA.
- Finasteride (5 mg OD) - type 2 inhibitor
- Dutasteride (0.5 mg OD) - types 1 and 2 inhibitor (more potent)
- Reduce risk of AUR and need for surgery
- Side effects: decreased libido, erectile dysfunction, ejaculatory disorders, gynecomastia
- Lower PSA by ~50% - double measured PSA to estimate true value
Combination Therapy
- Alpha-blocker + 5-ARI (e.g., tamsulosin + dutasteride = Duodart) is superior to either alone for large prostates with significant symptoms (CombAT, MTOPS trials).
PDE-5 Inhibitors
- Tadalafil 5 mg OD - approved for BPH/LUTS, particularly useful if erectile dysfunction coexists
Anticholinergics / Beta-3 Agonists (for storage symptoms)
- If overactive bladder (OAB) symptoms dominate after outflow obstruction is managed
- Mirabegron (beta-3 agonist) - preferred over anticholinergics due to better tolerability
3. Minimally Invasive Procedures
| Procedure | Mechanism |
|---|---|
| TUMT (Transurethral Microwave Thermotherapy) | Heat ablation of prostatic tissue |
| TUNA (Transurethral Needle Ablation) | Radiofrequency energy to prostate |
| UroLift (Prostatic Urethral Lift) | Mechanical implants hold lobes apart; preserves ejaculation |
| Rezum (Water Vapor Therapy) | Steam ablation of prostatic tissue |
| Prostatic Artery Embolization (PAE) | Interventional radiology; reduces blood supply to prostate |
4. Surgical Management
Indicated when:
- Refractory urinary retention
- Recurrent UTIs due to BPH
- Bladder stones secondary to BPH
- Renal insufficiency due to BOO
- Large diverticula
- Failure of medical therapy
| Surgery | Notes |
|---|---|
| TURP (Transurethral Resection of Prostate) | Gold standard; "chip" resection; risk of TUR syndrome (with monopolar), retrograde ejaculation |
| Open Prostatectomy (Millin's/HoLEP) | For very large glands (>80-100 mL); Millin's = retropubic approach |
| Laser procedures: HoLEP, GreenLight (PVP) | Less bleeding, suitable for anticoagulated patients; HoLEP is preferred for large glands |
| TUIP (Transurethral Incision) | Small glands without median lobe; incises rather than resects |
TUR Syndrome: Hyponatremia (dilutional) from glycine irrigation absorption - presents with confusion, bradycardia, hypertension. Managed with hypertonic saline + furosemide. Avoided with bipolar TURP (saline irrigation).
Key Drug Interactions & Warnings
- 5-ARIs lower PSA - always double the value to get the "corrected" PSA
- Alpha-blockers + cataract surgery - warn ophthalmologist (intraoperative floppy iris syndrome - IFIS)
- Avoid anticholinergics, alpha-agonists (decongestants), opioids, alcohol, and antidepressants in patients with BPH - can precipitate acute retention
Summary Table
| Feature | Details |
|---|---|
| Zone affected | Transitional zone |
| Hormone | DHT (via 5-alpha reductase type 2) |
| Key symptom score | IPSS / AUA-SS |
| First-line drug (symptom relief) | Alpha-blocker (tamsulosin) |
| First-line drug (large prostate) | 5-ARI (finasteride/dutasteride) |
| Gold standard surgery | TURP |
| Surgical indication | AUR, renal failure, recurrent UTI, bladder stones |
The most current guidelines are from the AUA Guideline Amendment 2023 (Sandhu et al., J Urol 2024;211:11-19), which updated recommendations on medical and surgical management of LUTS/BPH.
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