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Updated: Jun 1 2023

Benign Prostatic Hyperplasia (BPH)

  • Snapshot
    • A 70-year-old man presents to his physician with difficulty initiating a stream and post-void dribbling. He also reports having increased urinary urgency and a weak urinary stream. Medical history is significant for hypertension and is not on medication. On digital rectal exam, his prostate is enlarged, non-tender, firm, and smooth. Urinalysis is unremarkable and prostate-specific antigen is elevated. He is started on tamsulosin to improve his lower urinary tract symptoms.
  • Introduction
    • Clinical definition
      • benign hyperplasia of the stromal and epithelial cells of the prostate that results in lower urinary tract symptoms (LUTS) such as
        • post-void dribbling
        • increased urinary frequency and urgency
        • nocturia
        • weak urinary stream
  • Epidemiology
    • Demographics
      • men > 45 years of age
  • Etiology
    • Pathogenesis
      • unclear; however, chronic inflammation and hormonal and vascular mechanisms may play a role
    • Associated conditions
      • obesity and metabolic syndromes
      • hypertension
      • type 2 diabetes mellitus
  • Presentation
    • Symptoms
      • issues with urinary storage
        • e.g., nocturia, increased urinary frequency, urinary incontinence, and urgency
      • issues with voiding
        • e.g., weak urinary stream, hesistancy, straining to void, and post-void dribbling
        • exacerbated by alpha-1 agonists
      • irritative issues
        • e.g., urgency and increased urinary frequency
    • Physical exam
      • digital rectal exam
        • a non-tender, smooth, elastic, and firm enlarged prostate
  • Studies
    • Labs
      • urinalysis
        • to detect the presence of a urinary tract infection or blood
      • prostate-specific antigen
        • non-specific
    • Diagnostic criteria
      • this is a clinical diagnosis based on history (e.g., storage, voiding, and/or irritating urinary symptoms) and physical exam (e.g., a non-tender, smooth, elastic, and firm enlarged prostate)
  • Differential
    • Prostate cancer
    • Prostatitis
    • Urinary tract infection
    • Bladder cancer
  • Treatment
    • Medical
      • α1-blockers (e.g., terazosin and tamsulosin)
        • indication
          • considered initial therapy in patients with LUTS secondary to BPH
            • results in immediate relief
            • caution in patients on a phosphodiesterase-5 inhibitor as this can cause severe hypotension
      • 5-α reductase inhibitors (e.g., finasteride)
        • indication
          • can be used as alternative treatment in patients with LUTS secondary to BPH who cannot tolerate α1-blockers
            • takes time (6-12 months) for symptom improvement to be appreciated
      • phosphodiesterase-5 inhibitors (e.g., sildenafil)
        • indication
          • a reasonable treatment option in patients with LUTS secondary to BPH who have erectile dysfunction
    • Surgical
      • transurethral resection of the prostate
        • indication
          • a treatment option in patients who are unresponsive to medical treatment
          • in patients with recurrent UTIs, bladder stones, or gross hematuria secondary to their BPH
        • complication
          • retrograde ejaculation
          • erectile dysfunction
            • this is uncommon
  • Complications
    • UTI
    • Nephrolithiasis
    • Bladder stones
    • Chronic kidney disease
    • Hydronephrosis
  • Prognosis
    • Symptoms slowly and progressively worsen
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