Benign Prostate Hypertrophy (BPH)

Benign Prostate Hypertrophy
• Benign prostatic hyperplasia refers to nonmalignant growth
of prostate.
– age-related phenomenon in nearly all men, starting at approx 40
years of age.
• Histologically
10% of men in their 30s
20% in 40s
50-60% in 60s
80-90% in their 70s and 80s.
• Prostate size increases from
– 25g to 30g for men in 40s
– 30g to 40g in 50s
– 35g to 45g in 60s.
• However, many men with histological BPH
may never develop symptoms, which is when
treatment is sought.
• Etiology
– poorly understood despite decades of intense
– hyperplasia thought to be stimulated by
dihydrotestosterone (DHT)
• Additional risk factors: positive family history
• Lower urinary tract symptoms (non-specific, can also
include those with prostatitis, prostate cancer, bladder
outlet obstruction like urethral stricture, stones, etc.)
• Hesitancy, frequency, urgency, straining, weak flow,
prolonged voiding, partial or complete urinary
retention, small voided volumes, nocturia, painful
• If peak urinary flow rate <10 mL/s, then subvesical
obstruction seen in 90% patients
• Risk factors: changes to bladder anatomy and function,
UTI, formation of bladder stones, renal failure
• Careful history and physical examination
including DRE
• DRE notoriously unreliable in assessing size, in
fact, shown to underestimate size of prostate
• Still important because some men found to have
prostate cancer based on DRE
• UA, serum Cr. PSA depending on patient’s life
expectancy and circumstances.
– PSA is an individualized decision to be made with
patient and physician
• Further evaluate with AUA Symptom Score, or International
Prostate Symptom Score (IPSS)—7 questions each on
severity scale of 0-5: frequency, nocturia, weak urinary
stream, hesitancy, intermittence, incomplete emptying, and
• If score <8, mildly symptomatic and recommend yearly
• If 8-35, may consider additional tests if history confounded
by neurological diseases, prior failed BPH therapy, and
those considering surgery.
• Optional tests:
– Urinary flow rate <10 mL/s highly suggestive of outlet
– Postvoid residual urine measurement with transabdominal
ultrasound or in-and-out catheterization.
• If no obstruction and limited discomfort, do
not need to treat!!
Non-pharmacological Management
Non-pharmacological Management
· Mild symptoms or limited discomfort?
o Watchful waiting and annual evaluation
o Lifestyle Modifications
 Avoid fluids prior to bedtime or going out
 Reduce caffeine and alcohol
 Scheduled urination at least once every 3
•  Double voiding: after urinating, wait and try
to urinate again.
Pharmacological Treatment
• Alpha-1-adrenergic antagonists
– Relax smooth muscle in the bladder neck, prostate capsule, and
prostatic urethra
– Immediate relief!
– Examples
• Terazosin, Doxazosin
– Initiate at bedtime (hypotension)
• Tamsulosin, Alfuzosin
– Lower potential to cause hypotension, syncope
– Minor differences in the adverse events profiles, equal clinical
– Major Side Effects
• Ejaculatory Dysfunction (particularly Tamsulosin)
• Interaction with phosphodiesterase-5 inhibitors
– Potentiated effects of hypotension
– Separate doses by at least 4 hours
Pharmacological Treatment
• 5-alpha-reductase inhibitors
– Reduces the size of the prostate gland
– Prevents conversion testosteronedihydrotestosterone (DHT)
– ~ 6 to 12 months before prostate size is sufficiently reduced to
improve symptoms!!
– Indefinite treatment, as discontinuation may lead to symptom
– Examples
• Finasteride (initiated and maintained at 5 mg once daily)
• Dutasteride
– Side Effects
• Sexual dysfunction
• Decrease PSA
– Take into account during interpretation
Pharmacological Treatment
• Anticholinergics
– monotherapy for patients with predominately
irritated symptoms related to overactive bladder
– Frequency, urgency, incontinence
– Examples
• Oxybutynin, Tolterodine
– Side Effects
• Extensive!
• Dry mouth, blurred vision, tachycardia, constipation etc
Pharmacological Treatment
• Combination therapy
– Severe symptoms without maximal response to
maximal monotherapy
– Alpha 1 and anticholinergics
– Alpha 1 and reductase inhibitors
If still fails?
• If all else fails: Surgery or Minimally Invasive
Surgical Therapies
– Many surgical/interventional options
• Transurethral needle ablation (TUNA), transurethral
microwave therapy (TUMT), Transurethral
Electroevaporation of The Prostate TUVP
– Surgery
• Open Prostatectomy
– Endoscope
• Transurethral Incision of the Prostatce (TURP)
• When to get Urology involved?
– Bladder Obstruction syndrome
– Men <45 years old
– Presence of hematuria in the absence of infection
– Abnormality on prostate exam (nodule,
induration, or asymmetry)
– Men with incontinence
– Severe symptoms
• Roehrborn CG. Benign prostatic hyperplasia:
an overview. Rev Urol. 2005;7 Suppl 9:S3-S14.
• McVary KT, Roehrborn CG, Avins AL, et al.
Update on AUA guideline on the management
of benign prostatic hyperplasia. J Urol. 2011
May;185(5):1793-803. doi:
10.1016/j.juro.2011.01.074. Epub 2011 Mar