Prostatic Hyperplasia, Benign (BPH)

BASICS

Definition: Proliferation of smooth muscle and epithelial cells in periurethral prostate, increasing prostate volume, may compress urethra and cause LUTS (lower urinary tract symptoms).
Symptoms: Storage (frequency, urgency, nocturia, dysuria) and/or voiding (difficulty initiating stream, weak stream, incomplete voiding) LUTS.
Progression: May cause upper/lower UTIs, bladder outlet obstruction, acute renal failure.

Age-related: Prevalence 70–90% by age 80; 8–20% by age 40.
Not all with BPH develop significant symptoms (about half have moderate/severe LUTS).

Unknown etiology.
Hyperplasia develops in periurethral/transition zone, increasing glandular (stromal + epithelial) components.

DRE: Symmetrical prostate enlargement (size does not correlate with symptom severity).
Look for signs of obstructive uropathy/renal failure.

Obstructive: Prostate cancer, urethral stricture/valves, bladder neck contracture, sphincter dysfunction
Neurogenic: SCI, stroke, Parkinson, MS
Medical: Diabetes, CHF
Meds: Diuretics, decongestants, opioids, TCAs
Other: Bladder cancer, OAB, nocturnal polyuria, stones, UTI/prostatitis/urethritis, OSA, caffeine

Urinalysis: Rule out infection, stones, cancer, stricture
PSA: For men with life expectancy ≥10 years (and surgical candidates)
PSA correlates with volume
Urine cytology, CT urogram, cystoscopy for hematuria or risk factors
Uroflowmetry: Peak flow <10 mL/sec = abnormal
PVR: >100 mL = incomplete emptying
Sleep study: If OSA suspected
No further testing for uncomplicated LUTS; consider further workup if refractory

Mild symptoms: (IPSS <7 or non-bothersome 8–15): Watchful waiting, lifestyle modification
Moderate/severe: Lifestyle + medication

α-Blockers: Tamsulosin, alfuzosin, doxazosin, terazosin
Relax prostatic/bladder neck smooth muscle
Rapid improvement (2–4 weeks)
Caution: Orthostatic hypotension, avoid perioperative use in cataract surgery, avoid PDE5i combos
5-α-Reductase inhibitors: Finasteride, dutasteride
Reduce DHT, shrink prostate (esp. >30 mL)
Clinical effect in 6+ months
Reduces retention and need for surgery
SE: ↓libido, ED, depressive symptoms
PSA is artificially reduced by ~50%—test before/after initiation
Best in combination for large prostates
Anticholinergics: Solifenacin, tolterodine, oxybutynin (for storage LUTS, avoid if PVR >250 mL)
β3 Agonists: Combine with α-blocker for storage LUTS
PDE5 Inhibitors: Tadalafil 5 mg/day (avoid in CrCl <30 or with α-blockers)

Refractory retention, severe symptoms, renal insufficiency, stones, hematuria, persistent infection
Options:
TURP (gold standard)—complications: bleeding, retrograde ejaculation, incontinence, TURP syndrome (hyponatremia)
TUVP, TUMT, TUIP, PVP, PUL, WVTT, HoLEP, ThuLEP, RWT
HoLEP/ThuLEP/PVP safe for patients on anticoagulants
PUL/WVTT preserve sexual function
Prostate artery embolization and transurethral needle ablation not recommended

Medical therapy delays but does not eliminate need for TURP.
Surgical indications: Retention, infection, stone, hematuria, renal insufficiency, failure of medical management.
Always consider prostate cancer in evaluation of LUTS.