Benign prostatic hyperplasia (BPH) is nonmalignant adenomatous overgrowth of the periurethral prostate gland. Symptoms are those of bladder outlet obstruction—weak stream, hesitancy, urinary frequency, nocturia, incomplete emptying, terminal dribbling, overflow incontinence, and complete urinary retention. Sometimes, other symptoms such as urinary frequency or urge incontinence can develop due to long-standing bladder changes. Diagnosis is based primarily on symptoms; cystoscopy, transrectal ultrasound, or other imaging studies. Urodynamics testing can help characterize the degree of BPH and direct therapy. Treatment options include 5 alpha-reductase inhibitors, alpha-blockers, tadalafil, minimally invasive procedures, and surgery.
Symptoms are determined using the International Prostate Symptom Score (also referred to as the American Urological Association Symptom Score; see table American Urological Association Symptom Score for Benign Prostatic Hyperplasia). Using the criteria of a prostate volume > 35 mL and a moderate or high IPSS/AUASS, the prevalence of BPH in men aged 55 to 74 years without prostate cancer is 19%. But if voiding criteria of a maximal urinary flow rate < 10 mL/second and a postvoid residual urine volume > 50 mL are included, the prevalence is only 4%. Based on autopsy studies, the prevalence of BPH increases from 8% in men aged 31 to 40 years to 40 to 50% in men aged 51 to 60 years and to > 80% in men > 80 years (1).
American Urological Association Symptom Score for Benign Prostatic Hyperplasia
Score | ||||||
|---|---|---|---|---|---|---|
Over About the Past Month | Never | < 20% of the Time | < 50% of the Time | About 50% of the Time | > 50% of the Time | Almost Always |
How often have you had a sensation of not emptying your bladder completely after you finish urinating? | 0 | 1 | 2 | 3 | 4 | 5 |
How often have you had to urinate again < 2 hours after you finished urinating? | 0 | 1 | 2 | 3 | 4 | 5 |
How often have you stopped and started again several times when urinating? | 0 | 1 | 2 | 3 | 4 | 5 |
How often have you found it difficult to postpone urination? | 0 | 1 | 2 | 3 | 4 | 5 |
How often has your urinary stream been weak? | 0 | 1 | 2 | 3 | 4 | 5 |
How often have you had to push or strain to begin urination? | 0 | 1 | 2 | 3 | 4 | 5 |
How many times did you most typically get up to urinate between going to bed at night and waking in the morning? | none = 0 | once = 1 | twice = 2 | 3 times = 3 | 4 times = 4 | ≥ 5 times = 5 |
American Urological Association symptom score = total ______. | ||||||
Symptom scores:
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Adapted from Barry MJ, Fowler FJ, O’Leary MP, et al: The American Urological Association symptom index for benign prostatic hyperplasia. J Urol 197(2S):S189-S197, 2017. doi: 10.1016/j.juro.2016.10.071 | ||||||
The etiology is unknown but probably involves hormonal changes associated with aging.
General reference
1. Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol 1984;132(3):474-479. doi:10.1016/s0022-5347(17)49698-4
Pathophysiology of BPH
Multiple fibroadenomatous nodules develop in the periurethral region of the prostate, probably originating within the periurethral glands rather than in the true fibromuscular prostate (surgical capsule), which is displaced peripherally by progressive growth of the nodules.
As the lumen of the prostatic urethra narrows and lengthens, urine outflow is progressively obstructed. Increased pressure associated with micturition and bladder distention can progress to hypertrophy of the bladder detrusor, trabeculation, cellule formation, and diverticula. Incomplete bladder emptying causes stasis and predisposes to calculus formation and infection. Prolonged urinary tract obstruction, even if incomplete, can cause hydronephrosis and compromise renal function.
Symptoms and Signs of BPH
Lower urinary tract symptoms
Symptoms of benign prostatic hyperplasia (BPH) include a constellation of symptoms that are often progressive, known collectively as lower urinary tract symptoms (LUTS):
Urinary frequency
Urgency
Nocturia
Hesitancy
Intermittency
Symptoms are divided into those related to storage and those affecting voiding.
Storage symptoms include nocturia, urgency, urinary frequency, and urinary incontinence. Storage symptoms arise from incomplete emptying and rapid refilling of the bladder and changes of the bladder wall that stimulate the bladder to want to empty.
Voiding symptoms include weak or intermittent stream, straining, hesitancy, terminal or post-void dribbling, incomplete emptying, and spraying/split stream. Voiding symptoms are due to blockage of the bladder causing a decreased size and force of the urinary stream.
Pain and dysuria are usually not present, but bladder overactivity can lead to discomfort with voiding, often felt at the tip of the penis. Straining to void can cause congestion of superficial veins of the prostatic urethra and trigone, which may rupture and cause hematuria. Straining also may acutely cause vasovagal syncope and, over the long term, may cause dilation of hemorrhoidal veins or inguinal hernias.
Urinary retention
Some patients present with sudden, complete urinary retention, with marked abdominal discomfort and bladder distention. Retention may be precipitated by any of the following:
Prolonged attempts to postpone voiding
Immobilization
Exposure to cold
Use of anesthetics, anticholinergics, sympathomimetics, opioids, or alcohol
Urinary tract infection causing swelling of the prostate
If distended, the urinary bladder can be palpated or percussed during abdominal examination.
Symptom scores
Symptoms can be quantitated by scores, such as the 7-question American Urological Association Symptom Score (see table American Urological Association Symptom Score for Benign Prostatic Hyperplasia). This score also allows clinicians to monitor symptom progression:
Mild symptoms: Scores 1 to 7
Moderate symptoms: Scores 8 to 19
Severe symptoms: Scores 20 to 35
Quality of Life scores (QOL) can be helpful in putting the symptoms into context with a patient's bother. The International Prostate Symptom Score (IPSS) QOL can drive decisions to pursue treatment (1).
A single "bother question" from the IPSS has been found to be a particularly useful predictor of QOL in patients with lower urinary tract symptoms like those in patients with PBH (2):
If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?
0 = Delighted
1 = Pleased
2 = Mostly satisfied
3 = Mixed about equally satisfied and dissatisfied
4 = Mostly dissatisfied
5 = Unhappy
6 = Terrible
Digital rectal examination
On digital rectal examination (DRE), the prostate usually is enlarged and nontender, has a rubbery consistency, and in many cases has lost the median furrow. However, prostate size as detected with DRE may be misleading; an apparently small prostate may cause obstruction, and a large one may cause no symptoms at all. Internal components of the prostate, such intravesical prostatic protrusion, cannot be detected with DRE. However, the DRE may provide some indication of prostate size and drive decisions regarding next steps in the evaluation. Firm or hard areas in the prostate may indicate prostate cancer.
Symptom references
1. Pinto JD, He HG, Chan SW, Wang W. Health-related quality of life and psychological well-being in men with benign prostatic hyperplasia: An integrative review. Jpn J Nurs Sci 2016;13(3):309-323. doi:10.1111/jjns.12115
2. Hopland-Nechita FV, Andersen JR, Beisland C. IPSS "bother question" score predicts health-related quality of life better than total IPSS score. World J Urol 2022;40(3):765-772. doi:10.1007/s00345-021-03911-2
Diagnosis of BPH
Lower urinary tract symptoms of BPH
Digital rectal examination (DRE)
Urinalysis and urine culture
Prostate-specific antigen level
Sometimes uroflowmetry and bladder ultrasound
Diagnosis of BPH, by definition, is based on histological evidence. However, conventionally, clinicians diagnose patients with "BPH" if they have lower urinary tract symptoms consistent with BPH. The lower urinary tract symptoms of benign prostatic hyperplasia (BPH) can also be caused by other disorders, including infection, prostate cancer, and overactive bladder. Furthermore, BPH and prostate cancer may coexist.
As many therapies are dependent upon prostate size, a DRE can be helpful in confirming prostatic enlargement and identifying other abnormalities. Although palpable prostate tenderness suggests infection, DRE findings in BPH and cancer often overlap. Although cancer may cause a stony, hard, nodular, irregularly enlarged prostate, most patients with cancer, BPH, or both have a benign-feeling, enlarged prostate. Thus, further testing should be considered for patients with symptoms or palpable prostatic abnormalities.
Typically, urinalysis and urine culture are done to exclude hematuria and infection, and serum prostate-specific antigen (PSA) levels are measured. PSA levels can be elevated in BPH but should prompt evaluation for prostate cancer.
Men with moderate or severe symptoms of obstruction may also have uroflowmetry (an objective test of urine volume and flow rate) with measurement of postvoid residual volume by bladder ultrasound. Flow rate < 15 mL/second suggests obstruction, and postvoid residual volume > 100 mL suggests retention.
Prostate-specific antigen (PSA) levels
Interpreting prostate-specific antigen (PSA) levels can be complex. PSA levels vary based on many factors which include age, prostate size, inflammation, infection, urinary retention, recent instrumentation, prostate infarction, and cancer. Therefore, in men with lower urinary tract symptoms due to BPH, it is not unusual to find an elevated PSA and this value should be taken in context of the entire clinical picture (1). In general, if the PSA level is > 4 ng/mL (4 mcg/L), further discussion/shared decision-making regarding other tests or biopsy is recommended.
For men < 50 years or those at high risk of prostate cancer, a lower cutoff (PSA > 2.5 ng/mL [2.5 mcg/L]) may be used. Other measures, including rate of PSA increase, free-to-bound PSA ratio, and other markers, may be useful (see also Prostate Cancer Screening and Diagnosis).
Other testing
Clinical judgment must be used to evaluate the need for further testing. The most recent AUA Guidelines (2) recommend assessing prostate size and morphology prior to procedural intervention. Many different options exist for evaluating prostate anatomy. These can include
CT, ultrasound, or MRI imaging that includes the prostate (ie, pelvic views)
Testing done for other reasons that includes the prostate, such as transrectal ultrasound done at the time of prostate biopsies in the evaluation of prostate cancer
Cystoscopy
When available, CT and MRI may give information about the prostate size and shape and also about any changes to the bladder compatible with outlet obstruction, such as a thickened bladder wall and/or presence of bladder stones or diverticula. Upper urinary tract abnormalities that can result from bladder outlet obstruction include upward displacement of the terminal portions of the ureters (fish hooking), ureteral dilation, and hydronephrosis. In patients with known contrast allergy or elevated serum creatinine level , ultrasound may be preferred because it avoids radiation and IV contrast exposure.
Cystoscopy with or without urodynamics can be useful in looking for other causes of obstruction such as urethral strictures and in determining the optimal surgical approach if a procedure is required. Invasive or noninvasive urodynamics testing can be performed either with or without fluoroscopic guidance. These tests measure the bladder pressure during filling and voiding and can indicate how much pressure is required to empty. They also can differentiate storage symptoms due to obstruction from those due to primary bladder overactivity, such as occurs with neurologic diseases.
Diagnosis references
1. Oesterling JE, Jacobsen SJ, Chute CG, et al. Serum prostate-specific antigen in a community-based population of healthy men. Establishment of age-specific reference ranges. JAMA 1993;270(7):860-864.
2. Sandhu JS, Bixler BR, Dahm P, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023. J Urol 2024;211(1):11-19. doi:10.1097/JU.0000000000003698
Treatment of BPH
Identification and elimination of contributory medications (eg, anticholinergics, sympathomimetics, opioids)
Trial of medications, including alpha-adrenergic blockers (eg, terazosin, doxazosin, tamsulosin, alfuzosin, silodosin), 5 alpha-reductase inhibitors (finasteride, dutasteride), or the phosphodiesterase type 5 inhibitor tadalafil, especially if there is concomitanterectile dysfunction; combination therapy with medications such as 5 alpha-reductase inhibitors and alpha blockers, can also be used
Procedural intervention, ranging from minimally invasive office-based procedures to surgical therapies
Sometimes vibegron, a beta-3 agonist, for overactive bladder symptoms in patients receiving pharmacological therapy for BPH
Urinary retention
Significant urinary retention requires immediate decompression. Passage of a standard urinary catheter is first attempted; if a standard catheter cannot be passed, a catheter with a coudé tip may be effective. If this catheter cannot be passed, flexible cystoscopy is necessary. Insertion of filiforms and followers (guides and dilators that progressively open the urinary passage) is not commonly done but, if needed, should only be performed by a urologist or someone trained in their use. Suprapubic percutaneous decompression of the bladder may be used if transurethral approaches are unsuccessful.
Pharmacotherapy
For partial obstruction with troublesome symptoms, all anticholinergics and sympathomimetics (many available in over-the-counter [OTC] preparations), and opioids should be stopped, and any infection should be treated with antibiotics. Occasionally, some anticholinergic medications may be given under the guidance of a urologist.
For patients with mild to moderate obstructive symptoms, alpha-adrenergic blockers (eg, terazosin, doxazosin, tamsulosin, alfuzosin) may decrease voiding problems. The 5 alpha-reductase inhibitors (finasteride, dutasteride) may reduce prostate size, decreasing voiding problems over months, especially in patients with larger (> 30 mL) glands. A combination of both classes of medications is superior to monotherapy (1). For men with concomitant erectile dysfunction, daily tadalafil may help relieve both conditions. Many OTC complementary and alternative agents are promoted for treatment of BPH, but none, including the thoroughly studiedsaw palmetto, has been shown to be more efficacious than placebo.
For men with symptoms of overactive bladder (OAB) who are receiving pharmacological therapy for BPH, vibegron, a beta-3 agonist, may be helpful.
Surgery
Surgery is done when patients do not respond to pharmacotherapy or develop complications such as recurrent urinary tract infection, urinary calculi, severe bladder dysfunction, or upper tract dilation (1). Transurethral resection of the prostate (TURP) is the historical standard (2, 3). Erectile function and continence are usually retained, although about 5 to 10% of patients experience some acute postsurgical problems, most commonly retrograde ejaculation. The incidence of erectile dysfunction after TURP is between 1 and 35%, and the incidence of incontinence is about 1 to 3%. However, technical advances such as the use of a bipolar resectoscope, which allows use of saline irrigation, have greatly improved the safety of TURP by averting hemolysis and hyponatremia. About 10% of men undergoing TURP need the procedure repeated within 10 years because the prostate continues to grow (1).
Surgical alternatives to TURP include various laser ablation techniques and robotic approaches, including simple prostatectomy and water jet therapy. Larger prostates (usually > 75 grams) are typically managed with simple open or robotic-assisted prostatectomy, endoscopic enucleation (holmium laser enucleation of the prostate [HoLEP] or diode laser endoscopic enucleation of the prostate [DiLEP])., other laser ablation therapies, high-pressure water jet, or other alternative procedures. All surgical methods typically require postoperative catheter drainage for 1 to 7 days.
Other procedures
Alternatives to surgical approaches involving prostatectomy, often referred to as MIST (minimally invasive surgical technologies), include laser ablation therapies, microwave thermotherapy, high-intensity focused ultrasound, transurethral needle ablation, radiofrequency vaporization, pressurized water jet therapy, , heated steam injection therapy, urethral life, temporary implanted devices, intraurethral stents, and prostatic artery embolization (PAE).
All of these therapies disrupt tissue or blood supply, and improvement is typically realized 30 or more days after the procedure as tissue is reabsorbed, creating a more open channel. These procedures generally yield more modest results than surgery that removes tissue. However, while they often lead to less robust improvements in flow rates and reduction in prostate size, they have fewer negative outcomes such as incontinence and retrograde ejaculation. For some men, one of these therapies may be preferred over medication. In patients with refractory hematuria, PAE may be the ideal first approach (4).
The option to perform many of these procedures in a physician's office or ambulatory surgery center with local anesthesia or sedation makes them attractive options, particularly for patients who are poor candidates for anesthesia and/or surgery. Undergoing one of these procedures does not obviate ta more invasive procedure in the future should symptoms persist.
Treatment references
1. Sandhu JS, Bixler BR, Dahm P, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023. J Urol 211(1):11-19, 2024. doi:10.1097/JU.0000000000003698
2. Lerner LB, McVary KT, Barry MJ, et al: Management of benign prostatic hyperplasia/lower urinary tract symptoms: AUA Guideline part I, initial work-up and medical management. J Urol 206:806, 2021.
3. Lerner LB, McVary KT, Barry MJ, et al: Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA Guideline part II — Surgical evaluation and treatment. J Urol 206(4):818-826, 2021. doi: 10.1097/JU.0000000000002184
4. Dias US, Liberato de Moura MR, Viana PCC, et al: Prostatic artery embolization: Indications, preparation, techniques, imaging evaluation, reporting, and complications. RadioGraphics Published online: August 20, 2021. https://doi.org/10.1148/rg.2021200144
Key Points
Benign prostatic hyperplasia (BPH) is extremely common with aging but only sometimes causes symptoms.
Acute urinary retention can develop with prolonged attempts to postpone voiding, immobilization, urinary tract infections, or use of anesthetics, anticholinergics, sympathomimetics, opioids, or alcohol.
Symptomatic patients should have a urinalysis to determine the need for treatment of infection or evaluation of hematuria.
A digital rectal examination and prostate specific antigen measurement provide information about prostate size and anatomic abnormalities and help determine the need for imaging studies.
Consider relieving troublesome obstructive symptoms with alpha-adrenergic blockers (eg, terazosin, doxazosin, tamsulosin, alfuzosin), 5 alpha-reductase inhibitors (finasteride, dutasteride), or tadalafil, especially if there is concomitant erectile dysfunction.
Consider referral to a urologist for procedural intervention if symptoms persist despite medical therapy, the patient does not desire medication, or the BPH causes complications (eg, recurrent calculi or infection, bladder dysfunction, upper tract dilation).
In men with BPH, use anticholinergics, sympathomimetics, and opioids with caution.
