Benign prostatic hyperplasia (BPH) is a common condition in aging men that results from hyperplasia of the prostate gland. Key points: - BPH results in lower urinary tract symptoms in about 10% of men affected by middle age due to prostate enlargement obstructing urine flow. - Evaluation involves medical history, physical exam including digital rectal exam, and urinalysis. Management focuses on lifestyle changes and medications like alpha-blockers and 5-alpha-reductase inhibitors. - Differential diagnoses include urinary tract infections and prostate cancer, which require further workup and monitoring. Most patients see improvement in symptoms with medical treatment but some may require referral for surgical management.

1. Benign Prostatic Hyperplasia
Bander Ali Alamry, BSc., MBBS, Family Medicine PGY-1
Supervised by;
Dr. Ahmad Alsabban, Consultant Family Medicine and Diabetes

2. Objectives
• Overview
• Relevant clinical anatomy of the prostate
• Natural history
• Pathogenesis and risk factors
• Presentation (Medical history review and physical examination)
• Investigative workups
• Important differential diagnoses
• Medical management and surgical indications
• Monitoring and prognosis

3. Overview
• Benign prostatic hyperplasia (BPH) is also known as Nodular
hyperplasia, glandular and stromal hyperplasia, and senile prostatic
enlargement (SPE), although the latter is used to describe this
nonmalignant growth seen in older males.
• The term “benign prostatic hypertrophy” is a misnomer, because all
hypertrophies are benign, and the pathological process is a hyperplasia
rather than a hypertrophy.

4. Overview
• BPH is a pathologic process that contributes to the development of
lower urinary tract symptoms (LUTS) in men.
• LUTS and other sequelae of BPH are not just due to a mass effect but
are also likely due to a combination of the prostatic enlargement and
age-related detrusor dysfunction.

5. Clinical Anatomy of the Prostate

6. Clinical Anatomy of the Prostate
• The normal adult prostate contains
several distinct regions
• The central zone (CZ),
• The peripheral zone (PZ),
• The transitional zone (TZ), or the
periurethral zone.

7. Clinical Anatomy of the Prostate
• BPH arises from more centrally
situated glands and is more likely to
produce urinary obstruction early in
its course than is carcinoma.
• Most carcinomas (70-80%) arise
from the peripheral glands of the
organ and are often palpable during
digital examination of the rectum.

8. Quiz
• Which of the following is accurate regarding BPH and prostate-related
issues?
a. All men with BPH demonstrate LUTS, and all men with LUTS have BPH.
b. The risk for acute urinary retention increases with age.
c. Prostate volume typically decreases over time in men with BPH.
d. Complications (eg, bladder stones or recurrent UTI) are frequent.

9. Natural History
• BPH is present in a significant number of men by the age of 40
• Its frequency rises progressively with age, reaching 90% by the eighth
decade.
• ≃ 40% (51-60 years of age), ≃ 80% (71-80 years of age)
• Clinical manifestations occur in only about 10% of men with the
disease.

10. Pathogenesis
• The etiology is unclear
• BPH is characterized by proliferation of both stromal and epithelial
elements, with resultant enlargement of the gland and, in some cases,
urinary obstruction.
• Hyperplasia of the epithelial and stromal compartments, particularly in
the transitional zone, may be attributed to various factors including
shifts in age-related hormonal changes creating androgen/estrogen
imbalances.

11. Pathogenesis
• Prostate growth and development are under the influence of
testosterone, and its more active metabolite dihydrotestosterone
(DHT).
• DHT is the major intracellular androgen and responsible for the
maintenance of BPH (hormonally-dependent growth).
• DHT results in increased production of epidermal growth factor
(EGF), which leads to hyperplasia.

12. Pathogenesis
• In aging, testosterone production is diminished, which suggests other
agents play an etiologic role.
• Reduction in apoptosis with relation to TGF-beta is characterized in
BPH pathogenesis.

13. Risk Factors
Modifiable
• Physical exercise
• Obesity
• Diabetes mellitus
• Sex steroid hormones
Nonmodifiable
• Age > 50 years (Strong RF)
• Family history
• Non-Asian ethnicity

14. LUTS - I
• Storage symptoms
Terminology Definition
 Frequency
 Urgency
 Nocturia
 Incontinence
The need to urinate frequently during the day or night
Sudden, urgent need to urinate if accident is to be avoided
Awakening at night to urinate
Involuntary loss of urine (End result and worst sign of storage symptoms)

15. LUTS - II
• Voiding symptoms:
Terminology Definition
 Urinary hesitancy
 Straining
 Weak stream
 Terminal dribbling
 Incomplete emptying
 Retention
Difficulty initiating the urinary stream
The need to strain or push to initiate and maintain urination
Subjective loss of force of the urinary stream over time
Poor urinary stream results in loss of small amount of urine
The feeling of persistent residual urine
End result and worst sign of voiding symptoms

16. Quiz
• Which of the following is accurate about the presentation of patients
with BPH?
a. The diagnosis of BPH can often be suggested based on history alone.
b. LUTS is not an independent risk factor for erectile dysfunction.
c. Urinary frequency typically involves voiding large amounts of urine with
each episode.
d. Urinary hesitancy suggests a disease process other than BPH.

17. Clinical Approach
• Medical history:
• Onset, duration, and severity of
LUTS
• History of fever, dysuria, gross
hematuria, pain suggestive of
stones, or previous urethral
instrumentation.
• Bladder irritants:
• Tobacco, alcohol, caffeine, highly
seasoned food
• Sexual dysfunction *
• Personal medical history:
• Diabetes mellitus, neurogenic bladder,
Parkinson’s disease ..
• Medications
• Antihistamines, decongestants,
diuretics, NSAIDS, opiates, and
tricyclic antidepressants ..
• Family history of prostate or bladder
cancer

18. Clinical Approach
• Physical examination:
• Abdominal examination
• Bladder distention
• Digital rectal examination
• Size, consistency, nodularity, and
symmetry
• Neurological examination
• Motor and sensory evaluation of the
lower limbs
• Decreased anal sphincter tone?

19. Clinical Approach
• Specific findings suggest specific differential diagnoses:
• BPH
• Firm, smooth, symmetrical enlargement with palpable median groove
• Prostate cancer
• Hard, asymmetrical, irregular gland with no palpable median groove
• Prostatitis
• Tenderness

20. Quiz
• Which of the following is accurate regarding the initial workup of
uncomplicated LUTS secondary to BPH?
a. Serum creatinine measurement
b. Urinalysis
c. Ultrasonography and intravenous urography
d. All patients with LUTS, even minor symptoms, should undergo basic
laboratory testing.

21. Quiz
• Which of the following is considered an optional test, and not an
explicitly recommended test, in patients with BPH?
a. Digital rectal examination
b. Neurologic examination
c. Prostate-specific antigen (PSA) testing in patients with a 10-year life
expectancy in whom the diagnosis of prostate cancer would change
management
d. Cytologic examination of the urine

22. Investigations
• Urinalysis
• May show BPH related UTI
• PSA level
• LUTS symptoms
• Life expectancy more than 10
years
• Individualized
• Urine cytology (optional)
• Noninvasive
• Viding symptoms
• Risk factors for bladder cancer
(smoking, personal or FHx of
bladder cancer)

23. Investigations
• Pressure flow studies, ultrasonography (US) of the prostate or upper urinary
tract, and endoscopy of the lower urinary tract are not recommended in the
routine evaluation of lower urinary tract symptoms.
• As per the American Urological Association, do not order creatinine or upper-tract
imaging for patients with benign prostatic hyperplasia.
• US is recommended in patients with history of:
• Urinary tract surgery, recurrent UTIs, hematuria, urolithiasis or renal insufficiency
• If US is done, prostate volume can be estimated by applying the following
equation:
• H × W × L × 0.52 = # cc

24. Differential Diagnoses
• UTI
• Signs and symptoms of inflammation
• Urinalysis reveals pyuria, positive nitrite and leukocyte esterase
• Prostate cancer
• Abnormal digital rectal examination with prostate nodules or asymmetry is
more consistent with prostate cancer.
• PSA levels
• Elevated total PSA for age
• Low free PSA
• Increased total PSA velocity greater than 0.75 ng/mL/year

25. Differential Diagnoses
• Prostate cancer
• PSA level in relation to age (years):
• <50 <2.5 ng/ml
• 50-60 <3.5 ng/ml
• 60-70 <4.5 ng/ml
• >70 <6.5 ng/ml

26. Differential Diagnoses
• Prostatitis
• Fever, suprapubic or low back pain
• Tender and enlarged prostate gland on rectal examination
• Blood count reveals leukocytosis
• Urethral stricture
• Voiding symptoms
• History of trauma or urological instrumentations or surgeries

27. Differential Diagnoses
• Bladder cancer
• Painless hematuria, suprapubic pain, voiding symptoms, heavy smoking
• Neurogenic bladder
• Storage symptoms
• Type 2 diabetes with neuropathy, neurological diseases, vascular disease

28. Management - Quiz
• Before medical treatment of BPH, which of the following should be
performed?
a. Symptom assessment with a validated screening tool
b. Transrectal ultrasound examination
c. CT scan of the pelvis
d. A and b

29. AUA-SI to Guide the Management

30. Management
AUA-SI score Suggested management plan
Mild symptoms (AUA-SI score of 0 to 7) No treatment is required
Non-bothersome moderate (8 to 19) to severe (20 to
35) symptoms
No treatment is required
Bothersome moderate to severe LUTS Lifestyle modifications, medications, and surgery

31. Management
• Watchful waiting
• Self-monitoring of symptom progression by the patient
• Periodic follow-up by the physician to re-assess the condition yearly

32. Management
• Lifestyle modifications
• Losing weight
• Decreasing evening fluid intake
• Avoiding excess alcohol, caffeine, or highly seasoned food
• Bladder training focused on timed and complete voiding
• Limiting medications known to cause LUTS

33. Management - Quiz
• BPH is a common condition in older men, and various medications
have been found to improve symptoms. Which one of the following
medications used in the treatment of BPH works by inhibiting the
transformation of testosterone to dihydrotestosterone?
a. Doxazosin
b. Finasteride
c. Prazosin
d. Tamsulosin

34. Management - Quiz
• One of your patients has tried and failed behavioral therapy for
incontinence. He describes a strong urge to urinate, followed by
involuntary loss of urine. Which of the following would be the best
medication for him to use?
a. Oxybutynin
b. Pseudoephedrine
c. Finasteride
d. Terazosin

35. Management
Medication Mechanism of action Adverse effects Comments
Selective α-1 blockers:
• Alfuzosin 10 mg
• Tamsulosin, 0.4 mg; titrate to maximum
of 0.8 mg daily
Smooth muscle relaxation; by
antagonizing α-1 receptors in the
prostatic urethra and bladder
neck
• Retrograde ejaculation
• Decreased ejaculation
• Highest risk of intraoperative
floppy iris syndrome
• Low risk of hypotension; no
blood pressure monitoring or dose
titration
Nonselective α-1 blockers
• Doxazosin 1 mg; titrate to maximum of 8
mg daily
• Terazosin 1 mg; titrate to maximum of 20
mg daily
Smooth muscle relaxation,
vasodilation by α-1 receptor
blockade
• Orthostatic hypotension • Requires blood pressure
monitoring and dose titration;
• Less expensive
5-α- reductase inhibitors:
• Dutasteride 0.5 mg
• Finasteride 5 mg
Gradual decrease in prostatic
volume; by blocking this
conversion; T  DHT
• Ejaculation disorder
• Decreased libido
• Erectile dysfunction
• No dose titration; three to six
months to take effect; decreases
PSA by 50%; DHT by 90-95%
• Combination therapy with an α-1
blocker is recommended in
patients with an enlarged prostate.
Anticholinergic agents
• Oxybutynin ER 10 mg
• Tolterodine ER 4 mg
• Solifenacin 5 mg
Competitive muscarinic receptor
antagonist; decreases bladder
contractions;
Tolterodine is more specific for
bladder than oxybutynin
• Dry mouth and eyes, blurred
vision, constipation, urinary
incontinence ..
• For patients with predominantly
storage symptoms (frequency and
urgency)
• Assess postvoid residual urine
before starting treatment (Normal
postvoid residual volume)

36. Management - Quiz
• At a routine health maintenance visit a 60-year-old male complains of
urinary frequency. A review of systems reveals nocturia but no
dysuria. He is otherwise healthy. He has smoked 1 pack of cigarettes
per day since age 18 and has a history of BPH. On examination his
prostate is smooth and enlarged without nodules. A dipstick urinalysis
shows 1+ blood but is otherwise negative. Urine microscopy reveals 7
RBCs/hpf and 2 WBCs/hpf. Which one of the following would be
most appropriate at this point?
a. Reassuring the patient that his BPH is causing microscopic hematuria
b. A repeat urinalysis with microscopy in 6 months
c. Urine cytology
d. BUN and creatinine levels, CT urography, and referral for cystoscopy

37. Management
• Indications for urological referral
• Medical therapy failure
• Complications:
• Recurrent UTI
• Bladder calculi
• Hematuria
• Renal insufficiency
• Urinary retention
• Suspicious DRE findings
• Abnormal PSA level findings
• Patient’s preference to undergo a surgery

38. Monitoring
• Watchful waiting
• Yearly with AUA-SI
• Progression is defined as increase in AUA-SI of 4 or more points.
• Patients treated with α-1blockade may be re-assessed within 1 or 2
weeks.
• Patients on 5-α-reductase inhibitors will begin to see improvement in 4
to 6 months.

39. Monitoring
• Prostate cancer screening
• Annually with DRE and PSA level in men 55 to 69 years of age and 10 years
life expectancy after shared decision making (USPSTF Grade C)
• The USPSTF recommends against routine screening for men age 70 and older

40. Bill Bryson. The Body: A Guide for Occupants, 2019

41. Prognosis
• Most patients with BPH can expect at least moderate improvement of
their symptoms with medical treatment.
• BPH related LUTS may affect sexual wellbeing including erectile
function. Medical therapy for BPH may also affect sexual function, so
this must be considered on an individual basis.
• Patients with a low risk for progression may be able to discontinue
first-line therapy with alpha-blockers after several months of therapy.
However, many patients will require ongoing therapy.

42. Recommendations for Practice by AAFP

43. Summary
• DHT is the major hormonal stimulus for proliferation.
• Most affected region is the inner periurethral zone of the prostate.
• Clinical symptoms are seen in 10% of affected patients.
• The mainstay of BPH treatment is 5-α reductase inhibitors.

44. References
Benign Prostatic Hyperplasia. In: BMJ Best Practice. London: BMJ
Publishing Group; 2019 [cited 2020, Jan 1st]. Available From:
Https://Bestpractice.Bmj.Com/Topics/En-gb/208
Kumar, P., And S. Robbin. "Textbook Of Basic Pathology." The Male Genital
System. 8th Ed. London: WB Saunders (2007).
Pearson R, Williams Pm. Common Questions About The Diagnosis And
Management Of Benign Prostatic Hyperplasia. American Family Physician.
2014 Dec; 90(11):769-74.