Benign prostatic hyperplasia (BPH) is a common nonmalignant prostate growth phenomenon in men, especially after 40, with histological occurrence increasing significantly with age. Symptoms include lower urinary tract issues such as hesitancy, urgency, and weak flow, although many men may remain asymptomatic. Management options range from lifestyle modifications and pharmacological treatments to surgical interventions, with careful evaluation necessary to determine the best approach.

1. Benign Prostate Hypertrophy
(BPH)

2. Introduction
• 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.

3. Introduction
• However, many men with histological BPH may
never develop symptoms, which is when
treatment is sought.
• Etiology
– poorly understood despite decades of intense
research
– hyperplasia thought to be stimulated by
dihydrotestosterone (DHT)
• Additional risk factors: positive family history

4. Symptoms
• 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 urination.
• 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

5. Diagnosis
• 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

6. Diagnosis
• 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 urgency.
• If score <8, mildly symptomatic and recommend yearly
reevaluation
• 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 obstruction
– Postvoid residual urine measurement with transabdominal
ultrasound or in-and-out catheterization.

8. Management
• If no obstruction and limited discomfort, do
not need to treat!!

9. 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 hours.
• § Double voiding: after urinating, wait and try to
urinate again.

10. 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 effectiveness
– Major Side Effects
• HYPOTENSION!
• Ejaculatory Dysfunction (particularly Tamsulosin)
• Interaction with phosphodiesterase-5 inhibitors
– Potentiated effects of hypotension
– Separate doses by at least 4 hours

11. Pharmacological Treatment
• 5-alpha-reductase inhibitors
– Reduces the size of the prostate gland
– Prevents conversion testosteroneàdihydrotestosterone (DHT)
– ~ 6 to 12 months before prostate size is sufficiently reduced to improve
symptoms!!
– Indefinite treatment, as discontinuation may lead to symptom relapse.
– Examples
• Finasteride (initiated and maintained at 5 mg once daily)
• Dutasteride
– Side Effects
• Sexual dysfunction
• Decrease PSA
– Take into account during interpretation

12. 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

13. Pharmacological Treatment
• Combination therapy
– Severe symptoms without maximal response to
maximal monotherapy
– Alpha 1 and anticholinergics
– Alpha 1 and reductase inhibitors

14. If still fails?
• If all else fails: Surgery or Minimally Invasive
Surgical Therapies
– Many surgical/interventional options
– MIST
• Transurethral needle ablation (TUNA), transurethral microwave
therapy (TUMT), Transurethral Electroevaporation of The
Prostate TUVP
– Surgery
• Open Prostatectomy
– Endoscope
• Transurethral Incision of the Prostatce (TURP)

15. Management
• 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

17. References
• 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
21.