What is benign prostatic hyperplasia?

Benign prostatic hyperplasia (also called BPH) is a condition that affects the prostate gland in men.
The prostate is a gland found between the bladder (where urine is stored) and the urethra (the tube
urine passes through). As men age, the prostate gland slowly grows bigger (or enlarges). As the
prostate gets bigger, it may press on the urethra and cause the flow of urine to be slower and less
forceful. "Benign" means the enlargement isn't caused by cancer or infection. "Hyperplasia" means
enlargement.

What are the symptoms of BPH?

Most symptoms of BPH start gradually. One symptom is the need to get up more often at night to
urinate. Another symptom is the need to empty the bladder often during the day. Other symptoms
include difficulty in starting the urine flow and dribbling after urination ends. The size and strength
of the urine stream may decrease.

These symptoms can be caused by other things besides BPH. They may be signs of more serious
diseases, such as a bladder infection or bladder cancer. Tell your doctor if you have any of these
symptoms, so he or she can decide which tests to use to find the possible cause.

How will my doctor know if I have BPH?

After your doctor takes a complete history of your symptoms, a rectal exam is the next step. In a
rectal exam, your doctor checks your prostate by putting a gloved, lubricated finger into your
rectum to feel the back of your prostate gland. This exam allows your doctor to feel the size of the
prostate gland.

To make sure that your prostate problem is benign, your doctor may need to look at a sample of
your urine for signs of infection. Your doctor may also do a blood test. An ultrasound exam or a
biopsy of the prostate may help your doctor make the diagnosis.

How will my doctor treat my BPH?

Once your doctor is sure that your symptoms are caused by benign growth of the prostate gland,
treatment can be recommended. However, your doctor may suggest that you wait to see if your
symptoms get better. Sometimes mild symptoms get better on their own. If your symptoms get
worse, your doctor may suggest another treatment option.

Surgery is considered the most effective treatment and is used in men with strong symptoms that
persist after other treatments are tried. This is also the best way to diagnose and cure early cancer of
the prostate. Surgery is usually done through the urethra, leaving no scars. Surgery does have risks,
such as bleeding, infection or impotence. These risks are generally small.

Are there any drugs I can take?

Drug treatments are available. Finasteride (brand name: Proscar) and dutasteride (brand name:
Avodart) blocks a natural hormone that makes the prostate enlarge, but it does not help all patients.
The side effects of finasteride are rare and mild, but they usually have to do with sexual function.
They go away when the medicine is stopped. The prostate may enlarge again when the medicine is
stopped, so your doctor may suggest another treatment.

Another kind of medicine, called alpha-blockers, also can help the symptoms of BPH. Alpha-
blockers have been used for a long time to treat high blood pressure, but they can also help the
symptoms of BPH, even in men with normal blood pressure. Some of these drugs are terazosin
(brand name: Hytrin), doxazosin (brand name: Cardura), tamsulosin (brand name: Flomax) and
alfuzosin (brand name: Uroxatral). These medicines may not work in all men. The side effects of
alpha-blockers include dizziness, fatigue and lightheadedness. The side effects go away if you stop
taking the medicine.

Benign prostatic hyperplasia (BPH) also known as nodular hyperplasia, benign prostatic
hypertrophy (technically a misnomer) or benign enlargement of the prostate (BEP) refers to the
increase in size of the prostate in middle-aged and elderly men. To be accurate, the process is one of
hyperplasia rather than hypertrophy, but the nomenclature is often interchangeable, even amongst
urologists. It is characterized by hyperplasia of prostatic stromal and epithelial cells, resulting in the
formation of large, fairly discrete nodules in the periurethral region of the prostate. When
sufficiently large, the nodules compress the urethral canal to cause partial, or sometimes virtually
complete, obstruction of the urethra, which interferes the normal flow of urine. It leads to symptoms
of urinary hesitancy, frequent urination, dysuria (painful urination), increased risk of urinary tract
infections and urinary retention. Although prostate specific antigen levels may be elevated in these
patients because of increased organ volume and inflammation due to urinary tract infections, BPH
is not considered to be a premalignant lesion.
Adenomatous prostatic growth is believed to begin at approximately age 30 years. An estimated
50% of men have histologic evidence of BPH by age 50 years and 75% by age 80 years. In 40-50%
of these patients, BPH becomes clinically significant.[1]

Symptoms
Benign prostatic hyperplasia symptoms are classified as storage or voiding. Storage symptoms
include urinary frequency, urgency (compelling need to void that cannot be deferred), urgency
incontinence, and voiding at night (nocturia).
Voiding symptoms include weak urinary stream, hesitancy (needing to wait for the stream to begin),
intermittency (when the stream starts and stops intermittently), straining to void, dysuria (burning
sensation in the urethra), and dribbling. These storage and voiding symptoms are evaluated using
the International Prostate Symptom Score (IPSS) questionnaire, designed to assess the severity of
BPH.[2]
BPH can be a progressive disease, especially if left untreated. Incomplete voiding results in stasis of
bacteria in the bladder residue and an increased risk of urinary tract infections. Urinary bladder
stones are formed from the crystallisation of salts in the residual urine. Urinary retention, termed
acute or chronic, is another form of progression. Acute urinary retention is the inability to void,
while in chronic urinary retention the residual urinary volume gradually increases, and the bladder
distends. Some patients who suffer from chronic urinary retention may eventually progress to renal
failure, a condition termed obstructive uropathy.

[edit] Etiology
Androgens (testosterone and related hormones) are considered to play a permissive role in BPH by
most experts. This means that androgens have to be present for BPH to occur, but do not necessarily
directly cause the condition. This is supported by the fact that castrated boys do not develop BPH
when they age, unlike intact men. Additionally, administering exogenous testosterone is not
associated with a significant increase in the risk of BPH symptoms. Dihydrotestosterone (DHT), a
metabolite of testosterone is a critical mediator of prostatic growth. DHT is synthesized in the
prostate from circulating testosterone by the action of the enzyme 5α-reductase, type 2. This
enzyme is localized principally in the stromal cells; hence, these cells are the main site for the
synthesis of DHT.
DHT can act in an autocrine fashion on the stromalie cells or in paracrine fashion by diffusing into
nearby epithelial cells. In both of these cell types, DHT binds to nuclear androgen receptors and
signals the transcription of growth factors that are mitogenic to the epithelial and stromal cells.
DHT is 10 times more potent than testosterone because it dissociates from the androgen receptor
more slowly. The importance of DHT in causing nodular hyperplasia is supported by clinical
observations in which an inhibitor of 5α-reductase is given to men with this condition. Therapy with
5α-reductase inhibitor markedly reduces the DHT content of the prostate and in turn reduces
prostate volume and, in many cases, BPH symptoms.
There is growing evidence that estrogens play a role in the etiology of BPH. This is based on the
fact that BPH occurs when men generally have elevated estrogen levels and relatively reduced free
testosterone levels, and when prostate tissue becomes more sensitive to estrogens and less
responsive to DHT. Cells taken from the prostates of men who have BPH have been shown to grow
in response to high estradiol levels with low androgens present. Estrogens may render cells more
susceptible to the action of DHT.
On a microscopic level, BPH can be seen in the vast majority of men as they age, particularly over
the age of 70 years, around the world. However, rates of clinically significant, symptomatic BPH
vary dramatically depending on lifestyle. Men who lead a western lifestyle have a much higher
incidence of symptomatic BPH than men who lead a traditional or rural lifestyle. This is confirmed
by research in China showing that men in rural areas have very low rates of clinical BPH, while
men living in cities adopting a western lifestyle have a skyrocketing incidence of this condition,
though it is still below rates seen in the West.
Much work remains to be done to completely clarify the causes of BPH.

[edit] Diagnosis
Microscopic examination of different types of prostate tissues (stained with immunohistochemical
techniques): A. Normal (non-neoplastic) prostatic tissue (NNT). B. Benign prostatic hyperplasia.
C. High-grade prostatic intraepithelial neoplasia (PIN). D. Prostatic adenocarcinoma (PCA).
Prostate with a large median lobe bulging upwards. A metal instrument is placed in the urethra
(which passes through the prostate). This specimen was almost 7 centimeters long with a volume of
about 60 cubic centimetres on transrectal ultrasound and was removed during a Hryntschak
procedure or transvesical prostatectomy (removal of the prostate through the bladder) for benign
prostatic hyperplasia.
Rectal examination (palpation of the prostate through the rectum) may reveal a markedly enlarged
prostate, usually affecting the middle lobe.
Often, blood tests are performed to rule out prostatic malignancy: elevated prostate specific antigen
(PSA) levels needs further investigations such as reinterpretation of PSA results, in terms of PSA
density and PSA free percentage, rectal examination and transrectal ultrasonography. These
combined measures can provide early cancer detection.
Ultrasound examination of the testicles, prostate and kidneys is often performed, again to rule out
malignancy and hydronephrosis.
Screening and diagnostic procedures for BPH are similar to those used for prostate cancer. Some
signs to look for include[3]:
• Weak urinary stream
• Prolonged emptying of the bladder
• Abdominal straining
 • Hesitancy
• Irregular need to urinate
• Incomplete bladder emptying
• Post-urination dribble
• Irritation during urination
• Frequent urination
• Nocturia (need to urinate during the night)
• Urgency
• Incontinence (involuntary leakage of urine)
• Bladder pain
• Dysuria (painful urination)

[edit] Epidemiology
The prostate gets larger in most men as they get older, and overall, 45% of men over the age of 46
can expect to suffer from the symptoms of BPH if they survive 30 years. Incidence rates increase
from 3 cases per 1000 man-years at age 45-49 years, to 38 cases per 1000 man-years by the age of
75-79 years. Whereas the prevalence rate is 2.7% for men aged 45-49, it increases to 24% by the
age of 80 years.[4]
For some men, the symptoms may be severe enough to require treatment.

[edit] Treatment
[edit] Lifestyle
Patients should decrease fluid intake before bedtime, moderate the consumption of alcohol and
caffeine-containing products, and follow timed voiding schedules.

[edit] Medications
Alpha blockers (α1-adrenergic receptor antagonists) provide symptomatic relief of BPH symptoms.
Available drugs include doxazosin, terazosin, alfuzosin and tamsulosin. Older drugs,
phenoxybenzamine and prazosin are not recommended for treatment of BPH.[5] Alpha-blockers
relax smooth muscle in the prostate and the bladder neck, and decrease the degree of blockage of
urine flow. Alpha-blockers may cause ejaculation back into the bladder (retrograde ejaculation).
The 5α-reductase inhibitors (finasteride dutasteride) are another treatment option. This medication
inhibits 5a-reductase, which in turn inhibits production of DHT, a hormone responsible for
enlarging the prostate. When used together with alpha blockers a reduction of BPH progression to
acute urinary retention and surgery has been noted in patients with larger prostates.[6]
An extract from the fruit of the saw palmetto has been studied as a possible treatment for BPH.
Though it showed promise in early studies, later trials of higher methodological quality indicated no
difference from placebo.[7][8][9]
Other herbal medicines that have research support in systematic reviews include beta-sitosterol
from Hypoxis rooperi (African star grass) and pygeum (extracted from the bark of Prunus
africana), while there is less substantial support for the efficacy of Cucurbita pepo (pumpkin) seed
and Urtica dioica (stinging nettle) root.[10] At least one double-blind trial has also supported the
efficacy of rye flower pollen.[11]
Sildenafil shows some symptomatic relief, suggesting a possible common etiology with erectile
dysfunction.[12]
[edit] Minimally Invasive Therapies
While medication is often prescribed as the first treatment option, there are many patients who do
not achieve success with this line of treatment. For many patients medication is a good option;
however, patients may not respond to medical management, they may not achieve sustained
improvement in symptoms or they may stop taking the medication because of side effects.[13]
There are options for treatment in an urologist's office before proceeding to surgery. The two most
common types of office-based therapies are Transurethral microwave thermotherapy (TUMT) and
TransUrethral Needle Ablation (TUNA). Both of these procedures rely on delivering enough energy
to create sufficient heat to cause cell death (necrosis) in the prostate. The goal of the therapies is to
cause enough necrosis so that when the dead tissue is reabsorbed by the body the prostate shrinks,
relieving the obstruction of the urethra. These procedures are typically performed with local
anesthesia, and the patient returns home the same day. Some urologists have studied and published
long-term data on the outcomes of these procedures, with data out to five years. The most recent
American Urological Association (AUA) Guidelines for the Treatment of BPH in 2003 lists
minimally invasive therapies including TUMT and TUNA as acceptable alternatives for certain
patients with BPH.[14]
Transuretheral microwave therapy (TUMT) was originally approved by the FDA in 1996 with the
first generation system by EDAP Technomed. Since 1996 other companies have received FDA
approval for TUMT devices, including Urologix, Dornier, Thermatrix, Celsion and Prostalund.
Multiple clinical studies have been published on TUMT. The general principle underlying all the
devices is that a microwave antenna that resides in a urethral catheter is placed in the intraprostatic
area of the urethra. The catheter is connected to a control box outside of the patient's body and is
energized to emit microwave radiation into the prostate to heat the tissue and cause necrosis. It is a
one-time treatment that takes approximately 30 minutes to 1 hour, depending on the system used. It
takes approximately 4 to 6 weeks for the damaged tissue to reabsorb into the patient's body. Some
of the devices incorporate circulating coolant through the treatment area with the intent of
preserving the urethra while the microwave energy heats the prostatic tissue surrounding the
urethra.
Transuretheral needle ablation (TUNA) operates with a different type of energy, radio frequency
(RF) energy, but is designed along the same premise as TUMT devices, that the heat the device
generates will cause necrosis of the prostatic tissue and shrink the prostate. The TUNA device is
inserted into the urethra using a rigid scope much like a cystoscope. The energy is delivered into the
prostate using two needles that emerge from the sides of the device, through the urethral wall and
into the prostate. The needle-based ablation devices are very effective at heating a localized area to
a high enough temperature to cause necrosis. The treatment is typically performed in one session,
but may require multiple sticks of the needles depending on the size of the prostate.

[edit] Surgery
If medical treatment fails, and the patient elects not to try office based therapies or the physician
determines the patient is a better candidate for surgery transurethral resection of prostate (TURP)
surgery may need to be performed. TURP is still generally considered the Gold Standard of prostate
interventions for patients who require a procedure. This involves removing (part of) the prostate
through the urethra. There are also a number of new methods for reducing the size of an enlarged
prostate, some of which have not been around long enough to fully establish their safety or side
effects. These include various methods to destroy or remove part of the excess tissue while trying to
avoid damaging what's left. Transurethral electrovaporization of the prostate (TVP), laser TURP,
visual laser ablation (VLAP), ethanol injection, and others are studied as alternatives.
Newer techniques involving lasers in urology have emerged in the last 5-10 years, starting with the
VLAP technique involving the Nd:YAG laser with contact on the prostatic tissue. A similar
technology called Photoselective Vaporization of the Prostate (PVP) with the GreenLight (KTP)
laser have emerged very recently. This procedure involves a high powered 80 Watt KTP laser with a
550 micrometre laser fiber inserted into the prostate. This fiber has an internal reflection with a 70
degree deflecting angle. It is used to vaporize the tissue to the prostatic capsule. KTP lasers target
haemoglobin as the chromophore and typically have a penetration depth of 2.0mm (four times
deeper than holmium).
Another procedure termed Holmium Laser Ablation of the Prostate (HoLAP) has also been gaining
acceptance around the world. Like KTP the delivery device for HoLAP procedures is a 550um
disposable side-firing fiber that directs the beam from a high powered 100 Watt laser at a 70degree
from the fiber axis. The holmium wavelength is 2,140nm, which falls within the infrared portion of
the spectrum and is invisible to the naked eye. Where KTP relies on haemoglobin as a
chromophore, water within the target tissue is the chromophore for Holmium lasers. The penetration
depth of Holmium lasers is <0.5mm avoiding complications associated with tissue necrosis often
found with the deeper penetration and lower peak powers of KTP.
Both wavelengths, KTP and Holmium, ablate approximately one to two grams of tissue per minute.
Post surgery care often involves placement of a Foley Catheter or a temporary Prostatic stent to
allow healing and urine to drain from the bladder.

description
An in-depth report on the causes, diagnosis, treatment, and prevention of BPH.

Alternative Names
Transurethral Resection of the Prostate (TURP)

Complications
The progression of symptoms in benign prostatic hyperplasia (BPH) is typically very slow and
additional symptoms, when they occur, often come and go. Individual response to these symptoms
also varies widely. Some men can tolerate very uncomfortable sensations of abnormal urination,
while other men seek relief from mild symptoms. BPH does not appear to impair sexual function.
Problems with urination, however, can be very distressing and severely affect quality of life in some
cases.

Risk Factors
About 5.5 million American men have benign prostatic hyperplasia (BPH) that could warrant
medical attention. Age is the major risk factor. According to a British study, only 3.5% of men in
their late 40s have signs of BPH, but by age 80, 35% of men have BPH with lower urinary tract
symptoms. And, according to another study, as many as 80% of men have at least some signs of
BPH. Research into possible risk factors is ongoing. The problem appears to be more prevalent in
the US and Europe, and may be more common in married men than single men.

Ethnic Groups
Although some studies have suggested that African American men are at higher risk and Asian men
at lower risk for BPH than Caucasians, a 2000 study found no greater risk for African Americans
and only a slightly lower risk for Asians. Among Caucasians in the study, men of southern European
heritage were at greater risk while men of Scandinavian ancestry had a lower chance of developing
BPH. (The study reported no differences in male hormones among the Caucasian groups.)
Family History
A family history of BPH appears to increase a mans chance of developing the condition. One study
reported that men with BPH who had three or more family members with the condition had much
larger prostate glands than men with BPH without such a family history.

Medical Conditions
Some evidence has reported a higher incidence of benign prostatic hyperplasia -- particularly fast-
growing BPH -- in men with obesity, heart and circulatory diseases, and type 2 diabetes. Diabetes
and hypertension, in any case, worsens urinary tract symptoms in men with BPH. In one study, flow
rates were adversely affected by diabetes, although residual urine volumes were not significantly
greater.

Alternative Names
Transurethral Resection of the Prostate (TURP)

Treatment
Because BPH rarely causes serious complications, men usually have a choice between treating it or
opting for watchful waiting:
• Watchful Waiting. Watchful waiting involves lifestyle changes and an annual examination. It
should be noted that even when choosing watchful waiting, an initial examination is critical
to rule out other disorders.
• Treatment Options. The primary goals of treatment for BPH are to improve urinary flow and
to reduce symptoms. Many options are available. They include drug therapies, minimally
invasive procedures, and major surgery.

Choosing Between Treatment and Watchful Waiting

The choice between watchful waiting and treatment usually depends on a number of factors, such as
urine flow rates, prostate size, and PSA levels. Men with BPH who develop symptoms at around
age 50 are more likely to need treatment within their lifetimes than older men. Unfortunately, there
is no way at present to determine who specifically might be at risk for serious problems and need
early treatment.
The evaluation of symptoms has been made somewhat easier by the development of the
International Prostate Symptoms Score (IPSS). This scoring service serves as a benchmark for
determining severity. To treat or not to treat is typically based on the guidelines described below,
but the ultimate choice is often guided primarily by a mans perception of his own symptoms.
Mild or No Symptoms. Men with mild or no symptoms (IPSS scores of 7 or below) usually choose
watchful waiting even if their prostates are enlarged. BPH eventually progresses to the point of
needing treatment in about 15% of men with mild symptoms who wait. (It should be noted,
however, that urinary tract obstructions may be present in men with enlarged prostates even if they
have no symptoms, so there is some risk with this choice, although it is small.)
Moderate Symptoms. The choice is most difficult for men with moderate symptoms (scores between
8 and 19) and may simply depend on a mans ability to tolerate them. Some studies have reported
that up to 40% of men with moderate symptoms eventually seek treatment, and a quarter require
surgery. In a small percentage of patients, symptoms improve.
Severe Symptoms. Men with severe symptoms (scores over 20) nearly always choose treatment,
although if their prostate glands are small or normal-sized, symptoms may improve.
Deciding Between Surgery and Medication After Choosing Treatment
If a man opts for treatment, there are a number of choices. Most experts recommend a staged
approach as follows:
• Mild Symptoms. Medications are the best choice for men with mild symptoms who decide to
have their condition treated. There are two standard choices: alpha-blockers and anti-
androgens, nearly always finasteride (Proscar). Specific conditions determine the choice,
although most men take an alpha-blocker. Men with mild symptoms who choose surgery
only experience minor improvement afterward but face the same risks as patients with more
severe symptoms.
• Moderate to Severe Symptoms. Men with moderate to severe symptoms often respond to the
same medications as men mild symptoms. (Combinations of alpha-blockers and finasteride
are under investigation.) Recent developments in drug therapy have reduced the number of
surgical procedures needed and delayed their use. However, a quarter of men with moderate
symptoms, and even more men with severe symptoms eventually need surgery. If a man
chooses surgery, there are many choices. Transurethral resection of the prostate (TURP) is
the standard procedure, but less invasive procedures, particularly those using heat to destroy
prostate tissue, are gaining prominence.

Diagnostic Tests

International Prostate Symptoms Score

An indexing tool called the International Prostate Symptoms Score (IPSS) can help evaluate the key
lower urinary tract symptoms. As opposed to laboratory tests or other objective tests, this scoring
system measures the patients own experience. The higher the score, the more severe the conditions.
It is useful for many reasons:
• The patients score on this test gives a highly accurate assessment of the effect of lower
urinary tract symptoms on the quality of a mans life.
• It is a reasonable basis from which the patient and physician can discuss treatment options.
• The index is also often used to gauge treatment outcomes and may be a better indicator of
success than objective tests, such as the measurement of the prostate gland or the rate of
urine flow.
Limitations. It should be noted that the IPSS is useful only as a gauge of symptom severity, and has
the following limitations:
• Other conditions can produce similar scores, so the test is not used as a diagnostic tool for
BPH.
• The index does not include other urinary symptoms, such as dribbling and incontinence or
sexual health, that are important for quality of life. At the very least, the patient should have
a frank discussion with his physician if such symptoms are present and affect his life.
• It also does not reflect regional or ethnic differences that can vary the responses to these
symptoms.

International Prostate Symptoms Score (IPSS)

Symptoms over past month Never Less than 1Less than About half More Almost
time in 5 half the time the time than half always

Sensation that the bladder is 0 = 1 = One 2 = Twice 3 = three 4 = four 5 = five

not empty after urinating None time times times times or
more

Need to urinate within two 0= 1 = One 2 = Twice 3 = three 4 = four 5 = five

hours of a previous urination None time times times times or
more

Need to stop and start again 0 = 1 = One 2 = Twice 3 = three 4 = four 5 = five
several times while urinating None time times times times or
more

Have a weak urinary stream 0= 1 = One 2 = Twice 3 = three 4 = four 5 = five

None time times times times or
more

Need to strain to urinate 0= 1 = One 2 = Twice 3 = three 4 = four 5 = five

None time times times times or
more

Number of times during the 0 = 1 = One 2 = Twice 3 = three 4 = four 5 = five

night awakened by the need to None time times times times or
urinate more

Circle appropriate number. Totals of: 7 or less = mild symptoms; 8-19 = moderate; 20-35 = severe.

Other Indexing Systems

Other indexing systems, such as Symptom Problem Index (SPI) and the BPH Impact Index (BII),
which gauge different quality-of-life and disease issues, are being used in addition to the IPSS to
help assess the patient.

Physical Examination
Digital Rectal Exam. The digital rectal exam is used to detect an enlarged prostate. The doctor
inserts a gloved and lubricated finger into the patients rectum and feels the prostate to estimate its
size and to detect nodules or tenderness. The exam is quick and painless, but embarrassing for
some, and far from infallible. The test helps rule out prostate cancer or problems with the muscles
in the rectum that might be causing symptoms, but it generally underestimates the prostates size. It
is not accurate for diagnosing prostate cancer, and is never the primary diagnostic tool for either
BPH or cancer.
Other Physical Examinations. The physician will usually press on and manipulate (palpate) the
abdomen and sides to detect signs of kidney or bladder abnormalities. The physician will also check
for signs of anemia or swelling in the legs and arms. Certain procedures that test reflexes,
sensations, and motor response may be performed in the lower extremities to rule out possible
neurologic causes of bladder dysfunction.

Uroflowmetry
To determine whether the bladder is obstructed, the speed of urine flow is measured electronically
using a test called uroflowmetry. The test cannot determine the cause of obstruction, which can be
due not only to BPH, but possibly also to abnormalities in the urethra, weak bladder muscles, or
other causes.
• The patient is instructed not to urinate for several hours before the test and to drink plenty of
fluids so he has a full bladder and a strong urge to urinate.
• To perform this test, a patient urinates into a special toilet equipped with a uroflowmeter.
• It is important that the patient remains still while urinating to help ensure accuracy, and that
he urinates normally and does not exert strain to empty his bladder or attempt to retard his
urine flow.
• Many factors can affect urine flow (such as straining or holding back because of self-
consciousness) so experts recommend then that the test be repeated at least twice.
Q[max]. The rate of urine flow is calculated as milliliters of urine passed per second (mL/s). At its
peak, the flow rate measurement is recorded and referred to as the Q[max]. The higher the Q[max],
the better the patients flow rate. Men with a Q[max] of less than 12 mL/s have four times the risk
for urinary retention than men with a stronger urinary flow.
The Q[max] measurement is sometimes used as the basis for determining the severity of obstruction
and for judging the success of treatments. It is not very accurate, however, for a number of reasons:
• Urine flow varies widely among individuals as well as from test to test.
• The patients age must be considered. Flow rate normally decreases as men age, so the
Q[max] typically ranges from more than 25 mL/s in young men to less than 10 mL/s in
elderly men.
• The Q[max] level does not necessarily coincide with a patients perceptions of the severity of
his own symptoms.

Urinalysis
A urinalysis may be performed to detect signs of bleeding or infection. A urinalysis involves a
physical and chemical examination of urine. In addition, the urine is spun in a centrifuge to allow
sediments containing blood cells, bacteria, and other particles to collect. This sediment is then
examined under a microscope. Although urinary infection is uncommon in younger men, it occurs
more frequently in older men, particularly those with BPH. A urinalysis also helps rule out bladder
cancer.

Pre and Post Massage Test (PPMT)

To rule out prostatitis, a simple test called the Pre and Post Massage Test (PPMT) is about 90%
accurate. This test requires two cultures and microscopic examinations of urine samples taken
before and after massage of the prostate gland. To massage the prostate the doctor simply inserts a
gloved finger into the rectum and presses several times on the prostate. The following results are
indicated by findings on cultures after massage:
• Category II prostatitis (Chronic bacterial). Bacteria are found on post-massage.
• Category IIIA prostatitis (Inflammatory chronic pelvic pain syndrome). Leukocytes or other
cells are found that indication inflammation.
• Category IIIB prostatitis (Noninflammatory chronic pelvic pain syndrome). No signs of
inflammation or bacteria.

Serum Creatinine
In men with symptoms, blood tests are performed to measure a substance called serum creatinine,
which is a marker for kidney trouble. Kidney problems exist in an average of 13.6% of BPH
patients. Studies have reported rates as high as 30% and as low as 0.3%.

PSA Test for BPH and Prostate Cancer

A PSA test measures the level of prostate-specific antigen (PSA) in the patients blood. It is the
standard screening test for prostate cancer. A PSA is recommended annually for all men over 50
years old and for men over 40 who are at high risk for prostate cancer.
BPH itself can also raise PSA levels, but the test has generally been optional for men with suspected
BPH. One 2000 study indicated that PSA levels may be good predictors of future prostate growth in
men with BPH. In the study, men with the lowest PSA level groups (0.2 to 1.3 ng/mL) had prostate
growth rates of only 0.7 mL per year while those in the high PSA groups (3.3 to 9.9) had growth
rates of 3.3. mL per year. Other research has detected a specific molecular form of PSA, which has
been termed BPSA because it may be a specific marker for BPH. Such findings could eventually
lead to a shift from focusing on symptoms and flow rates for diagnosis to a more specific and
possibly preventive approach.
Certain treatments for BPH, including the drug finasteride (Proscar) and the surgical procedure
transurethral resection of the prostate (TURP), can reduce PSA levels and possibly mask the
existence of prostate cancer.
A more recent test identifies so-called free PSA, which is found in lower levels when prostate
cancer is present and in higher levels with benign prostate hyperplasia. This may be more accurate
than total PSA, regardless of whether a man is taking finasteride or not.

Postvoid Residual Urine

One of the important tests for urinary incontinence is the postvoid residual urine volume (PVR), the
amount of urine left after urination. Normally, about 50 mL or less of urine is left; more than 200
mL is a definite sign of abnormalities. Measurements in between require further tests. The most
common method for measuring PVR is with a catheter, a soft tube that is inserted into the urethra
within a few minutes of urination. PVR can also be measured using transabdominal
ultrasonography.

Ultrasound
Ultrasound of the prostate does not require a catheter and gives an accurate picture of the size and
shape of the prostate gland. Ultrasound is very beneficial when planning surgery and determining
treatment options and gauging their effectiveness. Ultrasound may also be used for detecting kidney
damage, tumors, and bladder stones. Ultrasound tests of the prostate generally use one of two
methods:
• Transrectal ultrasonography (TRUS) uses a rectal probe for assessing the prostate. TRUS is
significantly more accurate for determining prostate volume. It can sometimes detect cancer.
• Transabdominal ultrasonography uses a device placed over the abdomen. It can give an
accurate measure of postvoid residual urine and is less invasive and expensive than TRUS.

Filling Cystometry
Filling cystometry, also called cystometrography, is usually used for patients who cannot urinate
and in whom nerve damage or injury of the bladder is suspected. The test is used to determine the
absence or presence of a condition called uninhibited detrusor contractions (UDC), which often
occurs in men with storage urinary tract symptoms. The detrusor is the group of muscle fibers that
cover the outside of the bladder. The test does not add much information to results from less
invasive tests and is not used routinely.
Procedure.
• The patient is usually lying down and is told to remain as relaxed as possible.
• Sterile water (usually at body temperature) is instilled into the bladder and the pressure in
the bladder is continuously measured.
• The patient informs the physician about sensations experienced, and when the urge to
urinate is strong, this portion of the test is stopped.
• A fluid-inflatable balloon is inserted into the rectum for a second measurement. This reflects
abdominal pressure.
• A calculation is then made using the measurements of abdominal and bladder pressures. The
result provides an accurate assessment of detrusor contractions.
• If results are uncertain, the test may be repeated to provoke bladder response by having the
patient stand, by increasing the speed of the filling time, or by using ice-cold water.

Urethrocystoscopy
A urethrocystoscopy, also called cystourethroscopy, may be performed in men diagnosed with BPH,
particularly if they are surgical candidates or if other urinary tract problems are suspected. Such
problems include blood in the urine, infection, interstitial cystitis, bladder cancer, or prior surgery or
injury. The physician can determine the presence of a number of structural problems, including
enlargement of the prostate, obstruction of the urethra or neck of the bladder, anatomical
abnormalities, or the presence of stones.
Procedure. In this procedure, a flexible or rigid fiberoptic tube (an endoscope) is inserted into the
urethra to allow doctors to view the lower urinary tract.
Complication. The procedure is not without risks. Complications are uncommon but can include
allergic response to the anesthetic, urinary tract infection, bleeding, and urine retention.

Intravenous Excretory Urography

An x-ray called an intravenous excretory urography (IVU) is an invasive test that is used only when
complications in the upper urinary tract, particularly in the kidney, are suspected. Alternatively, an
abdominal ultrasound plus a normal x-ray may be as useful as IVU for most patients with suspected
upper urinary tract problems.
Complications and Side Effects. If there is any danger of kidney failure, the test should not be
performed, since it can exacerbate the condition. Severe side effects of the test occur in 0.1% of
patients.
Differentiating between BHP and Interstitial Cystitis (IC)
Some physicians believe that a number of men may be incorrectly diagnosed with BPH when they
have interstitial cystitis (an inflammation of the bladder that may be associated with allergic or
autoimmune response). The potassium sensitivity test is sometimes used to diagnose IC. Some
experts believe this test missed too many IC patients, although a 2001 study concluded that a
combination of potassium sensitivity and urodynamic tests is useful in distinguishing between BPH
and interstitial cystitis.

Benign Prostatic Hyperplasia (BPH)(Benign Prostatic

Hypertrophy)
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Benign prostatic hyperplasia is nonmalignant adenomatous overgrowth of the

periurethral prostate gland. Symptoms are those of bladder outlet obstruction—
weak stream, hesitancy, urinary frequency, urgency, nocturia, incomplete
emptying, terminal dribbling, overflow or urge incontinence, and complete
urinary retention. Diagnosis is based primarily on digital rectal examination and
symptoms; cystoscopy, transrectal ultrasonography, urodynamics, or other
imaging studies may also be needed. Treatment options include 5α-reductase
inhibitors, α-blockers, and surgery.

Using the criteria of a prostate volume > 30 mL and a high American Urological
Association Symptom Score (see Table 1: Benign Prostate Disease: American
Urological Association Symptom Score for Benign Prostatic Hyperplasia ), the
prevalence of benign prostatic hyperplasia (BPH) in men aged 55 to 74 without
prostate cancer is 19%. But if voiding criteria of a maximal urinary flow rate <
10 mL/sec 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 to 40 to 50% in men aged 51 to 60 and
to > 80% in men > 80.

Table 1

American Urological Association Symptom Score for Benign Prostatic

Hyperplasia
Score

Over About the Past Month

Never

< 1 in 5 Times

< 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?

How often have you had to urinate again < 2 h after you finished urinating?

How often have you stopped and started again several times when urinating?

0
1

How often have you found it difficult to postpone urination?

How often has your urinary stream been weak?

How often have you had to push or strain to begin urination?

5
How many times did you most typically get up to urinate between going to bed at
night and waking in the morning?

none =

once =

twice =

3 times =

4 times =

≥ 5 times

=5

American Urological Association symptom score = total ______

Adapted from Barry MJ, Fowler FJ, O'Leary MP, et al: The American Urological
Association symptom index for benign prostatic hyperplasia. Journal of Urology
148:1549, 1992.

The etiology is unknown but probably involves hormonal changes associated

with aging.

Pathophysiology

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
obstruction, even if incomplete, can cause hydronephrosis and compromise renal
function.
Symptoms and Signs

Symptoms include progressive urinary frequency, urgency, and nocturia due to

incomplete emptying and rapid refilling of the bladder. Pain and dysuria are
usually not present. Decreased size and force of the urinary stream produce
hesitancy and intermittency. Sensations of incomplete emptying, terminal
dribbling, overflow incontinence, or complete urinary retention may ensue.
Straining to void can cause congestion of superficial veins of the prostatic urethra
and trigone, which may rupture and produce hematuria. Straining also may
acutely cause vasovagal syncope and, over the long term, may cause dilation of
hemorrhoidal veins or inguinal hernias.

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 retain urine

• Immobilization
• Exposure to cold
• Use of anesthetics, anticholinergics, sympathomimetics, opioids, or
alcohol

Symptoms can be quantitated by the 7-question American Urological Association

Symptom Score (see Table 1: Benign Prostate Disease: American Urological
Association Symptom Score for Benign Prostatic Hyperplasia ). This score also
allows physicians to follow symptom progression: Scores > 10 but < 20 suggest
moderate symptoms, and scores > 20 suggest severe symptoms.

On digital rectal examination, the prostate usually is enlarged, nontender, has a

rubbery consistency, and in many cases has lost the median furrow. However,
prostate size as detected with digital rectal examination may be misleading; an
apparently small prostate may cause obstruction. If distended, the urinary bladder
may be palpable or percussible on abdominal examination.

Diagnosis

• Digital rectal examination

• Urinalysis and culture
• Prostate-specific antigen level
• Sometimes uroflowmetry and bladder ultrasonography

The lower urinary tract symptoms of BPH can also be caused by other disorders,
including infection and prostate cancer. Furthermore, BPH and prostate cancer
may coexist. Although palpable prostate tenderness suggests infection, digital
rectal examination findings in BPH and cancer often overlap. Although cancer
may produce a stony, hard, nodular, irregularly enlarged prostate, most patients
with cancer, BPH, or both have a benign-feeling, enlarged prostate. Thus,
patients with symptoms or palpable prostatic abnormalities should undergo
testing.

Typically, urinalysis and culture are done, and serum prostate-specific antigen
(PSA) levels are measured. Men with moderate or severe symptoms of
obstruction may also have uroflowmetry (an objective test of urine volume and
flow rate) with measurement of post-void residual volume by bladder
ultrasonography. Flow rate < 15 mL/sec suggests obstruction, and post-void
residual volume > 100mL suggests retention.

Interpreting PSA levels can be complex. The PSA level is moderately elevated in
30 to 50% of patients with BPH, depending on prostate size and degree of
obstruction, and is elevated in 25 to 92% of patients with prostate cancer,
depending on the tumor volume. Typically, if the PSA level is > 4 ng/mL or if the
digital rectal examination indicates an abnormality (other than smooth,
symmetric enlargement), then a transrectal biopsy is recommended. For men <
50 or those at high risk for prostate cancer, a lower cutoff (PSA > 2.5 ng/mL)
may be used. Other measures, including rate of PSA increase, free-to-bound PSA
ratio, and other markers, may be useful (for full discussion of prostate cancer
screening and diagnosis, see Genitourinary Cancer: Diagnosis).

Transrectal biopsy is usually done with ultrasound guidance. Transrectal

ultrasonography can also measure prostate volume.

Clinical judgment must be used to evaluate the need for further testing. Contrast
imaging studies, such as CT or IVU, are rarely necessary unless obstructive
symptoms have been severe and prolonged. Upper urinary tract abnormalities
that usually result from bladder outlet obstruction include upward displacement
of the terminal portions of the ureters (fish hooking), ureteral dilation, and
hydronephrosis. If an upper tract imaging study is warranted due to pain or
elevated serum creatinine level, ultrasonography may be preferred as it avoids
radiation and IV contrast exposure.

Treatment

• Avoidance of anticholinergics, sympathomimetics, and opioids

• Use of α-adrenergic blockers (eg, terazosin Some Trade Names
HYTRIN
Click for Drug Monograph
, doxazosin Some Trade Names
CARDURA
Click for Drug Monograph
, tamsulosin Some Trade Names
FLOMAX
Click for Drug Monograph
, alfuzosin Some Trade Names
UROXATRAL
Click for Drug Monograph
) or 5α-reductase inhibitors ( finasteride Some Trade Names
PROPECIA
PROSCAR
Click for Drug Monograph
, dutasteride Some Trade Names
AVODART
Click for Drug Monograph
)
 • Transurethral resection of the prostate or a less invasive procedure

Urinary retention: 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 or insertion of filiforms and followers (guides and
dilators that progressively open the urinary passage) may be necessary (this
procedure should usually be done by a urologist). Suprapubic percutaneous
decompression of the bladder may be used if transurethral approaches are
unsuccessful.

Drug therapy: For partial obstruction with troublesome symptoms, all

anticholinergics, sympathomimetics, and opioids should be stopped, and any
infection should be treated with antibiotics. For patients with mild to moderate
obstructive symptoms, α-adrenergic blockers (eg, terazosin Some Trade Names
HYTRIN
Click for Drug Monograph
, doxazosin Some Trade Names
CARDURA
Click for Drug Monograph
, tamsulosin Some Trade Names
FLOMAX
Click for Drug Monograph
, alfuzosin Some Trade Names
UROXATRAL
Click for Drug Monograph
) may improve voiding. The 5α-reductase inhibitors ( finasteride Some Trade
Names
PROPECIA
PROSCAR
Click for Drug Monograph
, dutasteride Some Trade Names
AVODART
Click for Drug Monograph
) may reduce prostate size, improving voiding over months, especially in patients
with larger (> 30 mL) glands. A combination of both classes of drugs is superior
to monotherapy.

Surgery: Surgery is done when patients do not respond to drug therapy or

develop recurrent UTI or upper tract dilation. Transurethral resection of the
prostate (TURP) is the standard. Erectile function and continence are usually
retained, although about 5 to 10% of patients experience some 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%. About 10% of men undergoing TURP need the
procedure repeated within 10 yr because the prostate continues to grow. Larger
prostates (usually > 75 g) require open surgery via a suprapubic or retropubic
approach. All surgical methods require postoperative catheter drainage for 1 to 7
days.

Other procedures: Less invasive procedures include microwave thermotherapy,

laser ablation, electrovaporization, high-intensity focused ultrasound,
transurethral needle ablation, radiofrequency vaporization, and intraurethral
stents. The circumstances under which these procedures should be used have not
been firmly established, but those done in the physician's office (microwave
thermotherapy and radiofrequency procedures) are being more commonly used
and do not require use of general or regional anesthesia. Their long-term ability
to alter the natural history of BPH is under study