REVIEW

CURRENT
OPINION Imaging in benign prostatic hyperplasia: what
is new?
Hamidreza Abdi, Amir Kazzazi, Soroush T. Bazargani, Bob Djavan, and
Shpetim Telegrafi

Purpose of review
This article discusses the new imaging techniques in diagnosis and treatment of benign prostatic
hyperplasia by reviewing the most recent publications.
Recent findings
Imaging study for the evaluation of patients with lower urinary tract symptoms is not suggested by
American Urology Association guidelines; however, European Association of Urology recommends the
assessment of the upper urinary tract by modalities like ultrasound. Several new imaging indices like
resistive index of capsular artery, presumed circle area ratio, prostatic urethral angle, intraprostatic
protrusion, and detrusor wall thickness are used to find a noninvasive way for bladder outlet obstruction
diagnosis. In addition to them, 3D transrectal ultrasound, near infrared spectroscopy, and MRI are used to
add more practical findings in patient management.
Summary
Urologists have requested more imaging studies than expected for benign prostatic hyperplasia patients in
recent years, and several studies have been done to find a noninvasive way to diagnose bladder outlet
obstruction. However, none of them could play the urodynamic studies role in bladder outlet obstruction
diagnosis.
Keywords
benign prostatic hyperplasia, diagnostic imaging, lower urinary tract symptoms, TRUS, ultrasound

INTRODUCTION One of the main areas of interest is to find a

Benign prostatic hyperplasia (BPH) is a histological
diagnosis; while lower urinary tract symptom
(LUTS) is a clinical term that has different causes
[1]. In addition, bladder outlet obstruction (BOO)
is more a functional and urodynamic definition.
As the disease is common and carries cost on the
health system, international urology associations
provide guidelines to direct urologists into a cost-
effective management method [1,2,3 ].
&
There is no worldwide agreement on how to
properly select these patients for treatment or even
randomize for clinical trials, neither is about the
comprehensive pretreatment evaluation which can
reduce the risk of unsatisfactory treatment results.
For a practicing urologist, there has always
been dilemma while requesting diagnostic imaging
for a BPH patient. This may start with the need for
routine imaging, indications for such studies, their
accuracy, and predictive value for outcome and
complications. None of the questions have received
an elucidation so far.
noninvasive diagnostic method for BOO. During
the last 2 years, many authors tried to use new
imaging techniques for the diagnosis of LUTS,
BPH, and BOO to substitute a cumbersome pres-
sure-flow study. The rationale behind so many novel
ideas may be the fact that it is not the prostate size
(BPE) that directly correlates with the degree of
obstruction. In addition, there may be factors such
as urethral dynamic angel, anatomic variations in
gland enlargement, prostate capsule elasticity, and
vascular component which play a significant role.
Department of Urology, New York University School of Medicine, NYU,
New York, New York, USA
Correspondence to Shpetim Telegrafi, MD, Director of Diagnostic Ultra-
sound, Associate Professor of Urology, Senior Research Scientist,
Department of Urology, NYU School of Medicine, 150 East 32nd Street,
2nd Floor, New York, NY 10016, USA. Tel: +1 646 825 6340; fax: +1
646 825 6380; e-mail: Shpetim.Telegrafi@nyumc.org
Curr Opin Urol 2013, 23:11–16
DOI:10.1097/MOU.0b013e32835abd91

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Benign prostatic hyperplasia
KEY POINTS

Indications for imaging in BPH are still controversial.
However, complications developed of BPH necessitate
imaging studies.

New concepts in imaging techniques for BPH have
emerged.

Intraprostatic protrusion (IPP) measurement and
eccentricity parameter-based correction of prostate
volume seem promising among others.

No single noninvasive test can substitute pressure-flow
study yet.
In this article, we review the recent findings
about the imaging techniques and their use in
BPH diagnosis and management.
REVIEW OF LITERATURE
We did a MEDLINE search with these keywords:
benign prostatic hyperplasia, bladder outlet obstruc-
tion, imaging techniques, BPH diagnosis, BPH man-
agement, BPH guidelines, MRI, ultrasound (US),
transrectal ultrasound (TRUS). During the study,
our focus was on the literature published in the last
2 years.
We reviewed the literature for the problems and
tried to figure out results through the controversies.
Then, new imaging techniques or improvements
are reported.
When should urologists perform imaging in
benign prostatic hyperplasia patients?
According to the American Urology Association
(AUA) panel in 2005 and its update on 2010,
imaging of the upper urinary tract is not recom-
mended as a routine preoperative evaluation.
Indications for imaging include infection, hematu-
ria, urolithiasis, and renal insufficiency. Residual
urine assessment is an optional test. However, the
European Association of Urology (EAU) guideline
recommends assessment of the upper urinary tract
with either serum creatinine or ultrasonography.
Post void residue (PVR) assessment is a routine
&
evaluation during initial assessment [1,2,3 ].
The guidelines offer a cost-effective framework
for clinical practice, but they are usually the result
of consensus [1]. Therefore, not all of the urologists
may follow them.
&
Bellinger et al. [4 ] reviewed 5% national sample
of Medicare beneficiaries from 2000 to 2007 and
separated 40 253 new cases to the urology clinic with
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LUTS and followed them for 12 months. According
to their finding, the total expenditure of BPH
imaging tests in the USA increased, although this
increment was less than the total imaging expendi-
ture increment covered by Medicare at the same
range of age. It is also less than the total expenditure
increment of other BPH evaluating tests which
was also less than overall increment of disease evalu-
ation in the same age range [4 ].
&
&
Strope et al. [5,6 ] investigated 10 248 men
during their initial visits for BPH by selecting a
5% sample of Medicare patients between the years
1999 and 2007. Patients were excluded if they left
the Medicare parts A and B or if they were enrolled in
a Medicare HMO for 2 years before the initial visit
by the urologist to 1 year after the visit. Patients
with prior surgical BPH therapy, prostate cancer or
neurologic disease were also excluded.
They studied physician level factor and practice
style, the level of recommendation for a test accord-
ing to AUA guidelines, and the patients’ comor-
bidities. They noticed that about 15-fold variation
among 748 urologists’ average per patient expendi-
tures existed. Costly style in BPH evaluation was
detected in the northeast and western part of the
USA, among the urologists working in urban area,
&
and who have fewer experiences [5,6 ].
Wei et al. [7] enrolled 6924 men with LUTS
and excluded those with lower urinary tract disease
or carcinoma, neurological disease, unresolved
sexually transmitted disease or urinary tract infec-
tion, gross hematuria, acute urinary retention,
and previous prostate surgery from January 2004
to February 2005. Urologists performed postvoid
residue, prostate ultrasound, and renal ultrasound
in 49.5, 24.1, and 13.6% of them, respectively [7,8].
Do they use imaging studies for better
differential diagnosis?
The differential diagnoses of LUTS caused by
BPH are overactive bladder, detrusor hyperactivity
impaired contractility (DHIC), bladder stone, ure-
thral stricture, bladder tumor, underlying medical,
neurologic disease, prostate cancer, and problems
like congestive heart failure, respiratory or renal
disease. More evidence is needed to show that the
recommended tests in guidelines are adequate to
differentiate BPH from other mentioned diseases.
Is DRE reliable for estimating prostate
volume for clinical purpose?
Ahmad et al. [9] concluded that digital rectal exami-
nation (DRE) usually underestimates the prostate
volume compared to TRUS, but it is an accurate tool
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 Imaging in benign prostatic hyperplasia: what is new? Abdi et al.
for identifying prostates more than 30 cc in 94% of
cases. This is adequate for clinical purposes like
starting 5ARIs. However, the accuracy is 49.4 and
37.5% in prostates less than 30 cc and more than
80 cc, respectively. In addition, DRE estimation in
patients with BMI over 30 is less accurate too [9].
Could urologists predict their patients’
outcome properly by these recommended
assessments before treatment?
According to EAU guidelines, PVR more than 200 cc
may indicate bladder dysfunction and predict a less
encouraging response [10]. AUA recommends PVR
assessment before starting anticholinergics in these
& Shinbo et al. [13,14], studied a relationship
patients [3 ].
This could be the reason to measure PVR more
than expected in US.
Could they evaluate properly the upper tract
damages?
Although 10% of patients with LUTS show some
degree of renal insufficiency, it is usually related to
concomitant diabetes mellitus (DM) or HTN, and
according to Medical Therapy of Prostatic Symp-
toms (MTOPS) survey the risk of renal insufficiency
by LUTS as a single factor is less than 1%. EAU
guidelines recommend that as it is hard to say which
patient is renal insufficient it is probably cost-effec-
tive to measure serum creatinine or performing
renal ultrasound. But there is a lack of evidence to
evaluate the cost-effectiveness [10,11].
According to AUA guidelines in 2010, renal
insufficiency in BPH patients seems to be not more
&
than peers in general population [3 ]. However,
again well designed studies are needed to show
the cost-effectiveness of this approach. Although
assessment of prostate shape and size by transab-
dominal or transrectal ultrasound is not recom-
mended by EAU guidelines in the first visit, they
recommend these evaluations before surgery and
medical therapy [10,11]. Therefore, indications for
ultrasonography during the disease process should
be studied and determined more precisely.
THE NEW IMAGING TECHNIQUES AND
CONCEPTS
Most of the recent imaging techniques are experi-
mental and should be evaluated more in well
designed clinical trials.
New concepts in transrectal ultrasound
TRUS has been the most common imaging modality
for prostate diseases. Recently, new concepts are
posed to improve its diagnostic efficacy.
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Resistive index measurement by Doppler
Previously, some authors emphasized on the
relationship between transitional zone index
(transitional zone volume/total prostatic volume)
and obstructive symptoms, mechanical bladder out-
let obstruction, or acute urinary retention [12,13].
Doppler TRUS provides information about
prostate blood flow. Power Doppler can detect low
flow small vessels more than color Doppler. The
prostate blood supply comes from urethral and cap-
sular arteries. Enlarged transitional zone compresses
the surgical capsule, so the vascular resistance in
capsular artery will rise. This can be measured by
Power Doppler.
between resistance index ¼ [(peak systolic
velocity – end diastolic velocity)/peak systolic
velocity], with BOO and risk of acute urinary reten-
tion (AUR) in patients with BPH. They studied 1962
men with LUTS and excluded all of the patients
with prostatic cancer, prostatitis, urethral stricture,
neurogenic bladder dysfunction, renal failure, heart
failure, liver cirrhosis, and history of TURP. A total of
245 of them were established AUR. They pointed
out that resistance index with cutoff value of more
than 0.75 is a more reliable predictor of BOO than
international prostate symptom score (IPSS), PVR,
and transitional zone index [13,14].
The questions to be answered before using this
index in future are the importance and difference
between resistance index in capsular or urethral
artery, the role of this index in patients who just
have medial lobe enlargement, patients who pre-
viously received medical therapy, the same age
group without symptoms, the effect of heart rate
during the study, the effect of patient position
during the study, and its reliability in patients with
DM, HTN, and vascular disease [13].
Presumed circle area ratio and capsule
elasticity
As prostate enlarges, the pressure transfers to the
surgical capsule and finally at one point the capsule
cannot stretch more, then prostate begins to trans-
form to a circle shape. The diversity in the elastic
characteristic of surgical capsule affects this process
and the final outcome will vary in different patients.
Presumed circle area ratio (PCAR) is calculated
where the horizontal section of prostate in TRUS
shows the biggest surface. Then the ratio of this
surface to the presumed circle with the same circum-
ference will be calculated. St Sauver et al. [15]
designed a cross-sectional study of 328 Caucasian
men residing in Olmsted County, Minnesota.
They measured IPSS, PVR, peak flow rate, and PCAR.
They show that the PCAR greater than 0.9 correlates
www.co-urology.com 13
 Benign prostatic hyperplasia
with symptom score after adjusting for age and
prostate volume. But it might not provide predictive
information more than transitional zone volume
[15].
3D-Transrectal ultrasound
Elwagdy et al. [16] started to use 3D extended trans-
rectal ultrasound (3DXI) and then processed images
with a software to get multiresolution ones to
differentiate the central and transitional zone which
is not possible in the routine TRUS. This technique
can accurately differentiate the histopathology
subtypes of BPH. They used this technique for
113 patients before TURP and compared their results
with histopathology of biopsy and TUR specimens.
Nodular balance and types (stromal versus glandu-
lar) beside the urethra has a correlation with symp-
tom severity and PVR. They supposed that these
two factors are more important than surgical capsule
elasticity and central gland volume. However,
the limited number of patients, lack of control
group without the need for surgery, and a long
learning curve were the barriers for using it in other
centers [16].
Prostatic urethral angle and intravesical
prostatic protrusion
Recent hypothesis about the role of prostatic
angle in LUTS [17] encouraged some authors to
examine this theory in LUTS patients. Prostatic
urethral angle (PUA) is the angle between prostatic
urethra and membranous urethra in midsagittal
plane in TRUS. Intraprostatic protrusion (IPP) is
the distance between bladder base and the top of
protruded prostate into bladder in the same plane.
Park et al. [18] studied 270 LUTS and BPH
patients retrospectively, and for minimizing the
effect of prostate size on voiding they excluded
patients with prostate weight more than 40 cc.
Patients with tumor, infection, neurogenic bladder,
and stone were also excluded. The IPSS was
separated into the storage symptom (IPSS-ss) and
voiding symptom (IPSS-vs) subscores. They noticed
that IPP was significantly correlated with IPSS, but
PUA was correlated just with IPSS-vs and not storage
scores. Higher PUA related to higher voiding symp-
toms [18].
Ku et al. [19] studied 260 men older than 50 years
with IPSS more than 8 and Qmax less than 10
retrospectively. They recorded IPSS, voiding diary,
prostate-specific antigen (PSA), PVR, pressure-flow
study and uroflowmetry, PUA, and IPP. Patients
with higher PUA (PUA 358) had higher PSA, larger
prostate volume, higher maximal urethral closure
pressure, higher detrusor pressure at maximum flow
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rate, and higher BOO index. But there was no
relationship between the degree of IPP and PUA
in that study [20].
None of these studies measured PUA during
voiding, which may change the results. In addition,
this index should be compared to an asymptomatic
cohort group. Therefore, this parameter needs to
be investigated in prospective well designed future
studies.
New concepts in abdominal ultrasonography
As mentioned before, there is controversy about
the indications of ultrasonography in BPH pre-
operatively. There have been some innovations to
help improve the diagnostic modality.
Intraprostatic protrusion in abdominal
ultrasound
IPP is mentioned as a predictive factor of obstruction
in several studies. It can be performed either trans-
abdominally or transrectally.
Lee et al. [20], investigated 256 patients with
LUTS and BPH by abdominal ultrasound. They
measured IPP and categorized them into three sub-
groups: Grade 1, less than 5 mm; grade 2, 5–10 mm;
and grade 3, more than 10 mm. IPSS, uroflowmetry,
PVR, and PSA were measured. Progression is defined
as PVR more than 100 cc, urinary retention, and
worsening of at least 4 points in IPSS score after a
mean follow-up of 32 months. The patients received
watchful waiting, alfa blocker, or 5ARI. They found a
relationship between a higher IPP grade and a higher
risk of clinical progression regardless of the treat-
ment types [20].
Detrusor wall thickness and intraprostatic
protrusion
Franco et al. [21] investigated 100 patients older
than 50 years with LUTS by abdominal ultrasound
and measured IPP and detrusor wall thickness
(DWT) when the bladder volume was about
200 cc. All patients with enlarged median lobe,
neurological disorders, renal insufficiency, bladder
stones, prostate cancer, urethral stricture, previous
pelvic surgery, or those who were on treatment were
excluded. Patients were assessed with pressure-
flow study. They found correlation between these
two parameters and BOO index. As a single variable,
they found 6 mm cut-off for DWT and 12 mm for
IPP. A combination of IPP more than 12 mm and
DWT more than 7 mm predicted obstruction better.
Patients with one of these two parameters have
a 90% chance of BOO on pressure-flow tests and
those with none of them have a 66% chance of no
Volume 23
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 Imaging in benign prostatic hyperplasia: what is new? Abdi et al.
obstruction. But more studies with larger case num-
ber should be done to find a precise cut-off for these
two parameters and also about the standard volume
of bladder during the measurement [21].
Prostate volume measurement by
transabdominal ultrasound
Yang et al. [22] after comparing the ultrasound
and CT scan measurement of prostate volume in
202 men claimed that the conventional ellipsoid
formula is not a valid tool. After analytical analysis,
they showed three different prostate shapes during
prostate growth. They suggested an eccentricity
parameter-based correction to the ellipsoid formula
for better estimation. Estimated volume for small
prostates by ellipsoid formula differed by 28% from
the CT estimated volume. After using the correction,
it reached to 7.6%. For large round shape prostate,
the difference is less.
Therefore, we need to re-evaluate the conven-
tional ellipsoid formula in high-volume studies if we
decide to use transabdominal ultrasound measuring
of prostate volume in clinical practice [22].
Near infrared spectroscopy
Reactive hyperemia occurs in bladder during
voiding and it can be detected by near infrared
spectroscopy (NIRS). BOO decreases this hemo-
dynamic reaction. NIRS is a method which can
monitor these hemodynamic changes by measuring
oxyhemoglobin (O2Hb) and deoxyhemoglobin
(HHb) in detrusor muscle using infrared. Chung
et al. [23] and Stothers et al. [24] compared NIRS
to urodynamic studies in 39 and 64 patients,
respectively. Stothers et al. proved a relationship
between BOO and NIRS, while Chung et al. could
not show any strong relationship. The concept is
new and noninvasive and needs to be more inves-
tigated in large series with matched control group.
MRI
Many studies used MRI to diagnose prostate disease
and especially to differentiate BPH from prostate
cancer, but none of them could replace prostate
biopsy. T2 W1 can distinguish peripheral zone from
central zone.
To increase the accuracy of MRI, a number of
authors have used special techniques such as
dynamic contrast-enhanced (DCE) MRI, magnetic
resonance spectroscopy, diffusion-weighted imag-
ing (DWI), and apparent diffusion coefficient
(ADC) to differentiate cancer from BPH, monitor
the medical treatment response, and measure the
microvasculature and relaxation properties of
prostate. But they are investigational and done in
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radiology departments with a small number of cases,
and a need further investigation [25,26].
New utilization of imaging in benign
prostatic hyperplasia treatment
Pisco et al. [27] used angiography to treat BPH.
They used arterial embolization with nonspherical
200 mm polyvinyl alcohol particles in 15 BPH
patients after failure of response to medical therapy.
They could catheterize the selective prostatic artery
and embolize at least one pelvic side artery in 14 of
them. After a mean follow-up of 7.9 months, IPSS
decreased by 6.5 points, prostate volume decreased
by 26.5 cc, quality of life improved by 1.14 points,
International Index of Erectile Function increased
by 1.7 points, and peak urinary flow increased by
3.85 ml/s. They reported one major complication,
ischemic area of the bladder wall, and four clinical
failures (28.6%). It is obvious that this technique
needs to be studied in randomized controlled trials
and compared with TURP in future [27].
CONCLUSION
Today, evidence-based clinical practice is an essen-
tial skill and every urologist should learn how to find
the accurate evidence for routine practice.
Indications for diagnostic imaging in BPH
remain controversial. All we have are consensuses
of expert societies, which still could be reliable as a
cost-effective framework for clinical practice.
Many novel noninvasive imaging techniques are
arising, but most are in the experimental phase.
Among them, IPP via TRUS or abdominal ultrasono-
graphy and eccentricity parameter-based correction
of prostate volume calculation through abdominal
ultrasound seem more promising. However, none
could replace the valuable pressure-flow study yet.
Acknowledgements
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
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January 2013