Benign Prostatic Hyperplasia
- The normal prostate volume in a young man is
approximately 20 g.
-The main function of the prostate gland is to secrete an
alkaline fluid that comprises approximately 70% of the
seminal volume.  modifiable, with factors such as age, genetics,
-The prostatic urethra is a conduit for semen and
prevents retrograde ejaculation (ie, ejaculation resulting in
semen being forced backwards into the bladder) by
closing off the bladder neck during sexual climax.
Definition:
-refers to the non-malignant growth or hyperplasia of
prostate tissue 
-there is an increase in the number of prostatic stromal
and epithelial cells, leading to the growth of prostate
tissue, typically within the transition zone of the prostate
Several definitions exist in the literature when describing
BPH. These include bladder outlet obstruction (BOO),
lower urinary tract symptoms (LUTS), and benign prostatic
enlargement (BPE).  Pathophysiology/Etiology:
BPH describes the histological changes
Benign prostatic enlargement (BPE) describes the
increased size of the gland (usually secondary to BPH)
Bladder outlet obstruction (BOO) describes the
obstruction to flow
Those with BPE who present with BOO are termed benign
prostatic obstruction.
Epidemiology:
Prevalence:
-commonly encountered in aging men
- increasing prevalence of BPH with age.
-a common cause of lower urinary tract symptoms in
aging men
Risk factors:
Risk factors may be divided into non-modifiable and
geographical location, and obesity, all shown to influence
the development of BPH.
Metabolic syndrome refers to conditions that include
hypertension, glucose intolerance/insulin resistance, and
dyslipidemia.
Meta-analysis has demonstrated those with metabolic
syndrome and obesity has significantly higher prostate
volumes.
Obesity has been shown to be associated with increased
risk of BPH in observational studies. Proposed
mechanisms include increased levels of systemic
inflammation and increased levels of estrogens.
Estrogen effects on the prostate gland may also be indirectly
mediated through alterations in other
serum hormones. Estrogens stimulate the pituitary release of
prolactin and prolactin induces prostate enlargement and
decreased apoptosis.
Genetic predisposition to BPH has been demonstrated in
cohort studies, first-degree relatives in one study
demonstrated a four-fold increase in the risk of BPH
compared to control.
Prostatic enlargement depends on the potent androgen
dihydrotestosterone (DHT).
-In the prostate gland, type II 5-alpha-reductase
metabolizes circulating testosterone into DHT, which
works locally, not systemically.
-DHT binds to androgen receptors in the cell nuclei,
potentially resulting in BPH.
-large numbers of alpha-1-adrenergic receptors are
located in the smooth muscle of the stroma and
capsule of the prostate, as well as in the bladder neck
(transition zone).
-Stimulation of these receptors causes an increase in
smooth-muscle tone, which can worsen LUTS.
Conversely, blockade of these receptors can reversibly relax
these muscles, with subsequent relief of LUTS.
The traditional theory behind BPH is that, as the prostate
enlarges, the surrounding capsule prevents it from
radially expanding, potentially resulting in urethral
compression..
As a result of compression of prostatic urethra, there will
be a concomitant bladder outlet obstruction.
This causes the bladder wall to hypertrophy due to
increasing pressure exerted to overcome the resistance of
the obstruction. The bladder wall becomes thickened,
trabeculated, and irritable
This also increases the sensitivity of bladder (detrusor
overactivity). Even with small volumes of urine in the
bladder, it gives the feeling of urge to urinate. Resulting
to symptom of urinary frequency. Also due to
obstruction, there is weak urinary stream.
Overtime, the bladder may gradually weaken due to
excessive deposition of collagen replacing or scarring
the smooth muscles/ detrussor and lose the ability to
empty completely
leading to increased residual urine volume and,
possibly, acute or chronic urinary retention.
Chronic bladder outlet obstruction (BOO) secondary to
BPH may lead to urinary retention, impaired kidney
function, recurrent urinary tract infections, gross
hematuria, and bladder calculi.  performed if the initial urinalysis findings indicate
Clinical Presentation:
Signs and symptoms
 Urinary frequency - The need to urinate frequently
during the day or night (nocturia), usually voiding
only small amounts of urine with each episode
 Urinary urgency - The sudden, urgent need to
urinate, owing to the sensation of imminent loss of
urine without control
 Hesitancy - Difficulty initiating the urinary stream;
interrupted, weak stream- straining
 Incomplete bladder emptying - The feeling of
persistent residual urine, regardless of the
frequency of urination
 Straining - The need strain or push (Valsalva
maneuver) to initiate and maintain urination in
order to more fully evacuate the bladder
 Decreased force of stream/weak stream - The
subjective loss of force of the urinary stream over
time
 Dribbling - The loss of small amounts of urine due
to a poor urinary stream
Complications:
Complications related to bladder outlet obstruction (BOO)
secondary to BPH include the following:
 Urinary retention
 Renal insufficiency
 Recurrent urinary tract infections
 Gross hematuria
 Bladder calculi
 Renal failure or uremia (rare in current practice)

Diagnosis:
Laboratory studies:
 Urinalysis - Examine the urine using dipstick
methods and/or via centrifuged sediment
evaluation to assess for the presence of blood,
leukocytes, bacteria, protein, or glucose
 Urine culture - This may be useful to exclude
infectious causes of irritative voiding and is usually
an abnormality
 Prostate-specific antigen (PSA) - Although BPH
does not cause prostate cancer, men at risk for BPH
are also at risk for this disease and should be
screened accordingly (although screening for
prostate cancer remains controversial)
 Electrolytes, blood urea nitrogen (BUN), and
creatinine - These evaluations are useful screening
tools for chronic kidney disease in patients who
have high postvoid residual (PVR) urine volumes;
however, a routine serum creatinine measurement
is not indicated in the initial evaluation of men with
lower urinary tract symptoms (LUTS) secondary to
BPH
Ultrasonography (abdominal, renal, transrectal) is useful
for helping to determine bladder and prostate size and
the degree of hydronephrosis (if any) in patients with
urinary retention or signs of renal insufficiency. Generally,
it is not indicated for the initial evaluation of
uncomplicated LUTS.
Cystoscopy may be indicated in patients scheduled for
invasive treatment or in whom a foreign body or
malignancy is suspected. In addition, endoscopy may be
indicated in patients with a history of sexually transmitted
disease (eg, gonococcal urethritis), prolonged
catheterization, or trauma.
Pharmacologic treatment
Prostate Symptom Score/American Urological
Association Symptom Index [IPSS/AUA-SI] score
≤7) and for those with moderate-to-severe
symptoms (IPSS/AUA-SI score ≥8) who are not
bothered by their symptoms and are not
experiencing complications of BPH. In those
patients, medical therapy is not likely to improve
their symptoms and/or quality of life (QOL).

Agents used in the treatment of BPH include the

Management: following:

Immediate:  Alpha-adrenergic receptor blockers

 5-alpha reductase inhibitors
Establish Diagnosis  Phosphodiesterase-5 enzyme inhibitors
 Anticholinergic agents
-Primary survey, history, secondary survey

-Laboratory tests and imaging Surgery

-establish severity of BPH  Transurethral resection of the prostate (TURP) - The

criterion standard for relieving BOO secondary to
The severity of BPH can be determined with the BPH
International Prostate Symptom Score
(IPSS)/American Urological Association Symptom  Open prostatectomy - Reserved for patients with:
Index (AUA-SI) 
o very large prostates (>75 g)
Questions concern incomplete emptying,
o patients with concomitant bladder stones
frequency, intermittency, urgency, weak stream,
or bladder diverticula
straining, and nocturia.
o patients who cannot be positioned for
transurethral surgery
Therapeutic options for benign prostatic hyperplasia
(BPH) include the following [1] :
Patients should be informed that the following
• Watchful waiting
lifestyle changes may help relieve symptoms of BPH:
• Drug therapy
 Avoid alcohol and caffeine
(eg, alpha-blockers, 5-alpha-reductase inhibitors)
 Avoid drinking fluids at bedtime; drink smaller
– For patients with bothersome, moderate-to-
amounts throughout the day
severe lower urinary tract symptoms (LUTS) from
BPH  Avoid taking decongestant and antihistamine
medications
• Interventional therapy (eg, transurethral
resection of the prostate [ TURP]) – For patients with  Get regular exercise
moderate-to-severe LUTS and those who have developed
acute urinary retention, or other complications of BPH  Make a habit of going to the bathroom when
theyhave the urge
Watchful waiting
 Practice double voiding (empty the bladder, wait a
-is the recommended strategy for patients with moment, then try again)
BPH who have mild symptoms (International
  Practice stress management and relaxation
techniques
Patients should be warned that if they become unable to
urinate, they are at risk for permanent kidney or bladder
injury and need to go to a hospital emergency
department.
A maximal flow rate (Qmax) is the single best
measurement, but a low Qmax does not help differentiate
between obstruction and poor bladder contractility. For
more detailed analysis, a pressure-flow study
(urodynamic testing) is required. A Qmax value of greater
than 15 mL/s is considered by many to be normal. A value
of less than 7 mL/s is widely accepted as low.
Obtain post-void residual (PVR) urine volume in order
to gauge the severity of bladder decompensation. PVR
can be determined invasively with a catheter or
noninvasively with a transabdominal ultrasonic scanner. A
high PVR (ie, 350 mL) may indicate bladder dysfunction
and/or bladder outlet obstruction and may predict a poor
response to treatment.
Short-term
The era of medical therapy for BPH dawned in the mid
1970s with the use of nonselective alpha-blockers such as
phenoxybenzamine. The medical therapeutic options for
BPH have evolved significantly since then, with the
development of receptor-specific alpha-blockers that
comprise current first-line therapy, as well as the approval
of 5-alpha-reductase inhibitors.
TURP has long been accepted as the criterion standard
for relieving bladder outlet obstruction (BOO) secondary
to BPH. In current clinical practice, most patients with BPH
do not present with obvious surgical indications; instead,
they often have milder lower urinary tract symptoms
(LUTS) and, therefore, are initially treated with medical
therapy. Several minimally invasive treatments for BOO
are also available.
The alpha-blocking agents studied in BPH can be
subgrouped according to receptor subtype selectivity and
the duration of serum elimination half-lives, as follows:
 Nonselective alpha-blockers - Phenoxybenzamine
 Selective short-acting alpha-1 blockers - Prazosin,
alfuzosin, indoramin
 Selective long-acting alpha-1 blockers -  Terazosin,
doxazosin, slow-release (SR) alfuzosin.
 Partially subtype (alpha-1a)–selective agents –
Tamsulosin (Flomax), silodosin (Rapaflo)
Two 5-alpha-reductase inhibitors (5-ARIs) are approved
for use in BPH: finasteride (Proscar) and
dutasteride (Avodart). American Urological Association
(AUA) guidelines advise that in men with lower urinary
tract symptoms (LUTS) and enlarged prostates, 5-
ARIs may help prevent progression of LUTS secondary to
BPH and reduce the risk of urinary retention and future
prostate-related surgery. 
Unlike alpha-blockers, which work by reducing smooth
muscle tone, 5-ARIs improve LUTS by reducing prostate
volume. Thus, patients with larger prostates may achieve a
greater benefit. Maximal reduction in prostate volume
requires 6 months of therapy.
results from a lack of 5-alpha-reductase activity.
Inhibition of 5-alpha-reductase type 2 blocks the
conversion of testosterone to DHT, resulting in lower
intraprostatic levels of DHT. 
Combination Therapy
American Urological Association (AUA) guidelines advise
that combination therapy with an alpha-blocker and a 5-
alpha-reductase inhibitor can be appropriate and effective
for patients with lower urinary tract symtpoms (LUTS) who
have enlarged prostates.  [1] The alpha-1-receptor blocker
provides rapid relief, while the 5-alpha-reductase inhibitor
targets the underlying disease process.  [13, 24]  A fixed-dose
combination capsule of tamsulosin 0.4 mg and
dutasteride 0.5 mg (Jalyn) is approved by the US Food
and Drug Administration (FDA) in 2010 for treatment of
symptomatic BPH in men with an enlarged prostate.
Transurethral Resection of the Prostate
TURP is considered the criterion standard for relieving
BOO secondary to BPH. The indications to proceed with a
surgical intervention include the following:
 Acute urinary retention
 Failed voiding trials
 Recurrent gross hematuria
 Urinary tract infection
  Renal insufficiency secondary to obstruction

Additional indications for surgical intervention include

failure of medical therapy, a desire to terminate medical
therapy, and/or financial constraints associated with
medical therapy. However, TURP carries a significant risk
of morbidity (18%) and a slight mortality risk (0.23%).

TURP is performed with regional or general

anesthesia and involves the placement of a working
sheath in the urethra through which a hand-held device
with an attached wire loop is placed. High-energy
electrical cutting current is run through the loop so that
the loop can be used to shave away prostatic tissue. The
entire device is usually attached to a video camera to
provide vision for the surgeon.

Although TURP is often successful, it has some drawbacks.

When prostatic tissue is cut away, significant bleeding
may occur, possibly resulting in termination of the
procedure, blood transfusion, and a prolonged hospital
stay. Patients are usually monitored overnight and
discharged the following morning, with or without a 
urinary catheter.

Open Prostatectomy

Open prostatectomy is now reserved for patients with any

of the following:

 A very large prostate (>75 g)

 Concomitant bladder stones or bladder diverticula

 INability to be positioned for transurethral surgery.

pen prostatectomy requires hospitalization and involves

the use of general/regional anesthesia and a lower
abdominal incision. The inner core of the prostate
(adenoma), which represents the transition zone, is
shelled out, thus leaving the peripheral zone behind. This
procedure may involve significant blood loss,
necessitating transfusion. Open prostatectomy usually has
an excellent outcome in terms of improvement of urinary
flow and urinary symptoms. Guidelines Summary

ong-term Monitoring The American Urological Association (AUA) updated its

Patients with BPH who have symptoms significant enough
to be placed on medication should be evaluated during
office visits to discuss the efficacy of the medication and
potential dose adjustment. These visits should take place
at least biannually. Patients should undergo prostate
cancer screening at least annually.
guideline on surgical management of lower urinary tract
symptoms (LUTS) attributed to benign prostatic
hyperplasia BPH) in 2020. Recommendations are listed
below; unless otherwise specified, recommendations are
based on clinical principles. [1]
Evaluation and Preoperative Testing
The initial evaluation of patients presenting with  Use a monopolar or bipolar approach to TURP,
bothersome LUTS possibly attributed to BPH should depending on clinician expertise with these
include the following: techniques.

 Medical history, utilizing the AUA Symptom Index he goals of pharmacotherapy for benign prostatic
(AUA-SI) hypertrophy (BPH) are to reduce morbidity and to prevent
complications. The agents used include the following,
 Physical examination alone or in combination:

 Urinalysis  Alpha-adrenergic blockers

 5-Alpha-reductase inhibitors

Prior to surgical intervention for LUTS attributed to BPH,  Phosphodiesterase-5 enzyme inhibitors
clinicians should do the following:

 Consider assessment of prostate size and shape via

abdominal or transrectal ultrasound, cystoscopy, or
by preexisting cross-sectional imaging (ie, magnetic
resonance imaging [MRI]/ computed tomography Long Term
[CT])

 Assess post-void residual (PVR)

 Consider uroflowmetry

 Consider pressure flow studies when diagnostic

uncertainty exists

Surgical Therapy

Surgery is recommended for patients with any of the

following resulting from BPH:

 Renal insufficiency

 Refractory urinary retention

 Recurrent urinary tract infections (UTIs)

 Recurrent bladder stones or gross hematuria

 LUTS, in patients unresponsive to, or unwilling to

use, other therapies

Clinicians should not perform surgery solely for an

asymptomatic bladder diverticulum. However, consider
evaluation for bladder outlet obstruction. 

Surgical approaches for men with LUTS attributed to BPH

are listed below.

Transurethral resection of the prostate (TURP):

 Offer TURP as a treatment option.