Contents

Search

benign prostatic hyperplasia (BPH)

A common disorder of men over the age of 50 characterized by enlargement of the prostate which may press against the urethra & obstruct the flow of urine. BPH is the most common cause of such anatomic obstruction in elderly men. Etiology: 1) cause unknown 2) does not occur in the absence of testes or androgens 3) begins in men at age 40, generally becomes symptomatic in 60s 4) high fat diet associated with BPH & prostate cancer [24] 5) risk factors a) smoking > 35 cigarettes/day b) abstinence from drinking Pathology: 1) arises from the transition zone 2) proliferation of glandular cells &/or smooth muscle cells 3) increased urinary outflow resistance 4) bladder detrusor muscle dysfunction Epidemiology: 1) prevalence of histologically confirmed BPH a) 50% in men > 60 years of age b) 90% in men > 90 years of age 2) 50% of men with microscopic BPH will develop macroscopic enlargement of the prostate 3) 50% of patients with prostatic enlargement will develop symptoms 4) 25% of men in the US will be treated for BPH Clinical manifestations: 1) also see lower urinary tract symptoms (LUTS) 2) also see AUA symptom index 3) urinary obstruction a) mechanism 1] dynamic component - alpha-adrenergic muscle fibers in prostate gland & in bladder capsule & neck contract increasing pressure on urethra 2] static component - glandular mass impinging upon urethra b) symptoms of urinary obstruction 1] urinary hesitancy 2] straining 3] dribbling 4] incomplete bladder emptying 5] urinary retention & overflow incontinence 4) irritation a) dysuria b) urinary frequency c) urgency d) nocturia e) urinary incontinence 5) enlarged prostate a) rubbery & smooth b) nodules, inhomogeniety may be a sign of malignancy 6) palpable distended bladder with severe obstruction 7) hematuria may occur, but may herald prostate carcinoma 8) hematospermia would suggest prostatitis Laboratory: 1) urinalysis a) pyuria suggests infection b) hematuria may be sign of: infection, malignancy c) trumps PVR even in the absence signs/symptoms of UTI [2] - ref [2] cites 'active urine sediment' as indicator of postobstructive uropathy 2) urine culture if pyuria (rule out infection) 3) serum chemistries not needed for diagnosis [2] a) urea nitrogen b) creatinine 4) prostate-specific antigen (PSA) - values above 10 ng/mL suggest prostate carcinoma or prostatitis - not needed for diagnosis of BPH [2] - obtain if rapid onset of symptoms or hematospermia Special laboratory: - postvoid residual volume quantifies urinary retention but is not needed for diagnosis of BPH [2] - cystoscopy not indicated for routine evaluation Radiology: 1) abdominal ultrasound a) if urinary retention b) rule out hydronephrosis c) assess post-void residual (PVR) 2) transrectal ultrasound a) palpable nodule b) elevated PSA c) assessment of prostate size Complications: 1) urinary tract infection 2) obstructive uropathy [6] 3) bladder stone 4) diverticula 5) hematuria 6) overactive bladder (see LUTS) Differential diagnosis: 1) prostatitis a) softer, more boggy gland b) may be tender c) urine culture may be positive d) hematospermia 2) prostate carcinoma a) hard nodule b) hematuria c) PSA > 10 ng/mL 3) urethral meatal stenosis 4) lower urinary tract symptoms (LUTS) urinary frequency & urinary urgency Management: 1) general a) depends on the severity of symptoms & whether or not the patient is bothered by these symptoms b) severity of symptoms may be assessed by AUA symptom index - symptoms rated as mild managed with observation [2] c) International Prostate Symptom Score alternate assessment of severity [33] d) reduce fluid intake, caffeinated beverages, alcohol e) evaluate for cognitive impairment, especially reversible causes [2] f) optimize mobility [2] g) scheduled toileting (bladder retraining) for urgency & urge incontinence h) avoid chronic indwelling catheter i) BPH complicated by recurrent urinary tract infections or elevated post-void residual volumes is best treated with surgery [36] 2) avoid medications that can worsen symptoms [6] a) alpha adrenergic agonists (OTC nasal decongestants) - may cause constriction of the muscle of the bladder neck & prostatic urethra [1] b) anticholinergics (parasympatholytics) - may worsen urinary retention - in combination with alpha blocker (GRS9) [1]; - decreases urinary frequency 30%; - decreases maximum flow rate 0.6 ml/sec; - increases post-void residual 11 mL; - number needed to cause 1 case of acute urinary retention = 101 [18] - low dose anticholinergic may be used without concern for urinary retention (GRS9) [1] - if major symptom is due to detrussor irritation & overactive bladder, anticholinergics may be of benefit [8,18,27] - (Detrol, Ditropan, tolterodine, fesoterodine etc ...) c) diuretics 3) alpha-1 adrenergic receptor antagonists a) alpha-1 receptor antagonist - tamsulosin (Flomax): - alfuzosin (Uroxatral) - may be agent of choice with orthostatic hypotension b) terazosin (Hytrin) start 1 mg QHS, increase to 10 mg QHS as tolerated c) prazosin (Minipress) d) doxazosin (Cardura) reduces daily symptoms, OK for elderly (GRS11) [1,5,11] - treats both symptomatic prostatic hypertrophy & uncontrolled hypertension [1] e) benefit may be apparent within 48 hours f) a 6 month trial is warranted before drug failure 4) 5-alpha reductase inhibitor a) finasteride (Proscar) 5 mg QD 1] minimizes need for invasive therapy [5] 2] not effective [11] 3] recommended as adjunctive treatment of BPH not responding adequately to alpha-1 blocker [2,15] 4] may take 4-6 months to be effective [1] b) dutasteride - appears to slow clinical progression of BPH [16] c) up to 6 months may be needed for benefit [2] - > 1 year of treatment for benefit [23] d) especially indicated if prostate is large (30-40 ml) [1,23] e) useful in patients with elevated serum PSA [2] f) combination of alpha-1 adrenergic receptor antagonist with 5-alpha reductase inhibitor may be more effective than either agent alone [2] 5) phosphodiesterase-5 inhibitor - tadalafil (Cialis) [20,33] - anticholinergic agent (tolterodine) preferred add-on therapy to tamsulosin especially with overactive bladder - see anticholinergics (parasympatholytics) above & combination therapy below 6) other hormonal therapies a) estrogens b) gonadotropin-releasing hormone (GnRH) analogues c) androgen antagonists d) dihydrotestosterone (available at compounding pharmacies) of no benefit [14] 7) combination therapy a) combination of alpha-1 adrenergic receptor antagonist plus 5-alpha reductase inhibitor (finasteride, dutasteride) works best to slow progression of BPH [2,4,5,10] b) combination of alpha-1 adrenergic receptor antagonist (tamsulosin) plus anticholineric (oxybutynin, tolterodine) - may be of benefit if overactive bladder [13,18] - minimal effect on urinary urgency & urinary frequency, potential adverse effects [35] - use in the elderly not recommended c) withdrawal of alpha-1 adrenergic receptor antagonist from combination therapy after 12 months does not exacerbate symptoms [28] 8) Saw palmetto not useful [7] 9) treatment of LUTS with Botox not useful [22] 10) surgery a) indications 1] ineffective medical therapy 2] persistent urinary retention 3] bladder stone 4] renal insufficiency 5] hematuria 6] recurrent urinary tract infection [2] b) procedures 1] transurethral resection (TURP) 2] open prostatectomy 3] transurethral a] incision (TUIP) b] laser resection (TULIP) c] thermotherapy 4] 8 endoscopic modalities all safer than TURP [31] a] bipolar TURP b] bipolar & laser enucleation c] bipolar vaporization d] laser vaporization (4 types) [31] 5] urethral stent 6] photoselective vaporization of the prostate (PVP) 7] prostatic implant (Urolift system) FDA-approved in 2013 8] Rezum water vapor therapy 9] prostatic urethral lift 11) interventional radiology - prostatic artery embolization. an outpatient procedure performed by interventional radiologists, is an option for managing urinary retention & severe hematuria caused by BPH [32] 12) indications for urology referral a) elevated PSA (see prostate specific antigen (PSA) in serum) b) hematuria: cystoscopy, upper urinary tract study c) symptoms of BPH not responding to medical therapy d) recurrent urinary tract infection e) severe irritative voiding symptoms - urgency, frequency may be a symptom of bladder cancer f) prostate nodule or induration [36] 12) patient education - prostatectomy does not eliminate prostate cancer risk

Related

American Urological Society (AUA) symptom index prostate cancer prostate specific antigen (PSA) in serum

General

prostatic disease hyperplasia chronic urogenital disease

References

  1. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Aronson WJ. in: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  4. Prescriber's Letter 9(7):41 2002
  5. Journal Watch 24(3):21, 2004 McConnell JD et al, The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 349:2387, 2003 PMID: 14681504
  6. Prescriber's Letter 11(1):3 2004 Detail-Document#: 200105 (subscription needed) http://www.prescribersletter.com
  7. Bent S et al, Saw palmetto for benign prostatic hyperplasia. N Engl J Med 2006, 354:557 PMID: 16467543 - Prescriber's Letter 13(3): 2006 Special Report: Natural Medicines in Clinical Management of Benign Prostatic Hyperplasia Detail-Document#: 220305 (subscription needed) http://www.prescribersletter.com - MacDonald R, Tacklind JW, Rutks I, Wilt TJ Serenoa repens monotherapy for benign prostatic hyperplasia (BPH): an updated Cochrane systematic review. BJU Int. 2012 Jun;109(12):1756-61. PMID: 22551330
  8. Prescriber's Letter 14(2): 2007 Pharmacotherapy of BPH with overactive bladder Detail-Document#: 230205 (subscription needed) http://www.prescribersletter.com
  9. Lepor H et al, The efficacy of terazosin, finasteride or both in benign prostatic hypertrophy. N Engl J Med 335:533 PMID: 8684407
  10. Roehrborn CG, Siami P, Barkin J, Damio R, Major-Walker K, Morrill B, Montorsi F; CombAT Study Group. The effects of dutasteride, tamsulosin and combination therapy on lower urinary tract symptoms in men with benign prostatic hyperplasia and prostatic enlargement: 2-year results from the CombAT study. J Urol. 2008 Feb;179(2):616-21; discussion 621. Epub 2007 Dec 21. PMID: 18082216
  11. Johnson TM 2nd, Burrows PK, Kusek JW, Nyberg LM, Tenover JL, Lepor H, Roehrborn CG; Medical Therapy of Prostatic Symptoms Research Group. The effect of doxazosin, finasteride and combination therapy on nocturia in men with benign prostatic hyperplasia. J Urol. 2007 Nov;178(5):2045-50; discussion 2050-1. Epub 2007 Sep 17. PMID: 17869295
  12. Prescriber's Letter 15(8): 2008 COMMENTARY: Combination Therapy for Benign Prostatic Hyperplasia (BPH) GUIDELINES: Management of Benign Prostatic Hyperplasia (Summary) GUIDELINES: Management of Benign Prostatic Hyperplasia (Canadian Guidelines) Detail-Document#: 240806 (subscription needed) http://www.prescribersletter.com
  13. MacDiarmid SA et al. Efficacy and safety of extended-release oxybutynin in combination with tamsulosin for treatment of lower urinary tract symptoms in men: Randomized, double-blind, placebo- controlled study. Mayo Clin Proc 2008 Sep; 83:1002. PMID: 18775200
  14. Idan A et al. Long-term effects of dihydrotestosterone treatment on prostate growth in healthy, middle-aged men without prostate disease: A randomized, placebo-controlled trial. Ann Intern Med 2010 Nov 15; 153:621. PMID: 21079217
  15. Juliao AA, Plata M, Kazzazi A, Bostanci Y, Djavan B. American Urological Association and European Association of Urology guidelines in the management of benign prostatic hypertrophy: revisited. Curr Opin Urol. 2012 Jan;22(1):34-9 PMID: 22123290
  16. Toren P et al Effect of dutasteride on clinical progression of benign prostatic hyperplasia in asymptomatic men with enlarged prostate: a post hoc analysis of the REDUCE study. BMJ 2013;346:f2109 PMID: 23587564
  17. Greco KA, McVary KT. The role of combination medical therapy in benign prostatic hyperplasia. Int J Impot Res. 2008 Dec;20 Suppl 3:S33-43 PMID: 19002123
  18. Filson CP et al. The efficacy and safety of combined therapy with alpha-blockers and anticholinergics for men with benign prostatic hyperplasia: A meta-analysis. J Urol 2013 Dec; 190:2153 PMID: 23727412 - NEJM Journal Watch. Jan 16, 2014 http://www.jwatch.org (subscription required)
  19. Paolone DR. Benign prostatic hyperplasia. Clin Geriatr Med. 2010 May;26(2):223-39 PMID: 20497842
  20. Roehrborn CG et al. Effects of tadalafil once daily on maximum urinary flow rate in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. J Urol 2014 Apr; 191:1045 PMID: 24445278 http://dx.doi.org/10.1016/j.juro.2013.10.074#sthash.Z5obxJcP.dpuf
  21. 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. PMID: 21420124
  22. McVary KT et al. A multicenter, randomized, double-blind, placebo controlled study of onabotulinumtoxinA 200 U to treat lower urinary tract symptoms in men with benign prostatic hyperplasia. J Urol 2014 Jul; 192:150. PMID: 24508634 http://www.jurology.com/article/S0022-5347%2814%2900249-3/abstract
  23. Fullhase C, Chapple C, Cornu JN, et al. Systematic review of combination drug therapy for non-neurogenic male lower urinary tract symptoms. Eur Urol. 2013;64:228-243 PMID: 23375241
  24. Shankar E, Bhaskaran N, MacLennan GT et al Inflammatory Signaling Involved in High-Fat Diet Induced Prostate Diseases. J Urol Res. 2015 Jan 1;2(1). pii: 1018. Epub 2015 PMID: 26417612
  25. AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol. 2003 Aug;170(2 Pt 1):530-47. PMID: 12853821
  26. Beckman TJ, Mynderse LA. Evaluation and medical management of benign prostatic hyperplasia. Mayo Clin Proc. 2005 Oct;80(10):1356-62. PMID: 16212149
  27. Lee SH, Lee JY. Current role of treatment in men with lower urinary tract symptoms combined with overactive bladder. Prostate Int. 2014;2(2):43-9. Review. PMID: 25032191 Free PMC Article
  28. Matsukawa Y, Takai S, Funahashi Y et al Effects of Withdrawing alpha1-Blocker from Combination Therapy with alpha1-Blocker and 5alpha-Reductase Inhibitor in Patients with Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia: A Prospective and Comparative Trial Using Urodynamics. J Urol. 2017 Oct;198(4):905-912. Epub 2017 May 10. PMID: 28499730
  29. Foster HE, Barry MJ, Dahm P, et al. Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline. J Urol. May 15, 2018. PMID: 29775639 https://www.ncbi.nlm.nih.gov/pubmed/29775639
  30. Sarma AV, Wei JT. Clinical practice. Benign prostatic hyperplasia and lower urinary tract symptoms. N Engl J Med 2012 Jul 20; 367:248 PMID: 22808960 https://www.nejm.org/doi/full/10.1056/NEJMcp1106637
  31. Huang SW, Tsai CY, Tseng CS et al. Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: Systematic review and network meta-analysis. BMJ 2019 Nov 14; 367:l5919 PMID: 31727627 Free Article
  32. Ayyagari R, Powell T, Staib L et al. Prostatic artery embolization in nonindex benign prostatic hyperplasia patients: Single-center outcomes for urinary retention and gross prostatic hematuria. Urology 2020 Feb; 136:212. PMID: 31734349 https://www.goldjournal.net/article/S0090-4295(19)30971-9/fulltext
  33. Lerner LB, McVary KT, Barry MJ et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA GUIDELINE PART I - Initial work-up and medical management. J Urol 2021 Oct; 206:806-817. PMID: 34384237 https://www.auajournals.org/doi/10.1097/JU.0000000000002183 - Lerner LB, McVary KT, Barry MJ et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA GUIDELINE PART II - Surgical evaluation and treatment. J Urol 2021 Oct; 206:818 PMID: 34384236 https://www.auajournals.org/doi/10.1097/JU.0000000000002184
  34. Wolinsky H A 'Cup of Tea' for the Prostate Improves Urine Flow. Medscape. Feb 24, 2922 https://www.medscape.com/viewarticle/969052 - Elterman D, Bhojani N, Vannabouathong C, Chughtai B, Zorn KC. Large, Multi-Center, Prospective Registry of Rezum Water Vapor Therapy for Benign Prostatic Hyperplasia. Urology. 2022 Feb 17:S0090-4295(22)00142-X PMID: 35182585
  35. Lenfant L et al. Role of antimuscarinics combined with alpha-blockers in the management of urinary storage symptoms in patients with benign prostatic hyperplasia: An updated systematic review and meta-analysis. J Urol 2023 Feb; 209:314. PMID: 36395428 https://www.auajournals.org/doi/10.1097/JU.0000000000003077
  36. NEJM Knowledge+ Nephrology/Urology
  37. Bortnick E, Brown C, Simma-Chiang V, Kaplan SA. Modern best practice in the management of benign prostatic hyperplasia in the elderly. Ther Adv Urol. 2020;12:1756287220929486. PMID: 32547642
  38. Lightner DJ, Gomelsky A, Souter L, et al. Diagnosis and treatment of overactive bladder (Non-neurogenic) in adults: AUA/SUFU guideline amendment 2019. J Urol. 2019;202:558-563. PMID: 31039103
  39. Prostate Enlargement: Benign Prostatic Hyperplasia http://kidney.niddk.nih.gov/kudiseases/pubs/prostateenlargement/index.htm - Medical Tests for Prostate Problems http://kidney.niddk.nih.gov/kudiseases/pubs/prostatetests/index.htm