BenignProstaticHypertrophy

Author:LeviADeters,MDChiefEditor:EdwardDavidKim,MD,FACSmore...
Updated:Oct12,2015

PracticeEssentials
Benignprostatichyperplasia(BPH),alsoknownasbenignprostatichypertrophy,isahistologicdiagnosis
characterizedbyproliferationofthecellularelementsoftheprostate.Chronicbladderoutletobstruction(BOO)
secondarytoBPHmayleadtourinaryretention,renalinsufficiency,recurrenturinarytractinfections,gross
hematuria,andbladdercalculi.Theimagebelowillustratesnormalprostateanatomy.

Normalprostateanatomy.Theprostateislocatedattheapexofthebladderandsurroundstheproximalurethra.

Signsandsymptoms
Whentheprostateenlarges,itmayconstricttheflowofurine.Nerveswithintheprostateandbladdermayalsoplay
aroleincausingthefollowingcommonsymptoms:
Urinaryfrequency
Urinaryurgency
HesitancyDifficultyinitiatingtheurinarystreaminterrupted,weakstream
IncompletebladderemptyingThefeelingofpersistentresidualurine,regardlessofthefrequencyof
urination
StrainingTheneedstrainorpush(Valsalvamaneuver)toinitiateandmaintainurinationinordertomore
fullyevacuatethebladder
DecreasedforceofstreamThesubjectivelossofforceoftheurinarystreamovertime
DribblingThelossofsmallamountsofurineduetoapoorurinarystream
SeeClinicalPresentationformoredetail.

Diagnosis
Digitalrectalexamination
Thedigitalrectalexamination(DRE)isanintegralpartoftheevaluationinmenwithpresumedBPH.Duringthis
portionoftheexamination,prostatesizeandcontourcanbeassessed,nodulescanbeevaluated,andareas
suggestiveofmalignancycanbedetected.
Laboratorystudies
UrinalysisExaminetheurineusingdipstickmethodsand/orviacentrifugedsedimentevaluationtoassess
forthepresenceofblood,leukocytes,bacteria,protein,orglucose
UrinecultureThismaybeusefultoexcludeinfectiouscausesofirritativevoidingandisusuallyperformedif
theinitialurinalysisfindingsindicateanabnormality
ProstatespecificantigenAlthoughBPHdoesnotcauseprostatecancer,menatriskforBPHarealsoat
riskforthisdiseaseandshouldbescreenedaccordingly(althoughscreeningforprostatecancerremains
controversial)
Electrolytes,bloodureanitrogen(BUN),andcreatinineTheseevaluationsareusefulscreeningtoolsfor
chronicrenalinsufficiencyinpatientswhohavehighpostvoidresidual(PVR)urinevolumeshowever,a
routineserumcreatininemeasurementisnotindicatedintheinitialevaluationofmenwithlowerurinarytract
symptoms(LUTS)secondarytoBPH [1]

Ultrasonography
Ultrasonography(abdominal,renal,transrectal)isusefulforhelpingtodeterminebladderandprostatesizeandthe
degreeofhydronephrosis(ifany)inpatientswithurinaryretentionorsignsofrenalinsufficiency.Generally,theyare
notindicatedfortheinitialevaluationofuncomplicatedLUTS.
Endoscopyofthelowerurinarytract
Cystoscopymaybeindicatedinpatientsscheduledforinvasivetreatmentorinwhomaforeignbodyormalignancy
issuspected.Inaddition,endoscopymaybeindicatedinpatientswithahistoryofsexuallytransmitteddisease(eg,
gonococcalurethritis),prolongedcatheterization,ortrauma.
IPSS/AUASI
TheseverityofBPHcanbedeterminedwiththeInternationalProstateSymptomScore(IPSS)/AmericanUrological
AssociationSymptomIndex(AUASI)plusadiseasespecificqualityoflife(QOL)question.QuestionsontheAUA
SIforBPHconcernthefollowing:
Incompleteemptying
Frequency
Intermittency
Urgency
Weakstream
Straining
Nocturia
Othertests
FlowrateUsefulintheinitialassessmentandtohelpdeterminethepatientsresponsetotreatment
PVRurinevolumeUsedtogaugetheseverityofbladderdecompensationitcanbeobtainedinvasively
withacatheterornoninvasivelywithatransabdominalultrasonicscanner
PressureflowstudiesFindingsmayproveusefulforevaluatingforBOO
UrodynamicstudiesTohelpdistinguishpoorbladdercontractionability(detrusorunderactivity)fromBOO
CytologicexaminationoftheurineMaybeconsideredinpatientswithpredominantlyirritativevoiding
symptoms
SeeWorkupformoredetail.

Management
Pharmacologictreatment
AgentsusedinthetreatmentofBPHincludethefollowing:
Alpha1receptorblockers
Alphaadrenergicreceptorblockers
Phosphodiesterase5enzymeinhibitors
5alphareductaseinhibitors
Anticholinergicagents
Surgery
Transurethralresectionoftheprostate(TURP)ThecriterionstandardforrelievingBOOsecondarytoBPH
OpenprostatectomyReservedforpatientswithverylargeprostates(>75g),patientswithconcomitant
bladderstonesorbladderdiverticula,andpatientswhocannotbepositionedfortransurethralsurgery
Minimallyinvasivetreatment
Transurethralincisionoftheprostate(TUIP)
LasertreatmentUsedtocutordestroyprostatetissue
Transurethralmicrowavetherapy(TUMT)Generatesheatthatcausescelldeathintheprostate,leadingto
prostaticcontractionandvolumereduction
Transurethralneedleablationoftheprostate(TUNA)
HighintensityultrasonographicenergytherapyCurrentlyintheclinicaltrialstage
ProstaticstentsFlexibledevicesthatexpandwhenputinplacetoimprovetheflowofurinepastthe
prostate
Laparoscopicprostatectomy
SeeTreatmentandMedicationformoredetail.

Background
Benignprostatichyperplasia(BPH),alsoknownasbenignprostatichypertrophy,isahistologicdiagnosis
characterizedbyproliferationofthecellularelementsoftheprostate.Cellularaccumulationandglandenlargement
mayresultfromepithelialandstromalproliferation,impairedpreprogrammedcelldeath(apoptosis),orboth.
BPHinvolvesthestromalandepithelialelementsoftheprostatearisingintheperiurethralandtransitionzonesof
thegland(seePathophysiology).Thehyperplasiapresumablyresultsinenlargementoftheprostatethatmay
restricttheflowofurinefromthebladder.
BPHisconsideredanormalpartoftheagingprocessinmenandishormonallydependentontestosteroneand
dihydrotestosterone(DHT)production.Anestimated50%ofmendemonstratehistopathologicBPHbyage60
years.Thisnumberincreasesto90%byage85years.
Thevoidingdysfunctionthatresultsfromprostateglandenlargementandbladderoutletobstruction(BOO)is
termedlowerurinarytractsymptoms(LUTS).Ithasalsobeencommonlyreferredtoasprostatism,althoughthis
termhasdecreasedinpopularity.TheseentitiesoverlapnotallmenwithBPHhaveLUTS,andlikewise,notall
menwithLUTShaveBPH.ApproximatelyhalfofmendiagnosedwithhistopathologicBPHdemonstratemoderate
tosevereLUTS.

ClinicalmanifestationsofLUTSincludeurinaryfrequency,urgency,nocturia(awakeningatnighttourinate),
decreasedorintermittentforceofstream,orasensationofincompleteemptying.Complicationsoccurless
commonlybutmayincludeacuteurinaryretention(AUR),impairedbladderemptying,theneedforcorrective
surgery,renalfailure,recurrenturinarytractinfections,bladderstones,orgrosshematuria.(SeeClinical
Presentation.)
ProstatevolumemayincreaseovertimeinmenwithBPH.Inaddition,peakurinaryflow,voidedvolume,and
symptomsmayworsenovertimeinmenwithuntreatedBPH(seeWorkup).TheriskofAURandtheneedfor
correctivesurgeryincreaseswithage.
PatientswhoarenotbotheredbytheirsymptomsandarenotexperiencingcomplicationsofBPHshouldbe
managedwithastrategyofwatchfulwaiting.PatientswithmildLUTScanbetreatedinitiallywithmedicaltherapy.
Transurethralresectionoftheprostate(TURP)isconsideredthecriterionstandardforrelievingbladderoutlet
obstruction(BOO)secondarytoBPH.However,thereisconsiderableinterestinthedevelopmentofminimally
invasivetherapiestoaccomplishthegoalofTURPwhileavoidingitsadverseeffects(seeTreatmentand
Management).

Anatomy
Theprostateisawalnutsizedglandthatformspartofthemalereproductivesystem.Itislocatedanteriortothe
rectumandjustdistaltotheurinarybladder.Itisincontinuumwiththeurinarytractandconnectsdirectlywiththe
penileurethra.Itisthereforeaconduitbetweenthebladderandtheurethra.(Seetheimagebelow.)

Normalprostateanatomy.Theprostateislocatedattheapexofthebladderandsurroundstheproximalurethra.

Theglandiscomposedofseveralzonesorlobesthatareenclosedbyanouterlayeroftissue(capsule).These
includetheperipheral,central,anteriorfibromuscularstroma,andtransitionzones.BPHoriginatesinthetransition
zone,whichsurroundstheurethra.

Pathophysiology
Prostaticenlargementdependsonthepotentandrogendihydrotestosterone(DHT).Intheprostategland,typeII5
alphareductasemetabolizescirculatingtestosteroneintoDHT,whichworkslocally,notsystemically.DHTbindsto
androgenreceptorsinthecellnuclei,potentiallyresultinginBPH.
Invitrostudieshaveshownthatlargenumbersofalpha1adrenergicreceptorsarelocatedinthesmoothmuscleof
thestromaandcapsuleoftheprostate,aswellasinthebladderneck.Stimulationofthesereceptorscausesan
increaseinsmoothmuscletone,whichcanworsenLUTS.Conversely,blockadeofthesereceptors(seeTreatment
andManagement)canreversiblyrelaxthesemuscles,withsubsequentreliefofLUTS.
Microscopically,BPHischaracterizedasahyperplasticprocess.Thehyperplasiaresultsinenlargementofthe
prostatethatmayrestricttheflowofurinefromthebladder,resultinginclinicalmanifestationsofBPH.The
prostateenlargeswithageinahormonallydependentmanner.Notably,castratedmales(ie,whoareunableto
maketestosterone)donotdevelopBPH.
ThetraditionaltheorybehindBPHisthat,astheprostateenlarges,thesurroundingcapsulepreventsitfromradially
expanding,potentiallyresultinginurethralcompression.However,obstructioninducedbladderdysfunction
contributessignificantlytoLUTS.Thebladderwallbecomesthickened,trabeculated,andirritablewhenitisforced
tohypertrophyandincreaseitsowncontractileforce.
Thisincreasedsensitivity(detrusoroveractivity[DO]),evenwithsmallvolumesofurineinthebladder,isbelievedto
contributetourinaryfrequencyandLUTS.Thebladdermaygraduallyweakenandlosetheabilitytoempty
completely,leadingtoincreasedresidualurinevolumeand,possibly,acuteorchronicurinaryretention.
Inthebladder,obstructionleadstosmoothmusclecellhypertrophy.Biopsyspecimensoftrabeculatedbladders
demonstrateevidenceofscarcesmoothmusclefiberswithanincreaseincollagen.Thecollagenfiberslimit
compliance,leadingtohigherbladderpressuresuponfilling.Inaddition,theirpresencelimitsshorteningofadjacent
smoothmusclecells,leadingtoimpairedemptyingandthedevelopmentofresidualurine.
Themainfunctionoftheprostateglandistosecreteanalkalinefluidthatcomprisesapproximately70%ofthe
seminalvolume.Thesecretionsproducelubricationandnutritionforthesperm.Thealkalinefluidintheejaculate
resultsinliquefactionoftheseminalplugandhelpstoneutralizetheacidicvaginalenvironment.

Theprostaticurethraisaconduitforsemenandpreventsretrogradeejaculation(ie,ejaculationresultinginsemen
beingforcedbackwardsintothebladder)byclosingoffthebladderneckduringsexualclimax.Ejaculationinvolvesa
coordinatedcontractionofmanydifferentcomponents,includingthesmoothmusclesoftheseminalvesicles,vasa
deferentia,ejaculatoryducts,andtheischiocavernosusandbulbocavernosusmuscles.

Epidemiology
BPHisacommonproblemthataffectsthequalityoflifeinapproximatelyonethirdofmenolderthan50years.
BPHishistologicallyevidentinupto90%ofmenbyage85years.Asmanyas14millionmenintheUnitedStates
havesymptomsofBPH.Worldwide,approximately30millionmenhavesymptomsrelatedtoBPH.
TheprevalenceofBPHinwhiteandAfricanAmericanmenissimilar.However,BPHtendstobemoresevereand
progressiveinAfricanAmericanmen,possiblybecauseofthehighertestosteronelevels,5alphareductaseactivity,
androgenreceptorexpression,andgrowthfactoractivityinthispopulation.Theincreasedactivityleadstoan
increasedrateofprostatichyperplasiaandsubsequentenlargementanditssequelae.

Prognosis
Inthepast,chronicendstageBOOoftenledtorenalfailureanduremia.Althoughthiscomplicationhasbecome
muchlesscommon,chronicBOOsecondarytoBPHmayleadtourinaryretention,renalinsufficiency,recurrent
urinarytractinfections,grosshematuria,andbladdercalculi.

PatientEducation
Forpatienteducationinformation,seetheProstateHealthCenterandKidneysandUrinarySystemCenter,aswell
asEnlargedProstate,BladderControlProblems,andInabilitytoUrinate.
ClinicalPresentation

ContributorInformationandDisclosures
Author
LeviADeters,MDAttendingPhysician,SpokaneUrology
Disclosure:Nothingtodisclose.
Coauthor(s)
RaymondJLeveillee,MD,FRCS(Glasg)ProfessorofClinicalUrology,RadiologyandBiomedicalEngineering,
DepartmentofUrology,UniversityofMiamiMillerSchoolofMedicineChief,Divisionof
Endourology/LaparoscopyandMinimallyInvasiveSurgery,DepartmentofUrology,JacksonMemorialHospital
RaymondJLeveillee,MD,FRCS(Glasg)isamemberofthefollowingmedicalsocieties:AmericanUrological
Association,EndourologicalSociety,SigmaXi,SocietyofLaparoendoscopicSurgeons
Disclosure:ReceivedhonorariafromACMI/GyrusforspeakingandteachingReceivedhonorariafromBoston
ScientificforspeakingandteachingReceivedhonorariafromAppliedMedicalforspeakingandteaching
ReceivedhonorariafromIntuitiveSurgicalforspeakingandteachingReceivedgrant/researchfundsfromIntio
forother.
VipulRPatel,MDConsultingSurgeon,GlobalRoboticsInstitute,FloridaHospitalCelebrationHealth
VipulRPatel,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,American
UrologicalAssociation,EndourologicalSociety,OhioStateMedicalAssociation,SocietyofLaparoendoscopic
Surgeons
Disclosure:ReceivedhonorariafromIntuitiveSurgicalforspeakingandteachingReceivedhonorariafromPfizer
forspeakingandteaching.
RaymondACostabile,MDJayYGillenwaterProfessorofUrologyandViceChairman,SeniorAssociateDean
forClinicalStrategy,UniversityofVirginiaHealthSystem
RaymondACostabile,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
MedicalAssociation,AmericanSocietyofAndrology,AmericanUrologicalAssociation,PhiBetaKappa
Disclosure:Nothingtodisclose.
CharlesRMoore,MDEndourologyFellow,DepartmentofUrology,UniversityofMiamiSchoolofMedicine
CharlesRMoore,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanUrological
Association
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
ChiefEditor
EdwardDavidKim,MD,FACSProfessorofSurgery,DivisionofUrology,UniversityofTennesseeGraduate
SchoolofMedicineConsultingStaff,UniversityofTennesseeMedicalCenter
EdwardDavidKim,MD,FACSisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,
TennesseeMedicalAssociation,SexualMedicineSocietyofNorthAmerica,AmericanSocietyforReproductive
Medicine,AmericanSocietyofAndrology,AmericanUrologicalAssociation

Disclosure:Serve(d)asadirector,officer,partner,employee,advisor,consultantortrusteefor:Repros.
Acknowledgements
TheauthorsandeditorsofMedscapeReferencegratefullyacknowledgethecontributionsofpreviousauthor
VincentGBird,MD,tothedevelopmentandwritingofthesourcearticle.

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