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For further information, see CMDT Part 23-08: Benign Prostatic Hyperplasia

Key Features

Essentials of Diagnosis

  • Obstructive or irritative voiding symptoms

  • Enlarged prostate on rectal examination

  • Absence of urinary tract infection, neurologic disorder, urethral stricture disease, prostatic or bladder malignancy

General Considerations

  • Smooth, firm, elastic enlargement of the prostate


  • Multifactorial

  • Endocrine: dihydrotestosterone (DHT)

  • Aging


  • The most common benign tumor in men

  • Incidence is age related

  • Prevalence

    • ~20% in men aged 41–50

    • ~50% in men aged 51–60

    • > 90% in men aged 80 and older

  • Symptoms are also age related

    • At age 55, ~25% of men report obstructive voiding symptoms

    • At age 75 years, 50% of men report a decrease in the force and caliber of the urinary stream

Clinical Findings

History and Physical Examination

  • History to exclude other possible causes of symptoms

  • Physical examination, digital rectal examination (DRE), and a focused neurologic examination

  • DRE: note size and consistency of the prostate

  • Examine lower abdomen for a distended bladder

Symptoms and Signs

  • Can be divided into obstructive and irritative complaints

  • Obstructive symptoms

    • Hesitancy

    • Decreased force and caliber of stream

    • Sensation of incomplete bladder emptying

    • Double voiding (urinating a second time within 2 h)

    • Straining to urinate

    • Postvoid dribbling

  • Irritative symptoms

    • Urgency

    • Frequency

    • Nocturia

  • American Urological Association (AUA) Symptom Index (Table 23–3) should be calculated for all patients starting therapy

    • Seven questions quantitate the severity of obstructive or irritative complaints on a scale of 0–5. Thus, the score can range from 0 to 35

    • An estimation of post-void residual can provide important information on bladder emptying and the need for more urgent intervention

Table 23–3.American Urological Association symptom index for benign prostatic hyperplasia.1

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