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

• Etiology is multifactorial but the development of benign prostatic hyperplasia (BPH) requires both

  • The effect of endocrine compounds (eg, dihydrotestosterone [DHT]) on prostate growth and

  • The impact of aging

Demographics

• Common

• Incidence rises with increasing age

• Prevalence

  • ∼20% in men aged 41–50

  • ∼50% in men aged 51–60

  • > 90% in men over age 80

• Bothersome urinary symptoms related to BPH also increase with age

  • 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

• History to reveal comorbidities such as diabetes mellitus, heart failure, Parkinson disease, and obstructive sleep apnea

• 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 minutes)

  • Straining to urinate

  • Postvoid dribbling

• Irritative symptoms

  • Urgency

  • Dysuria

  • Frequency

  • Nocturia

• American Urological Association (AUA) symptom index (Table 25–4)

  • Used to establish a baseline and to monitor response to treatment or disease progression over time

  • Patients with significant nocturia should be assessed for 24-hour polyuria or nocturnal polyuria

  • A simple frequency-volume chart is a useful tool to identify these patients

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