Benign prostatic hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) is a non-malignant enlargement of the prostate gland resulting from hyperplasia of stromal and epithelial cells within the transitional zone of the prostate. The condition commonly affects ageing men and leads to lower urinary tract symptoms (LUTS) due to bladder outlet obstruction.

BPH prevalence increases progressively with age and represents one of the most common causes of urinary symptoms in men over 50 years. Management depends primarily on symptom severity assessed using the International Prostate Symptom Score (IPSS) and the presence of complications.

Risk Factors

Non-Modifiable Risk Factors

• Increasing age (>50 years)

• Male sex hormones (androgen-dependent growth)

• Family history of BPH

• Genetic predisposition

Modifiable Risk Factors

• Obesity

• Sedentary lifestyle

• Metabolic syndrome

• Diabetes mellitus

• Hypertension

• Excess alcohol intake

Pathophysiology

BPH results from:

• Increased activity of 5-alpha reductase enzyme

• Conversion of testosterone to dihydrotestosterone (DHT)

• Prostatic stromal and epithelial proliferation

• Progressive compression of the urethra

• Increased bladder outlet resistance

Chronic obstruction may lead to:

• Bladder hypertrophy

• Reduced bladder compliance

• Urinary retention

• Renal impairment

Signs and Symptoms

Symptoms are divided into:

1. Voiding (Obstructive) Symptoms

• Weak urinary stream

• Hesitancy

• Intermittent stream

• Straining during urination

• Prolonged voiding

• Incomplete bladder emptying

• Post-void dribbling

2. Storage (Irritative) Symptoms

• Urinary frequency

• Nocturia

• Urgency

• Urge incontinence

Complicated Presentation

• Acute urinary retention

• Recurrent urinary tract infections

• Hematuria

• Bladder stones

• Renal insufficiency

Diagnostic Criteria

Diagnosis is clinical and supported by investigations:

• Weak, intermittent urinary stream

• Irritative voiding symptoms

• Digital rectal examination (DRE):

  • Smooth

  • Firm

  • Symmetrically enlarged prostate

• Possible palpable distended bladder

• Pelvic or transrectal ultrasound confirming enlargement

• PSA usually within normal range (used mainly to exclude prostate cancer)

Investigations

Clinical Assessment

• International Prostate Symptom Score (IPSS)

• Quality of Life (QoL) assessment

• Abdominal examination for bladder distension

• Digital rectal examination

Laboratory Tests

• Urinalysis (exclude infection/hematuria)

• Serum creatinine and renal function tests

• Prostate Specific Antigen (PSA)

Imaging

• Ultrasound kidney–ureter–bladder (KUB)

• Transrectal ultrasound (TRUS)

• Post-void residual urine measurement

Additional Tests (When Indicated)

• Uroflowmetry

• Cystoscopy

• Urodynamic studies

Management

Treatment depends on:

• IPSS severity score

• Degree of obstruction

• Presence of complications

• Patient preference

Non-Pharmacological Management

Watchful Waiting (Mild Symptoms)

Recommended for IPSS mild disease.

Lifestyle modification includes:

• Reduce evening fluid intake

• Limit caffeine and alcohol

• Timed voiding

• Weight reduction

• Regular follow-up monitoring

Management of Acute Urinary Retention

• Immediate urethral catheterization

• Stabilization before referral

• Trial without catheter after treatment initiation

Surgical Management

Indications:

• Severe symptoms

• Recurrent urinary retention

• Recurrent UTI

• Hematuria due to BPH

• Bladder stones

• Renal insufficiency

Procedures:

Transurethral Resection of Prostate (TURP)

• Prostate ≤75 g

• Gold standard procedure

Open Prostatectomy

• Prostate >75 g

Other minimally invasive options (specialist centres):

• Laser prostatectomy

• Prostatic urethral lift

Pharmacological Management

Patients with moderate symptoms (IPSS) should receive medical therapy unless surgery is preferred.

1. Alpha-Adrenergic Blockers

Relax smooth muscle of prostate and bladder neck.

• Tamsulosin 0.4 mg orally once dailyOR

• Alfuzosin 10 mg orally once daily

Benefits:

• Rapid symptom relief

• Improved urinary flow

Side effects:

• Postural hypotension

• Dizziness

• Ejaculatory dysfunction

2. 5-Alpha Reductase Inhibitors

Reduce prostate size by inhibiting DHT formation.

• Finasteride 5 mg orally once dailyOR

• Dutasteride 0.5 mg orally once daily

Best for:

• Enlarged prostate (>40 g)

• Long-term disease control

Effects appear after 3–6 months.

3. Combination Therapy

Alpha blocker + 5-alpha reductase inhibitor recommended for:

• Moderate–severe symptoms

• Large prostate volume

• High risk of progression

Medication Review

Avoid drugs worsening obstruction:

• Tricyclic antidepressants

• Anticholinergics

• Neuroleptics

• Decongestants

Referral

Refer patients with:

• Recurrent urinary retention

• Recurrent urinary tract infections

• Hematuria

• Bladder stones

• Renal impairment

• Suspected prostate cancer

• Failure of medical therapy

Referral should be made to centres with urological expertise.

Complications

• Acute urinary retention

• Chronic urinary retention

• Hydronephrosis

• Chronic kidney disease

• Recurrent UTIs

• Bladder diverticula

• Bladder calculi

Prevention

Primary Prevention

• Maintain healthy weight

• Regular physical activity

• Control diabetes and hypertension

• Reduce alcohol intake

Secondary Prevention

• Early evaluation of urinary symptoms

• Routine screening in ageing men

• Regular follow-up for diagnosed patients

Patient Education

Patients should be advised that:

• BPH is not cancer.

• Symptoms progress gradually.

• Early treatment prevents complications.

• Medication improves symptoms but may require long-term use.

• Sudden inability to pass urine is a medical emergency.

Prognosis

BPH is a chronic but manageable condition. With appropriate therapy:

• Symptom control is excellent.

• Progression can be slowed.

• Surgical outcomes are generally favourable.