Benign Prostatic Hyperplasia (BPH)- Management

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland caused by progressive proliferation of prostatic stromal and epithelial cells. It is a common condition among ageing men and may lead to bladder outlet obstruction and lower urinary tract symptoms (LUTS).

BPH affects the transition zone of the prostate, causing compression of the prostatic urethra and increased resistance to urinary flow. The severity of symptoms varies between individuals and does not always correlate with the size of the prostate gland.

Management of BPH depends on symptom severity, which is commonly assessed using the International Prostate Symptom Score (IPSS). Patients are categorized as having mild, moderate, or severe symptoms, guiding decisions regarding observation, medical therapy, or surgical intervention.

Epidemiology

BPH is one of the most common urological conditions affecting older men. The prevalence increases with age, with histological evidence of prostatic enlargement found in a large proportion of men above 50 years.

Although prostate enlargement is common with ageing, only some men develop clinically significant lower urinary tract symptoms or complications requiring treatment.

Risk factors

• Increasing age

• Family history of BPH

• Obesity

• Metabolic syndrome

• Diabetes mellitus

• Reduced physical activity

• Hormonal changes associated with ageing

• Chronic inflammation of the prostate

• Cardiovascular disease

Pathophysiology

The development of BPH is associated with age-related hormonal changes, particularly the action of dihydrotestosterone (DHT), which is produced from testosterone by the enzyme 5-alpha reductase.

DHT stimulates growth of prostatic stromal and epithelial tissue, resulting in enlargement of the prostate, especially within the transition zone. The enlarged prostate compresses the urethra, increasing resistance to urine flow and causing bladder outlet obstruction.

Bladder smooth muscle responds by increasing contraction strength, leading initially to compensation. Over time, persistent obstruction causes bladder hypertrophy, reduced bladder compliance, incomplete emptying, urinary retention, and possible upper urinary tract complications.

Clinical presentation

Clinical manifestations are related to bladder outlet obstruction and changes in bladder function. Symptoms are classified into:

• Obstructive (voiding) symptoms

• Irritative (storage) symptoms

The severity of symptoms should be assessed using the International Prostate Symptom Score (IPSS).

Symptoms

Obstructive symptoms

• Weak urinary stream

• Intermittent urinary stream

• Difficulty initiating urination (hesitancy)

• Straining during urination

• Feeling of incomplete bladder emptying

• Prolonged urination

Irritative symptoms

• Urinary frequency

• Nocturia

• Urinary urgency

• Increased daytime urination

Complication-related symptoms

• Acute urinary retention

• Recurrent urinary tract infections

• Haematuria

• Bladder stones

• Lower abdominal discomfort

Clinical signs

• Digital rectal examination:

  • Uniform enlargement of the prostate

  • Smooth surface

  • Firm consistency

  • Palpable median sulcus

• Palpable enlarged bladder due to urinary retention

• Features of urinary tract obstruction

• Signs of complications such as recurrent infection or renal impairment

A distended bladder may occur even in patients without severe urinary symptoms; therefore, abdominal examination for bladder enlargement is important.

Diagnostic criteria

Diagnosis of BPH is based on:

• Presence of lower urinary tract symptoms

• Evidence of prostate enlargement

• Exclusion of other causes of urinary symptoms

Assessment should include:

• Symptom severity grading using the International Prostate Symptom Score (IPSS):

  • Mild symptoms

  • Moderate symptoms

  • Severe symptoms

Investigations

Digital rectal examination

Used to assess:

• Prostate size

• Surface characteristics

• Consistency

• Presence of nodules suggestive of malignancy

Urinalysis

Performed to detect:

• Urinary tract infection

• Haematuria

• Other urinary abnormalities

Prostate-specific antigen (PSA)

• PSA levels are usually within the normal range in uncomplicated BPH.

• Raised PSA requires evaluation for prostate cancer, prostatitis, or other causes.

Ultrasound examination

Pelvic or transrectal ultrasound may be used to:

• Confirm prostate enlargement

• Estimate prostate volume

• Assess bladder emptying

• Detect urinary stones or complications

Additional investigations where indicated

• Serum creatinine to assess renal function

• Post-void residual urine volume measurement

• Uroflowmetry

• Further urological assessment when diagnosis is uncertain or complications are present

Management

Management depends on symptom severity, patient preference, prostate size, and presence of complications.

The treatment approach includes:

• Lifestyle modification and monitoring for mild symptoms

• Medical therapy for moderate symptoms

• Surgical intervention for severe symptoms or complications

Non-pharmacological treatment

Mild symptoms (IPSS)

Patients with mild symptoms should undergo watchful waiting, including:

• Lifestyle modification

• Regular clinical follow-up

• Monitoring symptom progression

Lifestyle measures include:

• Reducing fluid intake, especially in the evening

• Avoiding caffeinated drinks

• Avoiding excessive alcohol intake

• Timed voiding and bladder training

• Maintaining physical activity

Severe symptoms

Patients with severe symptoms require surgical management.

Surgical options include:

• Transurethral resection of the prostate (TURP) for prostate glands weighing up to 75 g

• Open prostatectomy for prostate glands weighing more than 75 g

Acute urinary retention

• Insert a urethral catheter as a temporary measure.

• Transfer the patient to a facility with urological expertise for definitive management.

Medication review

Discontinue or modify medications that may worsen urinary obstruction, including:

• Tricyclic antidepressants

• Neuroleptics

• Other drugs causing impaired bladder emptying

Pharmacological treatment

Patients with moderate symptoms according to IPSS should receive medical therapy unless they choose surgical treatment.

Medical therapy includes:

• Alpha-adrenergic blockers

• 5-alpha reductase inhibitors

• Combination therapy where indicated

• Anticholinergic therapy for persistent storage symptoms

Adrenergic alpha blockers

• Tamsulosin 0.4 mg orally once daily.

OR

• Alfuzosin 10 mg orally once daily.

Alpha blockers improve urinary flow by relaxing smooth muscle in the prostate and bladder neck.

5-alpha reductase inhibitors

• Finasteride 5 mg orally once daily.

OR

• Dutasteride 0.5 mg orally once daily.

These medications reduce conversion of testosterone to dihydrotestosterone, leading to reduction in prostate volume over time.

Anticholinergics

For patients with persistent urinary urgency despite appropriate therapy:

• Oxybutynin 5 mg orally every 8 hours.

Patients should be monitored for urinary retention when anticholinergic medicines are used.

Management according to underlying cause

BPH with urinary retention

• Immediate bladder decompression using catheterization.

• Specialist evaluation for definitive treatment.

BPH with recurrent urinary tract infection

• Treat infection appropriately.

• Surgical management may be required to relieve obstruction.

BPH with haematuria

• Investigate other causes of haematuria.

• Refer for specialist evaluation.

BPH with renal impairment

• Assess renal function.

• Relieve obstruction to prevent further kidney damage.

BPH with bladder stones

• Surgical management is usually required.

Referral

Refer patients to a urologist or specialized centre if:

• Severe symptoms requiring surgery

• Acute urinary retention

• Recurrent urinary tract infections

• Haematuria associated with BPH

• Kidney insufficiency

• Bladder stones

• Hernia associated with chronic straining

• Failure of medical therapy

• Suspected prostate cancer

• Chronic or progressive symptoms

Complications

• Acute urinary retention

• Recurrent urinary tract infections

• Bladder stones

• Haematuria

• Bladder diverticula

• Renal impairment

• Hydronephrosis

• Recurrent catheter dependence

• Reduced quality of life

Prognosis

BPH is a chronic progressive condition. Many patients with mild symptoms remain stable with lifestyle modification and monitoring. Patients with moderate symptoms usually respond well to medical therapy. Severe symptoms and complications require surgical intervention, which generally provides significant improvement in urinary flow and quality of life.

Early recognition and appropriate management reduce the risk of urinary retention, infection, and renal complications.

Prevention

Although age-related prostate enlargement cannot be completely prevented, progression and complications may be reduced through:

• Regular medical assessment in older men with urinary symptoms

• Maintaining healthy body weight

• Regular physical activity

• Control of diabetes and cardiovascular risk factors

• Avoiding unnecessary medications that worsen urinary symptoms

• Early evaluation of lower urinary tract symptoms

• Prompt management of urinary obstruction