Benign prostatic hypertrophy

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management

Definition

Benign Prostatic Hypertrophy (BPH), also known as benign prostatic enlargement (BPE), is a non-cancerous enlargement of the prostate gland that leads to bladder outlet obstruction and lower urinary tract symptoms (LUTS).

Aetiology

The exact cause of BPH is not fully understood, but it is associated with ageing and hormonal changes:

  • Increased dihydrotestosterone (DHT): DHT stimulates prostate cell growth.
  • Oestrogen influence: elevated oestrogen levels may contribute to glandular hyperplasia.
  • Chronic inflammation: may promote prostatic tissue remodelling.

Pathophysiology

  • Hyperplasia of stromal and epithelial cells leads to prostatic enlargement.
  • Increased resistance to urine flow results in bladder outlet obstruction.
  • Bladder detrusor muscle compensates by hypertrophy, but over time, it weakens, leading to urinary retention.

Risk Factors

  • Age >50 years.
  • Family history of BPH.
  • Obesity and metabolic syndrome.
  • Diabetes mellitus.
  • Physical inactivity.
  • Chronic inflammation.

Signs and Symptoms

Lower Urinary Tract Symptoms (LUTS):

  • Storage symptoms: increased frequency, urgency, nocturia.
  • Voiding symptoms: weak stream, hesitancy, dribbling.
  • Incomplete emptying: feeling of residual urine.
  • Acute urinary retention: sudden painful inability to pass urine.

Investigations

  • International Prostate Symptom Score (IPSS): assesses symptom severity.
  • Digital Rectal Examination (DRE): enlarged, smooth prostate.
  • Urinalysis: to exclude infection or haematuria.
  • Serum Prostate-Specific Antigen (PSA): raised in BPH but also in prostate cancer.
  • Renal Function Tests (U&Es): to assess for chronic retention.
  • Bladder Ultrasound: checks post void residual volume.

Management

1. Lifestyle Modifications:

  • Reduce caffeine and alcohol intake.
  • Bladder training to improve control.
  • Avoid late evening fluid intake.

2. Medical Treatment:

  • Alpha-blockers:
    • Tamsulosin 400mcg OD – relaxes prostate smooth muscle.
    • Side effects: postural hypotension, retrograde ejaculation.
  • 5-alpha reductase inhibitors:
    • Finasteride 5mg OD – reduces prostate size.
    • Useful in larger prostates (>40mL volume).
  • Anticholinergics: (e.g., Oxybutynin) for predominant storage symptoms.

3. Surgical Treatment:

  • Transurethral Resection of the Prostate (TURP): first line for severe symptoms.
  • Urolift: minimally invasive procedure to relieve obstruction.
  • Holmium Laser Enucleation of the Prostate (HoLEP): used in larger prostates.

4. Referral Criteria:

  • Recurrent urinary retention.
  • Haematuria without infection.
  • Raised PSA with suspicion of malignancy.
  • Failed medical management.
RenalmypanotesBenign prostatic hypertrophy, BPH