A systematic search of medical literature was performed on July
21, 2005, and again on August 8, 2007, for relevant clinical trials
and reviews using the terms benign prostatic
hyperplasia, BPH, lower urinary tract symptoms, LUTS, alpha-receptor
antagonists, alpha-blockers, and 5-alpha-reductase inhibitors. The
search, limited to human subjects and journals in English language,
included the Cochrane database, PubMed, and UpToDate®.
Benign prostatic hyperplasia (BPH) is a very common condition
in aging men. Lower urinary tract symptoms (LUTS) are the clinical
hallmark of BPH. Diagnosis of BPH is a process of exclusion of other
potential causes of LUTS through history, physical examination,
and selected laboratory tests. Once BPH is diagnosed, treatment
may be safely undertaken using pharmacologic and/or surgical
The prostate is a chestnut-shaped gland responsible for the production
of the milky fluid discharged during male ejaculation. It is also
structured similar to a doughnut, with the male urethra passing
through the doughnut hole, and it is highly innervated with alpha-1
adrenergic receptors (Fig. 31-1). BPH is common in men due to age
and testosterone-related enlargement of the prostate. Smoking, ethnic
origin, chronic diseases, and other factors may relate to enlargement
of the prostate, but these have not been well defined. At autopsy,
pathologically demonstrated BPH is frequently found in men, including
about 8% of men, aged 30 to 40 years, 50% of men,
aged 50 to 60 years, and more than 80% of men older than
70 years.1,2 One study found a 45% chance that
a 45-year-old asymptomatic man who lives to the age of 75 will develop
Representation of the anatomy of and alpha-adrenergic
receptor distribution in the prostate, urethra, and bladder. (from
Narayan P, Indudhara R. West J Med.
1994;161:501. Reproduced with permission from the BMJ Publishing
LUTS are the hallmark of symptomatic BPH. LUTS include weak stream,
frequency, nocturia, intermittent stream, incomplete emptying, straining,
and urgency. The American Urological Association (AUA) has developed
a tool called the “Symptom Index for BPH” used
to quantify the subjective symptom severity,4 which asks
the patient to grade the severity of these seven symptoms on a scale
from 0 to 5. The score can help guide the need for intervention
as well as evaluate efficacy of treatment.
Complications of BPH include acute urinary retention, urinary
tract infection, chronic renal failure, overflow urinary incontinence,
bladder stones, and the need for prostate surgery (including subsequent
adverse effects discussed in the section on “Surgery”).
The goal of the initial evaluation—history, physical
examination, and laboratory tests—is to identify other
medical conditions that might be the cause of LUTS so that an appropriate
treatment can be instituted. Table 31-1 presents a summary of the
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