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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 interventions.

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 symptomatic BPH.3

Figure 31-1.

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 Group.)

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 diagnostic evaluation.4,6

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