Brief Overview: BPH is a common condition treated in primary care and general urology. BPH is the change of prostate cells increasing and size and number which frequently causes outflow obstruction and obstructive voiding symptoms including decreased force of urine stream, intermittent stream, hesitancy, etc. May or may not include an enlargement in the size of the prostate gland itself. It is typically divided into categories of obstructing/nonobstructing and with or without LUTS (lower urinary trace symptoms).
- 0 Enlarged prostate without LUTS
- 1 Enlarged prostate with LUTS
- Histologic evidence of BPH increases with age
- 30s- 10%
- 40s- 20%
- 60s- 50-60%
- 70/80s- 80-90%
- Men with significant prostate enlargement are 3.5 times more likely to have moderate-severe LUTS
- Having histologic changes of BPH does not always result in clinical symptoms!
Etiology: BPH is a condition that is defined as histologic (or cellular level) changes within the prostate gland, including abnormal microscopic hyperplasia and macroscopic growth, or growth in the size and/or number of prostatic cells. An increasing rise in detrusor (or bladder muscle) pressure to overcome the outlet resistance causes common storage symptoms of frequency, urgency, and nocturia. Chronic outlet obstruction can lead to bladder decompensation, or inability to achieve the pressure needed to fully empty the bladder.
Risk factors:- Primarily family history and advancing age.
- A family history of BPH can influence younger age of onset and larger prostate glands.
- Weak evidence for environmental, dietary, or lifestyle factors.
- OAB- urinary urgency, frequency, nocturia, and urge incontinence
- Sexual dysfunction- erectile and/or ejaculatory dysfunction
- Voiding/obstructive symptoms- hesitancy, intermittency, weak stream, straining to initiate stream, postvoid dribbling, incomplete emptying
- Storage symptoms or irritative voiding symptoms-
- Frequency, nocturia, urgency, urge incontinence, enuresis, dysuria
- Contributing factors of both types of symptoms can include medications- cold medications, particularly decongestants/antihistamines, and diuretics
- IPSS (International Prostate Symptom Score) is a standardized screening tool used to determine the severity of symptoms and responses to treatment. 0-7=mild, 8-19= moderate, 20-35= severe.
- Urinalysis to r/o infection
- Uroflowmetry- a noninvasive urodynamic study that measures voided volume, voiding time, and average and maximum flow rates. The patient voids into a funnel that collects into a graduated canister, the canister sits on a calibrated device that generates these measurements.
- PVR- Post void residual, used to measure the urine volume remaining in the bladder after voiding. May not correlate with the severity of symptoms.
- Voiding diaries- helpful for monitoring irritative voiding symptoms for establishing a baseline and treatment response
- Cystoscopy- not essential for diagnosis of BPH, but used for ruling out malignancy, obstruction by foreign body, or stricture. Useful for evaluating the lower urinary tract to determine the most appropriate surgical treatments/minimally invasive options.
- General evaluation of abdomen/pelvis for bladder distention, masses; anus and rectum for tone/masses
- DRE- Digital rectal examination- used to estimate prostate size and detect abnormal findings such as firmness, nodularity concerning for malignancy. Can be hot, boggy w/ prostatitis.
- Treatment options directed at quality of life and preventing complications including hydronephrosis, bladder calculi, recurrent infections, and urinary retention.
- Consider monitoring and conservative lifestyle interventions for mild symptoms. This includes routine IPSS monitoring, fluid restrictions, decreased alcohol, caffeine intake.
- 1st line treatment is medical therapy, which may require multiple medications and approaches for symptom control.
- Alpha blockers- tamsulosin, alfuzosin, doxazosin, terazosin, silodosin.
- The most common side effects include dizziness, orthostatic hypotension, and ejaculatory dysfunction including retrograde ejaculation.
- 5-alpha reductase inhibitors- finasteride, dutasteride.
- Best used for larger-volume glands. Blocks cell regeneration cycles, therefore delayed onset of symptom improvement, up to 6-12 mo.
- Generally well tolerated, but can rarely cause impotence, abnormal ejaculation, or gynecomastia.
- PDE-5- Tadalafil/Cialis. 5mg daily dosage, FDA approved for BPH/ED-contraindicated in CAD, use of nitrates for chest pain.
- Patients may use one or a combination of both for maximum medical therapy.
- Occasionally OAB medications are added in addition to this for help with irritative voiding symptoms such as frequency, urgency, and incontinence- but must be used with caution due to the risk of retention.
- Alpha blockers- tamsulosin, alfuzosin, doxazosin, terazosin, silodosin.
- 2nd line treatment is surgical intervention after failure of maximum medical therapy, or 1st line if severe urinary retention/very large volume prostate gland.
- TURP (Transurethral resection of prostate) is the gold standard. Risks include urinary incontinence and erectile dysfunction due to heat/electricity used during the procedure. Typically involves a hospital stay, continuous bladder irrigation, and short-term catheter use.
- Many minimally invasive surgical procedures exist
- Urolift-surgical clips to retract prostatic urethra
- ITIND-stent type structure
- Rezum- water/steam vaporization
- Aquablation-high pressure water dissection of tissue
- TUNA- transurethral needle ablation
- TUIP- Transurethral incision of prostate
- Laser resection/enucleation/ablation of prostate
- Complementary/alternative therapies- plant extracts including saw palmetto, stinging nettle, pumpkin seed, and lycopene for prostate health.
- Some patients may not desire surgical intervention or may not be surgical candidates due to comorbidities and may require long-term catheterization vs SIC in order to empty the bladder in the case of chronic urinary retention.
- Chronic indwelling foley or suprapubic catheters- require monthly catheter changes. Some patients go to clinics or use home health services. Family can also be trained. Supplies via DME companies. Risk of infection with long-term catheterization. Requires vigilant antibiotic stewardship, avoiding unnecessary antibiotics due to high rates of resistance and asymptomatic bacteriuria/ colonization. Do not recommend urine cultures unless hematuria or + symptoms of UTI.
- SIC- Self intermittent catheterization. May be 1-2x/day or PRN for incomplete retention, allowing the patient to empty in the event of acute retention or to avoid UTIs due to incomplete emptying. If complete retention, typically 4-6x/day. The main education point is hand hygiene, assistance with supplies, and not reusing catheters.
Complications: urinary tract infections, hematuria, bladder calculi, bladder decompensation, incontinence, hydronephrosis and upper urinary tract decompensation, acute urinary retention. A common risk of retention postoperatively (any type of surgery).
Ongoing Patient Monitoring: periodic monitoring of symptoms with IPSS, PVR, and uroflow. Upper tract imaging and measuring renal function if large volume retention/chronically elevated PVR.
General Health and Lifestyle Guidance: Avoiding caffeine, and alcohol which can worsen irritative voiding symptoms. Avoid high-risk medications including decongestants and antihistamines that can cause retention. No specific lifestyle/dietary recommendations for BPH, other than maintaining a healthy diet and exercise for managing comorbidities.
Questions to Ask Patients:- How is your force of stream? Weak, strong, etc
- Do you have to strain to initiate the urine stream? (hesitancy)
- Does your urine stream stop and start multiple times? (intermittency)
- Do you have urine leakage if you can’t get to the restroom fast enough? (urgency)
- Do you wake at night to void? How many times on average? (nocturia)
- Do you have to void more than once every 2 hrs on average? (frequency)
- Do you feel that you are able to fully empty your bladder?
- Are you compliant with your medications? Are you experiencing any side effects?
- Do you have visible blood in your urine? *if yes, always recommend f/u with urologist.
- Do you have a routine follow-up scheduled with your urologist? (if very stable may be annually).
- Are you interested in any minimally invasive/surgical options in order to improve your symptoms or reduce your medications? Your urologist may have options for you! *Do not recommend any particular surgical options as urologists differ in their preferences and training. Surgical options are also based on patients’ individual anatomic findings*
- Are you experiencing recurrent UTIs?
- General health maintenance
- Routine prostate cancer screenings
- Avoiding bladder irritants such as coffee, tea, soda, alcohol, energy drinks. Even foods high in spice level and acidity can cause dysuria.
- Recommend appropriate water hydration/intake. General recommendations by FDA etc are 6-8 8oz glasses of water daily, but may be less if restrictions in place due to cardiac, renal or endocrine disorders.
- If significant nocturia, aim for intake of majority of fluids earlier in the day and avoid fluid intake approximately 2 hours prior to bedtime.
- Some medications (such as the 5 ARIs) may take several months before you notice the intended benefit.
- Consider BP monitoring, logs if experiencing dizziness/hypotension with alpha-blockers.