Benign Prostatic Hyperplasia (BPH)
Summary
Benign prostatic hyperplasia (BPH) is a non-malignant enlargement of the prostate gland that occurs almost universally in ageing men. It results from hyperplasia of the stromal and epithelial cells in the transitional zone surrounding the urethra. BPH causes lower urinary tract symptoms (LUTS), which include voiding symptoms (hesitancy, poor stream, terminal dribbling) and storage symptoms (frequency, urgency, nocturia). Severity is assessed using the International Prostate Symptom Score (IPSS). Management ranges from watchful waiting for mild symptoms to medical therapy (alpha-blockers, 5-alpha reductase inhibitors) and surgical intervention (TURP, HoLEP) for significant symptoms or complications.
Key Facts
- Prevalence: Histological BPH in 50% of men at 50 years, 90% by 80 years
- Symptomatic: 25% of men over 55 have moderate-severe LUTS
- Key symptom score: IPSS (0-7 mild, 8-19 moderate, 20-35 severe)
- First-line medical: Alpha-blockers (tamsulosin) — rapid symptomatic relief
- Second-line: 5-alpha reductase inhibitors (finasteride) — reduce prostate size
- Gold standard surgery: TURP (Transurethral Resection of Prostate)
Clinical Pearls
IPSS Drives Management: Mild symptoms (IPSS 0-7) = watchful waiting. Moderate-severe (8+) = consider medication. Score also tracks treatment response.
Alpha-Blockers Are Fast: Tamsulosin works within days. 5-ARIs take 6 months but shrink the prostate and reduce long-term risk of retention.
Exclude Prostate Cancer: Always perform DRE. A hard, nodular prostate requires urgent investigation. PSA should be interpreted with prostate size in mind (larger glands = higher PSA).
Why This Matters Clinically
BPH is extremely common and significantly affects quality of life. Untreated severe BPH can lead to acute urinary retention, chronic retention with renal impairment, recurrent UTIs, and bladder stones. Early treatment improves symptoms and prevents complications.
Incidence & Prevalence
- Histological BPH: 50% at age 50; 90% by age 80
- Clinical BPH (symptomatic): ~25% of men over 55
- Retention risk: 2-5% lifetime risk without treatment
Demographics
| Factor | Details |
|---|---|
| Age | Risk increases linearly with age |
| Sex | Males only |
| Ethnicity | More common/severe in Black men |
Risk Factors
| Factor | Impact |
|---|---|
| Age | Major risk factor |
| Family history | Genetic component |
| Obesity | Associated with larger prostates |
| Diabetes | Increased risk |
| Androgens | Required for BPH development |
Mechanism
Step 1: Hormonal Influence
- Testosterone converted to dihydrotestosterone (DHT) by 5-alpha reductase
- DHT promotes prostate growth
Step 2: Hyperplasia
- Stromal and epithelial cells proliferate in transitional zone
- Nodular enlargement around the urethra
Step 3: Urethral Obstruction
- Static component: Physical compression by enlarged tissue
- Dynamic component: Increased smooth muscle tone (alpha-adrenergic)
Step 4: Bladder Response
- Detrusor muscle hypertrophy (compensatory)
- Eventually detrusor failure (decompensation)
- Trabeculation, diverticula, residual urine
Bladder Outlet Obstruction (BOO)
| Phase | Features |
|---|---|
| Compensated | Detrusor hypertrophy; increased voiding pressures |
| Decompensated | Detrusor failure; high residual volume; overflow |
Lower Urinary Tract Symptoms (LUTS)
Voiding (Obstructive) Symptoms:
Storage (Irritative) Symptoms:
International Prostate Symptom Score (IPSS)
| Score | Severity |
|---|---|
| 0-7 | Mild |
| 8-19 | Moderate |
| 20-35 | Severe |
Complications
| Complication | Features |
|---|---|
| Acute urinary retention | Painful inability to void; distended bladder |
| Chronic retention | Painless; high residual; may cause renal impairment |
| UTI | Recurrent; due to stasis |
| Bladder stones | Due to stasis |
| Haematuria | From mucosal congestion |
Red Flags
[!CAUTION] Red Flags — Investigate urgently if:
- Hard, irregular prostate (prostate cancer)
- Elevated PSA disproportionate to size
- Haematuria
- Recurrent UTIs
- Renal impairment with high residual
- Acute retention
Structured Approach
Abdominal Examination:
- Palpable bladder (chronic retention)
- Suprapubic tenderness (acute retention)
Digital Rectal Examination (DRE):
- Size: Enlarged (normal = walnut size)
- Surface: Smooth (BPH) vs nodular (cancer)
- Consistency: Firm-rubbery (BPH) vs hard (cancer)
- Median sulcus: May be obliterated in BPH
- Tenderness: Suggests prostatitis
General:
- Signs of uraemia (advanced CKD from obstruction)
First-Line
| Test | Purpose |
|---|---|
| IPSS | Quantify symptom severity |
| Urinalysis | Exclude infection, haematuria |
| Renal function (eGFR, U&Es) | Exclude renal impairment |
| PSA | Exclude prostate cancer (interpret with caution) |
| Flow rate (uroflowmetry) | Assess obstruction (Qmax less than 10 mL/s = obstructed) |
| Post-void residual (USS) | Assess voiding efficiency |
Second-Line / Specialist
| Test | Indication |
|---|---|
| Transrectal USS | Prostate size measurement |
| Urodynamics | Distinguish BOO from detrusor underactivity |
| Cystoscopy | If haematuria, suspected stricture |
| MRI prostate | If cancer suspected |
PSA Interpretation
| PSA Level | Notes |
|---|---|
| less than 1.5 ng/mL | Normal; unlikely significant enlargement |
| 1.5-4.0 ng/mL | May be normal; correlate with size |
| greater than 4.0 ng/mL | Further investigation; may be BPH or cancer |
| PSA density | PSA ÷ prostate volume; greater than 0.15 suspicious |
Management Algorithm
BPH / LUTS
↓
┌─────────────────────────────────────────┐
│ 1. Assess Severity (IPSS) │
│ - Mild (0-7) │
│ - Moderate (8-19) │
│ - Severe (20-35) │
└─────────────────────────────────────────┘
↓
┌─────────────────────────────────────────┐
│ 2. Exclude Red Flags │
│ - DRE: Hard/nodular = cancer │
│ - PSA: Consider prostate cancer │
│ - Retention, renal impairment │
└─────────────────────────────────────────┘
↓
┌─────────────────────────────────────────┐
│ 3. Treatment by Severity │
├─────────────────────────────────────────┤
│ MILD: Watchful waiting + lifestyle │
│ MODERATE: Alpha-blocker ± 5-ARI │
│ SEVERE/REFRACTORY: Surgery │
└─────────────────────────────────────────┘
Conservative / Lifestyle
- Reduce caffeine and alcohol
- Avoid large evening fluid intake
- Bladder training
- Double voiding
- Review medications (diuretics, anticholinergics)
Medical Treatment
| Drug Class | Examples | Mechanism | Onset |
|---|---|---|---|
| Alpha-blockers | Tamsulosin, Alfuzosin | Relax smooth muscle | Days |
| 5-Alpha Reductase Inhibitors | Finasteride, Dutasteride | Block DHT; shrink prostate | 3-6 months |
| PDE5 Inhibitors | Tadalafil | Smooth muscle relaxation | Weeks |
| Combination | Alpha-blocker + 5-ARI | Better than monotherapy | Variable |
Alpha-Blocker Side Effects:
- Postural hypotension
- Dizziness
- Retrograde ejaculation
- Intraoperative floppy iris syndrome (inform ophthalmology)
5-ARI Side Effects:
- Erectile dysfunction
- Decreased libido
- Gynaecomastia
- PSA reduced by 50% (adjust interpretation)
Surgical Treatment
| Procedure | Description | Notes |
|---|---|---|
| TURP | Transurethral resection | Gold standard; TUR syndrome risk |
| HoLEP | Holmium laser enucleation | For large glands; less bleeding |
| UroLift | Mechanical clips | Preserves ejaculation |
| Rezum | Water vapour thermal ablation | Minimally invasive |
| Open prostatectomy | Suprapubic | Very large glands (greater than 80-100g) |
Indications for Surgery
- Refractory to medical therapy
- Recurrent urinary retention
- Renal impairment from obstruction
- Recurrent UTI
- Bladder stones
- Significant haematuria
Of BPH
| Complication | Management |
|---|---|
| Acute urinary retention | Catheterisation; TWOC or surgery |
| Chronic retention / CKD | Prolonged catheterisation; surgery |
| UTI | Antibiotics; address obstruction |
| Bladder stones | Cystolitholapaxy; prostate surgery |
| Haematuria | Usually minor; exclude cancer |
Of Treatment
| Complication | Notes |
|---|---|
| TUR syndrome | Hyponatraemia from glycine absorption (TURP) |
| Retrograde ejaculation | Common after TURP (50-90%) |
| Erectile dysfunction | 5-10% after TURP |
| Urethral stricture | Late complication |
| Incontinence | Rare |
Natural History
- Progressive in most men
- 14% per year require escalation of treatment
- 5-year risk of AUR: ~5% untreated; reduced by 50% with 5-ARI
Outcomes
| Treatment | Symptom Improvement |
|---|---|
| Alpha-blocker | 30-40% improvement |
| 5-ARI | 20-30% (+ reduced retention risk) |
| TURP | 70-80% significant improvement |
| HoLEP | Similar to TURP; less morbidity |
Key Guidelines
- NICE NG140: Lower urinary tract symptoms in men (2019) — UK standard.
- EAU Guidelines on Management of LUTS — European Association of Urology.
- AUA Guideline on BPH (2021) — American Urological Association.
Landmark Trials
MTOPS Trial (2003)
- Combination therapy (doxazosin + finasteride) superior to monotherapy
- Reduced progression by 66%
- PMID: 14736927
CombAT Trial (2010)
- Dutasteride + tamsulosin better than either alone
- PMID: 20141676
Evidence Strength
| Intervention | Level | Key Evidence |
|---|---|---|
| Alpha-blockers | 1a | Multiple RCTs |
| 5-ARI | 1a | MTOPS, CombAT |
| TURP vs medical | 1b | RCTs |
| HoLEP | 1b | Non-inferior to TURP |
What is BPH?
BPH stands for benign prostatic hyperplasia. It means your prostate gland has grown larger. The prostate surrounds the tube that carries urine out of your body (urethra). When it enlarges, it can squeeze this tube and make it harder to pass urine.
What are the symptoms?
- Difficulty starting to urinate
- Weak or slow urine stream
- Needing to urinate frequently, especially at night
- Feeling that your bladder is not empty after urinating
- Dribbling at the end of urination
How is it treated?
- Lifestyle changes: Reduce caffeine and alcohol, don't drink too much in the evening.
- Medications: Tablets that relax the prostate muscle (tamsulosin) or shrink the prostate (finasteride).
- Surgery: If tablets don't work, procedures like TURP can remove part of the prostate.
What to expect
- Symptoms often improve with treatment
- You may need to take tablets for life
- Surgery is very effective but has some risks (like dry ejaculation)
When to see a doctor
- Blood in urine
- Unable to pass urine (emergency)
- Frequent infections
- Feeling unwell with urinary symptoms
Primary Guidelines
- National Institute for Health and Care Excellence (NICE). Lower urinary tract symptoms in men: management (NG140). 2019. nice.org.uk/guidance/ng140
Key Trials
- McConnell JD, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia (MTOPS). N Engl J Med. 2003;349(25):2387-98. PMID: 14736927
- Roehrborn CG, et al. The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes (CombAT). Eur Urol. 2010;57(1):123-31. PMID: 20141676
Further Resources
- Prostate Cancer UK: prostatecanceruk.org
- NHS BPH: nhs.uk/conditions/prostate-enlargement
Last Reviewed: 2025-12-24 | MedVellum Editorial Team
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.