CLINICAL OVERVIEW

Benign Prostatic Hypertrophy

Elsevier Point of Care (ver detalles)
Actualizado January 22, 2024. Copyright Elsevier BV. All rights reserved.

Synopsis

Urgent Action
Always perform catheter drainage with urinary retention, particularly if there is clinical evidence of
urinary tract infection or obstructive uropathy

Urinary tract infections require urgent antibiotic treatment and drainage, if urinary retention exists

Key Points
Benign prostatic hypertrophy (hyperplasia) is non-malignant proliferation of smooth muscle and epithelial cells
within the prostatic transition zone

Usually occurs in men older than 50 years

Lower urinary tract symptoms are common, and without proper evaluation and treatment they can lead to
complications, as follows:

Chronic bladder weakening and incompetence

Recurrent urinary tract infection and bladder stones

Urinary incontinence

Urinary retention and renal insufficiency

Prostate-specific antigen testing is indicated because the symptoms of prostate cancer are indistinguishable from
benign prostatic hypertrophy

Prostate-specific antigen level is not routinely measured in men without symptoms of benign prostatic
hypertrophy

Common symptoms include bladder storage symptoms (frequency, nocturia, urgency), and voiding symptoms
(weak stream, intermittency, straining, and feeling of incomplete emptying)
Esquema
 Conservative treatment options include watchful waiting, behavioral and lifestyle modification, and medications

If medications are prescribed, choice of medications depends on nature of symptoms and bladder dysfunction,
but anticholinergic medications and α₁-adrenergic blockers are first line therapies

Surgical options aim to reduce obstructive effect of enlarged prostate when conservative options fail, when
patient has prohibitive adverse effects from pharmacotherapy, or when more definitive therapy is sought

Transurethral resection of prostate or simple prostatectomy are the standard, accepted surgical options for
benign prostatic hypertrophy

Pitfalls
For patients with planned cataract surgery, do not initiate treatment with tamsulosin until after surgery 1

Men with benign prostatic hypertrophy are at increased risk for urinary retention after taking sympathomimetic
drugs (such as pseudoephedrine) or anticholinergic drugs 2

Offer anticholinergics or β3-adrenergic agonists to patients with overactive bladder symptoms who do not have
an elevated postvoid residual urine volume (180 mL or greater) 3

Terminology

Clinical Clarification
Benign prostatic hypertrophy (hyperplasia) is non-malignant proliferation of smooth muscle and epithelial cells
within the prostatic transition zone

Definitive diagnosis is histologic 4

Cross sectional imaging (eg, transrectal ultrasonography, multiparametric MRI) can estimate prostate size,
classify by enlargement location, and estimate likelihood of prostate cancer 5 6

Classification
Microscopic form 7

Histologic evidence of cellular proliferation of prostate

Macroscopic form (also called benign prostatic enlargement) 7

Enlargement of prostate progressing from microscopic form

Clinical (or symptomatic) form (also called benign prostatic obstruction) 7

Lower urinary tract symptoms

Bladder dysfunction, hematuria, urinary retention, and/or urinary tract infection
Diagnosis

Clinical Presentation

History
Condition can be asymptomatic

International Prostate Symptom Score: validated, self-administered assessment 8

7 questions on urinary symptoms assigned scores of 0 through 5, based on level of severity (asymptomatic to
very symptomatic); maximum score 35 8

Feeling of incomplete emptying

Frequent urination

Intermittency

Urgency, with or without incontinence

Weak or slow stream

Straining

Nocturia
An eighth question (bother score) is included to assess patient opinion of symptom severity and effect on
quality of life 8

“If you were to spend the rest of your life with your urinary condition just the way it is now, how would you
feel about that?”

Responses: Delighted, Pleased, Mostly satisfied, Mixed, Mostly dissatisfied, Unhappy, Terrible (or 0-6)

Score of 0 to 7: mild symptoms 8

Score of 8 to 19: moderate symptoms 8

Score of 20 to 35: severe symptoms 8

Common additional symptoms and signs include the following: 2

Urinary retention

Urinary retention causes back and flank pain

Dribbling

During urination or after micturition (post void dribbling)

 Burning during urination

Physical examination
Abdomen

With urinary retention, an enlarged bladder is palpable and can be tender in the setting of acute urinary
retention 9

Urinary retention or high pressure urinary storage can cause ureteral dilation and hydronephrosis

Hydroureteronephrosis is typically bilateral, but it may be more prominent on one side or the other,
depending on individual anatomy, and can occasionally be associated with flank pain and tenderness

Digital rectal examination 7

Palpable prostate enlargement is usually present but is not necessary for a diagnosis of microscopic benign
prostatic hyperplasia

Firmness or nodularity may indicate prostate cancer

Diagnosis of malignancy cannot be made on the basis of digital rectal examination alone

Causes and Risk Factors

Causes
Precise cause is unknown; likely the result of a multifactorial process 4

Male androgenic steroid hormones testosterone and dihydrotestosterone are believed to play a pathophysiologic
role 4

Risk factors and/or associations

Age
Approximately as follows:

8% of men aged 31 to 40 years 10

50% of men aged 51 to 60 years 11

70% of men aged 61 to 70 years 10

90% of men aged 81 to 90 years 11

Sex
Affects males only
Genetics
Autosomal dominant form exists; accounts for less than 10% of cases 1

Diagnostic Procedures

Primary diagnostic tools

Direct measurement of prostatic hyperplasia is only possible on histologic examination; thus, the use of
surrogates are recommended for diagnosis

History (clinical surrogate)

Query regarding symptomatic lower urinary tract symptoms

International Prostate Symptom Score

Physical examination (anatomical surrogate)

Including abdominal palpation and digital rectal examination

Imaging (radiographic surrogate)

Transabdominal ultrasonography of the bladder

Transabdominal or transrectal ultrasonography of prostate

Transrectal more accurate for prostate volume greater than 30 mL (prostate size may be expressed in
mL or g and are roughly equivalent, as prostate specific gravity is 1.05 g/mL) 13 12

Laboratory (biochemical surrogate)

Prostate-specific antigen level

Elevation in free prostate-specific antigen is linked to benign conditions while increased bound
prostate-specific antigen is associated with cancer; may be helpful with borderline levels 14

Urinalysis

Functional testing (physiological surrogate)

Urine flow rate determination

Pressure-flow urodynamic testing

Laboratory

Imaging
 Functional testing

Other diagnostic tools

Differential Diagnosis

Most common
Overactive bladder

Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary
incontinence, in the absence of urinary tract infection or other obvious pathology 22

Occurs in the absence of bladder outlet obstruction

Diagnosis is made via history (frequency, urgency, urge incontinence), focused physical examination
(abdominal examination to assess for bladder fullness and tenderness), laboratory testing (urinalysis to rule
out infection, measurement of post void residual urine to rule out retention), and voiding diary (to quantify
urinary frequency, voided volume, and incontinence episodes)

Urethral stricture

Scars from previous injuries and infections cause narrowing of urethra with decreased and incomplete bladder
emptying; symptoms are similar to those of benign prostatic hypertrophy (Related: Bladder and Urethral
Injury)

Diagnosis is made via retrograde urethrogram or urethroscopy

Urinary tract infection (Related: Urinary Tract Infection in Adults)

Common symptoms of urinary tract infection and benign prostatic hypertrophy can include urinary
frequency, urgency, dysuria, and hematuria

Urinary tract infection can be distinguished from benign prostatic hypertrophy by any of the following:

Urinalysis dipstick test indicating leukocyte esterase and nitrite positivity

Microscopic urinalysis indicating WBCs and bacteria

Positive urine culture for bacteria

Diabetes mellitus (Related: Diabetes Mellitus Type 2 in Adults)

Common symptoms of benign prostatic hypertrophy and diabetes mellitus can include urinary frequency,
polyuria, and urinary retention

Diabetes mellitus can be distinguished from benign prostatic hypertrophy as follows:

Urinalysis dipstick test showing presence of glucose

 Serum laboratory tests showing high fasting glucose levels

Diabetes can coexist with benign prostatic hypertrophy, and imaging is necessary to differentiate the two

Neurologic conditions (eg, history of stroke, multiple sclerosis, Parkinson disease) (Related: Parkinson Disease)

Symptoms from neurologic autoimmune and inflammatory conditions include overflow incontinence,
hesitancy, and difficulty initiating urinary stream (Related: Multiple Sclerosis)

Urinary dysfunction is rarely the only symptom of stroke, multiple sclerosis, or Parkinson disease

Advanced central nervous system imaging (such as MRI, single-photon emission computed tomography, and
PET) and cerebrospinal fluid analysis are frequently necessary to confirm diagnosis of neurologic destructive
disease

Use of anticholinergic and sympathomimetic drugs

Anticholinergic medications can cause urinary retention that may be mistaken for benign prostatic
hypertrophy

Sympathomimetic medications can cause urinary frequency and retention that may be mistaken for benign
prostatic hypertrophy

Diagnosis can be differentiated by a period of drug abstinence

Prostate cancer (Related: Prostate Cancer) 16

May cause similar urinary symptoms

Definitive differentiation is by biopsy

Treatment

Goals 13
Reduce bothersome lower urinary tract symptoms and improve quality of life

Monitor for symptom progression

Prevent complications

Disposition

Admission criteria
Patients undergoing surgical resection for benign prostatic hypertrophy may require admission for postoperative
bladder irrigation and for care of postoperative complications
 Patients with urinary retention who are unable to reestablish urinary flow via urethral or suprapubic
catheterization in the emergency department require admission for surgical correction

Recommendations for specialist referral

Consult urologist for patients whose symptoms fail to respond adequately to medical therapy or who present
with complications of benign prostatic hypertrophy, as follows:

Gross hematuria

Pain with urination or lower abdominal or back pain

Urinary tract infection

Palpable bladder or documented urinary retention (350 mL or more) by ultrasonography

Bladder stones

Hydronephrosis

Elevated serum creatinine

Treatment Options
Initial treatment 13 23

Symptoms with little or no bother

Watchful waiting

Lifestyle changes 17

Limit daily intake of fluids to less than 2000 mL if there is no history of stone disease or urinary tract
infections
Restrict fluids before travel and within 2 hours of bedtime

Limit caffeine

Weight loss if BMI is 30 or greater 24

Timed or organized voiding (bladder retraining)

Avoidance or treatment of constipation

Avoidance or monitoring of certain drugs (eg, diuretics, decongestants, antihistamines, antidepressants)

Bothersome symptoms

Medical therapy

Predominant symptoms of bladder outlet obstruction (straining, hesitancy, intermittency, terminal

dribbling, incomplete emptying) 4
α₁-adrenergic blockers 25

Mechanism of action: relaxation of prostatic capsular and bladder outlet musculature

First line monotherapy option with any size prostate

Reduction in symptom score is similar for the available agents; there is no variable response by patient
characteristics to inform choice 4

Trial of an alternative same-class agent after insufficient response is not recommended, unless drug
was discontinued due to adverse effects 4

Alfuzosin, silodosin, and tamsulosin have less potential for orthostatic hypotension and syncope than
the non-specific α₁-adrenergic blockers doxazosin and terazosin, which are also approved for
treatment of hypertension 4

Silodosin and tamsulosin can cause ejaculatory dysfunction, which may be troublesome to some
patients 4

For patients with planned cataract surgery, do not initiate treatment with tamsulosin until after
surgery 26

May be given in combination with tadalafil, 5α-reductase inhibitors, anticholinergics, and β3-
adrenergic agonists

5α-reductase inhibitors

Mechanism of action: blocks conversion of testosterone to its active metabolite, thereby inhibiting
prostate growth

Clinical improvement can take 3 to 6 months

Typical prostate shrinkage is 15% to 25% at 6 months; may lower prostate-specific antigen levels by
50%, which requires consideration when prostate-specific antigen level is used for prostate cancer
screening

May cause gynecomastia and sexual dysfunction

Alternative first line treatment in patients with larger prostates (greater than 30 mL, prostate-specific
antigen level greater than 1.5 ng/mL, or palpably enlarged on exam)

May be used alone or with α₁-adrenergic blocker

Long-acting phosphodiesterase inhibitor (tadalafil) 4

Mechanism of action: unclear; may relax bladder outlet

Alternative first line monotherapy, especially for (but not limited to) patients with erectile dysfunction

May be used in combination with an α₁-adrenergic blocker or the 5α-reductase inhibitor finasteride
(weak evidence) 25
 Predominant moderate to severe storage symptoms (daytime frequency, nocturia, urgency, or urgency
incontinence)

Anticholinergics

Mechanism of action: reduces detrusor muscle activity by inhibiting muscarinic receptors in bladder
wall

Contraindicated in patients with palpable bladder or documented urinary retention (350 mL or more)
by ultrasonography

Use with caution in older patients owing to potential risk of dementia suggested in some studies and
reviews 27 28 29
May be given alone or in combination with an α₁-adrenergic blocker to patients with overactive
bladder symptoms who do not have an elevated postvoid residual urine volume (180 mL or more); but,
have proven safe even in the absence of an α₁-adrenergic blocker

β3-adrenergic agonists

Mechanism of action: relaxes detrusor smooth muscle, reducing bladder urgency

Typically given in combination with an α₁-adrenergic blocker to patients with overactive bladder
symptoms who do not have an elevated postvoid residual urine volume (180 mL or greater)

Urinary tract infections require antibiotic treatment; in the setting of urinary retention, treat urinary tract
infections with urethral catheterization to achieve adequate bladder drainage

Surgical options for progressive or persistent bothersome symptoms after medical management 13 25 30

Office-based minimally invasive surgery with the prostatic urethral lift procedure, transurethral water vapor
thermotherapy, or microwave thermotherapy

High preservation of sexual function

Less improvement in urinary flow rate and symptoms than are typically realized with surgical resection

Non–office-based procedures

Electrocautery resection (transurethral resection of the prostate) is the historical standard surgical
procedure

Photoselective vaporization of prostate

Water-jet resection

Holmium and thulium laser enucleation

Simple prostatectomy via open or laparoscopic approach

Prostate artery embolization

Drug therapy
31
α₁-adrenergic blocker 31

Alfuzosin

Alfuzosin Oral tablet, extended-release; Adults: 10 mg PO once daily.

Doxazosin

Immediate-release tablets

Doxazosin Mesylate Oral tablet; Adults: 1 mg PO once daily, initially. May double the dose every 1 to 2
weeks based on clinical response. Max: 8 mg/day.

Extended-release tablets

Doxazosin Mesylate Oral tablet, extended-release; Adults: 4 mg PO once daily, initially. May increase the
dose to 8 mg PO once daily after 3 to 4 weeks based on clinical response.

Silodosin

Silodosin Oral capsule; Adults: 8 mg PO once daily.

Tamsulosin

Tamsulosin Hydrochloride Oral capsule; Adults: 0.4 mg PO once daily, initially. May increase the dose to 0.8
mg PO once daily after 2 to 4 weeks based on clinical response.

Terazosin

Terazosin Hydrochloride Oral capsule; Adults: 1 mg PO once daily, initially. May increase the dose to 2 mg,
5 mg, then 10 mg PO once daily based on clinical response. Usual dose: 10 mg/day. Max: 20 mg/day.

5α-reductase inhibitor therapy 4

Dutasteride

Dutasteride Oral capsule; Adults: 0.5 mg PO once daily.

Finasteride

Finasteride Oral tablet [Benign Prostatic Hyperplasia]; Adults: 5 mg PO once daily.

Combination α₁-adrenergic blocker and 5α-reductase inhibitor therapy

Dutasteride-tamsulosin
Dutasteride, Tamsulosin Hydrochloride Oral capsule; Adults: 0.5 mg dutasteride/0.4 mg tamsulosin PO
once daily.

Anticholinergic therapy 32

Darifenacin
 Darifenacin Oral tablet, extended-release; Adults: 7.5 mg PO once daily, initially. May increase the dose to 15
mg PO once daily after 2 weeks based on clinical response. Coadministration of certain drugs may need to
be avoided or dosage adjustments may be necessary; review drug interactions.

Fesoterodine

Fesoterodine fumarate Oral tablet, extended-release; Adults: 4 mg PO once daily, initially. May increase the
dose to 8 mg PO once daily based on clinical response and tolerability. Coadministration of certain drugs
may need to be avoided or dosage adjustments may be necessary; review drug interactions.

Oxybutynin

Immediate-release tablets
Oxybutynin Chloride Oral tablet; Adults: 5 mg PO 2 to 3 times daily. Max: 5 mg PO 4 times daily.

Oxybutynin Chloride Oral tablet; Older Adults: 2.5 mg PO 2 to 3 times daily, initially. Usual dose: 5 mg
PO 2 to 3 times daily. Max: 5 mg PO 4 times daily.

Extended-release tablets

Oxybutynin Chloride Oral tablet, extended-release; Adults: 5 to 10 mg PO once daily, initially. May
increase the dose by 5 mg/week based on clinical response and tolerability. Max: 30 mg/day.

Transdermal patch

Oxybutynin Transdermal patch - biweekly; Adults: 3.9 mg/day patch topically twice weekly (every 3 to 4
days).

Solifenacin

Solifenacin Succinate Oral tablet; Adults: 5 mg PO once daily, initially. May increase the dose to 10 mg PO
once daily based on tolerability. Coadministration of certain drugs may need to be avoided or dosage
adjustments may be necessary; review drug interactions.

Tolterodine

Immediate-release tablets

Tolterodine Tartrate Oral tablet; Adults: 2 mg PO twice daily. May decrease dose to 1 mg PO twice daily
based on clinical response and tolerability. Coadministration of certain drugs may need to be avoided or
dosage adjustments may be necessary; review drug interactions.

Extended-release capsules

Tolterodine Tartrate Oral capsule, extended-release; Adults: 4 mg PO once daily. May decrease dose to 2
mg PO once daily based on clinical response or tolerability. Coadministration of certain drugs may need
to be avoided or dosage adjustments may be necessary; review drug interactions.

Trospium

Immediate-release tablets
 Trospium Chloride Oral tablet; Adults 18 to 74 years: 20 mg PO twice daily.

Trospium Chloride Oral tablet; Adults 75 years and older: 20 mg PO twice daily. May decrease dose to 20
mg PO once daily based on tolerability.

Extended-release capsules

Trospium Chloride Oral capsule, extended-release; Adults: 60 mg PO once daily.

β3-adrenergic agonist

Mirabegron

Mirabegron Oral tablet, extended-release; Adults: 25 mg PO once daily, initially. May increase the dose to 50
mg PO once daily after 4 to 8 weeks if needed.
Vibegron

Vibegron Oral tablet; Adults: 75 mg PO once daily.

Phosphodiesterase-5 inhibitor 4

Tadalafil 33

Tadalafil Oral tablet; Adults: 5 mg PO once daily. Coadministration of certain drugs may need to be avoided
or dosage adjustments may be necessary; review drug interactions.

Nondrug and supportive care

Always perform catheter drainage with acute urinary retention, particularly if there is clinical evidence of urinary
tract infection or obstructive uropathy

Various surgical options are available; 4 2 specialist referral is advised

Office-based procedures are considered safe when done in outpatient setting 34

Prostatic urethral lift

Water vapor thermotherapy

Microwave thermotherapy

Studies of comparative efficacy between all procedures are lacking and, for certain, there is no one single best
choice for every patient 13

For patients who take anticoagulants and must proceed to operative intervention without cessation of their
medication, laser surgery is the preferred choice 13

General explanation

Base choice of nondrug approach on patient's presentation (severity of symptoms and response to medical
therapy) and anatomy (prostate volume and presence or absence of a median lobe), surgeon's level of training and
experience, patient's sexual activity, and discussion of potential benefit and risks for complications 17
Indication

Surgery is recommended for patients with any of the following: 4

Renal insufficiency secondary to benign prostatic hypertrophy

Recurrent urinary tract infections

More than 1 urinary tract infection in a year is an indication for urologic referral and surgical consideration
(specialist opinion) 35

Bladder stones

Gross hematuria due to benign prostatic hypertrophy

Symptoms refractory to medical therapies

Refractory urinary retention secondary to benign prostatic hypertrophy

Hydronephrosis

Procedures 4 13 30

Transurethral resection of prostate

General explanation
Considered gold standard for surgical treatment of symptomatic benign prostatic hypertrophy 23

Instrument (resectoscope) is introduced into urethral meatus and, under direct visualization, layers of prostate
tissue cells are scraped away and removed with a loop of heated wire

End result is a urethral outflow canal with a larger diameter

Postoperative urine flow (Qmax) is expected to improve by at least 10 mL/second

Clinicians may use a monopolar or bipolar approach, depending on expertise 4

Indication
Refractory urinary retention

Recurrent urinary tract infections secondary to prostatic hypertrophy

Renal insufficiency secondary to bladder outlet obstruction

Recurrent gross hematuria

Bladder stones

Permanently damaged or weakened bladder

 Presence of bladder diverticulum that does not allow complete bladder emptying

Contraindications
Need for open resection of prostate

Large prostate adenomas

Large bladder stones not amenable to transurethral removal

Complex urethral conditions (eg, repaired hypospadias)

Contraindications for lithotomy position

Complications
Arterial bleeding

Venous bleeding

Infection
Micturition difficulties/incontinence

Erectile dysfunction

Retrograde ejaculation

Simple prostatectomy 36

General explanation
Diseased and enlarged prostatic adenomatous tissue is enucleated and removed, but remainder of reproductive
anatomy (vas deferens, seminal vesicles) is left intact

Approach may be retropubic, suprapubic, or perineal

Improved urine flow (Qmax increased by 10 mL/second or more) with decrease in bothersome symptoms

Indication
Indications for simple (open) prostatectomy are the same as for transurethral resection of prostate; the decision
to perform open prostatectomy is made by the treating urologic surgeon based on patient body habitus and
details of the case (eg, size of prostate, presence of bladder diverticula or stones)

Open prostatectomy offers improved operative visualization compared with transurethral resection of prostate

Consider open, laparoscopic, or robotic-assisted prostatectomy, depending on expertise, for patients with large
prostates 4

Contraindications
 Prostate cancer: radical prostatectomy is required, which removes entire prostate and some surrounding tissue,
including lymph nodes and seminal vesicles

Perineal simple (open) prostatectomy is relatively contraindicated in patients who especially value sexual
performance and potency

Complications
Bleeding

Retrograde ejaculation

Infection

Bladder neck stricture

Erectile dysfunction

Transurethral microwave thermotherapy

General explanation
Catheter delivers microwave radiation to prostate; local heating destroys excess tissue

Surgical retreatment rates are higher compared to transurethral resection of prostate 4

Fewer major adverse events than transurethral resection of prostate 37

Relegated to legacy status in recent guidelines with the development of newer techniques 25

Indication
Symptomatic benign prostatic hypertrophy

Complications
Urinary retention

Infection

Retrograde ejaculation

Prostate urethral lift 13

General explanation

Implants are placed to lift the prostate to relieve urethral obstruction

Indication

May be offered as an option for patients with symptoms attributed to benign prostate hypertrophy provided
prostate volume is less than 80 g and absence of an obstructive middle lobe has been verified
 May be offered to eligible patients who desire preservation of erectile and ejaculatory function; low rate of
ejaculatory dysfunction

Complications

Perioperative bleeding and exposure of metal clips with stone formation

Water vapor thermal therapy 13 30

General explanation

Vapor is injected into the prostate with a needle

Indication

May be offered to patients with symptoms attributed to benign prostatic hypertrophy provided their prostate
volume is less than 80 g

Water vapor thermal therapy may be offered to eligible patients who desire preservation of erectile and
ejaculatory function; low rate of ejaculatory dysfunction

Complications

Low risk of perioperative bleeding

Holmium laser enucleation of the prostate 13 30

General explanation

Endoscopic enucleation of the prostate using a continuous laser wave

Indication

Clinicians can consider this technique based on their expertise

May be particularly well-suited for large (80-150 mL) and very large (greater than 150 mL) prostates 25 38

Complications

Low risk of perioperative bleeding

High rate of stress urinary incontinence, retrograde ejaculation

Thulium laser enucleation of the prostate 13 30

General explanation
Endoscopic enucleation of the prostate using pulsed energy

Indication

Clinicians can consider this technique based on their expertise

Complications

Low risk of perioperative bleeding

 High rate of stress urinary incontinence, retrograde ejaculation
Water jet ablation of the prostate 13

General explanation

Transurethral procedure that uses high-pressure saline to remove parenchymal tissue through a heat-free
mechanism of tissue ablation

Indication

May be offered to patients with symptoms attributed to benign prostatic hypertrophy provided their prostate
volume is greater than 30 g and up to 150 g 39

Complications 30

Perioperative bleeding

Low rate of ejaculatory dysfunction

Comorbidities
Cardiovascular disease and hypertension (Related: Hypertension) 40

Age-related increases in sympathetic tone play a role in the pathophysiology of both benign prostatic
hypertrophy and cardiovascular disease and hypertension 40

Erectile dysfunction (Related: Erectile Dysfunction) 40

Treatment of benign prostatic hypertrophy symptoms improves sexual function in men whose erectile
dysfunction is related to coexistence of lower urinary tract symptoms

Special populations
Patients with benign prostatic hypertrophy are at increased risk for urinary retention after taking
sympathomimetic or anticholinergic drugs 2 23

Monitoring
There are no specific recommendations for long-term monitoring of benign prostatic hypertrophy

Initial reevaluation for improvements after starting medical therapy can be done in 4 to 12 weeks with the fast-
acting agents (α₁-adrenergic blockers, phosphodiesterase-5 inhibitors, β3-adrenergic agonists,
anticholinergics) but do not expect significant change for 3 to 6 months with 5α-reductase inhibitors 4

International Prostate Symptom Score is used to measure progression of symptoms and effectiveness of
treatment; repeat measures of postvoid residual urine volume and uroflowmetry may be useful 4
Complications and Prognosis

Complications
Urinary stone disease (eg, kidney stones, bladder stones)

Hematuria

Urinary retention

Urinary tract infection (Related: Urinary Tract Infection in Adults)

Bladder diverticula or stones

Hydronephrosis, renal insufficiency, or renal failure, related to long-standing urinary retention (Related: Acute
Kidney Injury)

Prognosis
Prognosis is good for symptomatic relief in patients who are properly evaluated and treated

Most men have a balance of bladder storage and voiding symptoms that slowly progress with age

Careful determination of predominant combination of symptom types helps guide selection of appropriate
therapies and improves prognosis

Screening and Prevention

Screening

At-risk populations
Men aged 40 to 70 years with lower urinary tract symptoms or any comorbidities

Screening tests
Urodynamic studies: generally performed by urologic specialist but can be ordered and interpreted by primary
care provider

Postvoid residual urine test measures amount of urine left in bladder after urination. After patient has voided
as much as possible, sonographic bladder scan is done or small catheter is introduced into bladder through
urethra; a positive result is 180 mL or more 41

Uroflowmetry measures maximum urinary flowrate. This may help to exclude the diagnosis of bladder outlet
obstruction in the setting of a high urinary flow rate
 Pressure-flow studies measure pressure in bladder during urination. They may help distinguish between
urinary symptoms caused by obstruction, such as benign prostatic hypertrophy, and those caused by a problem
affecting the bladder muscles or nerves

Cystometrogram measures bladder pressure, compliance, and storage capacity; may include a uroflowmetry
test (which measures how fast urine flows out of bladder)

Prevention
There are no documented effective strategies for prevention of benign prostatic hypertrophy

Regular physical activity may have a protective effect against development of the condition 42

Referencias
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