I. Definition
A. Enlargement of the prostate gland; a condition commonly seen in men older than age 50
B. Progressive condition that can cause obstruction of the urethra with interference in urine flow
C. BPH is a hyperplastic process that results from an increase in cell numbers.
II. Etiology/incidence
A. Incidence is age related.
1. Men ages 41 to 50: 20%
2. Men ages 51 to 60: 50%
3. Men older than age 80: more than 90%
B. Exact cause is unknown.
C. The condition may be a response of the prostate gland to androgen hormones over time.
D. Dietary fat may play a role.
III. Clinical manifestations
A. Irritative symptoms—consequence of bladder dysfunction
1. Frequency
2. Dysuria
3. Urgency
4. Nocturia
5. Incontinence
B. Obstructive symptoms
1. Hesitancy
2. Straining
3. Starting and stopping
4. Dribbling
5. Retention
6. Decreased force and caliber of stream
7. Sensation of incomplete bladder emptying
8. Double voiding (urinating a second time within 2 hours)
C. Focal or uniform enlargement
1. On digital rectal examination (DRE), the prostate may be enlarged. Size does not correlate with severity of symptoms or with degree of obstruction.
2. It should feel smooth and rubbery.
3. Focal enlargement, nodularity, or extreme hardness may represent malignancy; further investigation is indicated.
a. Transrectal ultrasound
b. Biopsy
D. Palpable bladder consistent with urinary retention
IV. Laboratory findings
A. Urinalysis
1. Pyuria suggests infection.
2. Hematuria may be a sign of malignancy.
B. Urine culture to rule out urinary tract infection if irritative symptoms are present
C. BUN/creatinine (CR) to assess for renal insufficiency
D. Prostate-specific antigen (PSA)
1. Considered optional, yet most practitioners include it in the initial evaluation
2. Values greater than 10 ng/ml suggest prostate cancer.
3. Because an overlap is seen between levels seen in BPH and in prostate cancer, its use is controversial.
E. Transrectal ultrasound with a palpable nodule or elevated PSA
V. Management
A. Mild symptoms
1. Patient may recover spontaneously over time (“watchful waiting”).
2. Avoid medication that can worsen symptoms.
a. Decongestants and other sympathomimetics (act on alpha receptors to enhance prostate muscle tone, which increases dynamic obstruction)
b. Anticholinergics (antihistamines), bowel antispasmodics, tricyclic antidepressants, and antipsychotics; these decrease bladder muscle contraction, thus increasing urine retention
B. Mild to moderate symptoms
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1. Alpha blockers relax muscle fibers in the prostate gland and capsule and in the internal urethral sphincter, thereby facilitating emptying of the bladder.
b. Prazosin (Minipress) (alpha1 blockade), 1-5 mg PO twice daily, may also be used.
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