Background

• Benign prostatic hyperplasia (BPH) is a nonmalignant enlargement of the prostate gland that may restrict the flow of urine from the bladder. The prevalence of BPH increases with age and is present in up to 90% of men by the age of 85 years. BPH is a common benign neoplasm in men and a leading cause of morbidity in the elderly.
• BPH occurs in all men as they age and can lead to symptoms such as weak urine flow, urinary urgency, and incomplete bladder emptying. If left untreated, BPH can lead to complications such as urinary tract infections, bladder stones, and kidney damage. 

Epidemiology

• Prevalence: BPH is a common benign neoplasm in aging men and its prevalence increases with age. The prevalence of BPH has been estimated to be around 50% in men aged 51-60 years, 60% in men aged 61-70 years, and 80% in men aged 71-80 years. 
• Incidence: The incidence of BPH increases with age. The onset of symptoms of BPH usually occurs after the age of 50, and by age 80, up to 90% of men have histologic evidence of BPH. 
• Mortality: BPH is not a lethal condition, but it can lead to serious complications such as urinary retention, recurrent urinary tract infections, and renal failure. 
• Race/Ethnicity: BPH is more common in African American men and less common in Asian men compared to Caucasian men. African American men also have a higher risk of developing BPH-related complications. 
• Comorbidities: Several comorbidities have an increased risk of developing BPH, including obesity, hypertension, diabetes, metabolic syndrome, and cardiovascular disease. 
• Risk factors: The major risk factors for developing BPH include age, genetics, hormonal factors, and lifestyle factors such as sedentary behavior, alcohol consumption, and smoking. 

Anatomy

Pathophysiology

• The exact pathophysiology of BPH is not completely understood, but it is believed to be related to the androgenic hormonal environment of the prostate gland, which is regulated by dihydrotestosterone (DHT). BPH occurs due to an imbalance between the proliferation and apoptosis of prostatic cells, resulting in the accumulation of cells and extracellular matrix components, leading to prostate enlargement. The exact mechanisms that lead to this imbalance are not known, but it is thought to involve several factors, including aging, genetics, inflammation, and hormonal changes. 
• The histological changes associated with BPH include an increase in the number of epithelial and stromal cells, which results in the formation of nodules in the periurethral and transitional zones of the prostate gland. These nodules can compress the urethra, leading to LUTS. The increase in stromal cells leads to an increase in extracellular matrix production, which contributes to the enlargement of the prostate gland. The exact mechanisms by which BPH nodules cause LUTS are not well understood, but it is believed to involve mechanical obstruction of the urethra, smooth muscle dysfunction, and sensory nerve dysfunction. 

Etiology

• Age: The risk of developing BPH increases with age, particularly after the age of 50. 
• Genetics: There may be a genetic component to the development of BPH. Men with a family history of BPH are at a higher risk of developing the condition. 
• Hormones: The growth and development of the prostate gland is influenced by hormones, particularly dihydrotestosterone (DHT), which is a derivative of testosterone.  
• Lifestyle factors: Certain lifestyle factors, such as obesity and lack of physical activity, may increase the risk of developing BPH. Additionally, smoking and alcohol consumption have also been linked to an increased risk of BPH. 
• Medical conditions: Certain medical conditions, such as type 2 diabetes and hypertension, have also been associated with an increased risk of BPH. 
• Medications: Certain medications, such as alpha-blockers used to treat high blood pressure, may also increase the risk of developing BPH. 

Genetics

Prognostic Factors

• Age: BPH is more common in older men, and the incidence increases with age. 
• Severity of symptoms: It is a predictor of disease progression and may also influence treatment decisions. 
• Prostate size: The size of the prostate gland may be an indicator of disease severity and may influence the type of treatment recommended. 
• Urinary flow rate: A decreased urinary flow rate may indicate more severe obstruction and may also be a predictor of disease progression. 
• Post-void residual volume: An increased post-void residual volume may indicate more severe obstruction and may also be a predictor of disease progression. 
• Co-existing medical conditions: Co-existing medical conditions, such as diabetes or cardiovascular disease, may impact the prognosis of BPH and the management of the disease. 
• Response to treatment: The response to initial treatment may predict the likelihood of disease progression and the need for further interventions. 

Clinical History

Age group: BPH is a condition that affects men as they age, with the prevalence of the condition increasing with advancing age. BPH is rare in men below the age of 40, but its prevalence increases to about 50% in men aged 60 years and above. 

Physical Examination

• Digital Rectal Examination (DRE): The healthcare provider inserts a gloved and lubricated finger into the rectum to feel the prostate gland for its size, shape, and any abnormalities. 
• Neurological examination: A neurological exam can be performed to assess the muscle tone, reflexes, and sensations of the lower extremities. 
• Urinalysis: A urine sample may be analysed to detect the presence of blood or signs of infection. 
• Prostate-specific antigen (PSA) blood test: This test can be performed to measure the level of PSA in the blood, which can indicate the possibility of prostate cancer. 
• Uroflowmetry: This test measures the rate of urine flow and can help determine if there is an obstruction in the urethra. 
• Post-void residual (PVR) urine volume: This test measures the amount of urine left in the bladder after urination to determine if there is incomplete bladder emptying. 
• Bladder ultrasound: This test used for sound waves to create an image of the bladder to determine if there is an enlarged prostate or bladder outlet obstruction. 
• Cystoscopy: In this procedure, a thin tube with a camera at the end is inserted into the urethra to examine the bladder and urethra. This procedure can help detect any abnormalities that may be causing urinary symptoms. 

Age group

Associated comorbidity

• BPH is often associated with other medical conditions such as obesity, hypertension, type 2 diabetes, and cardiovascular diseases. Certain medications such as antihistamines and decongestants may also exacerbate BPH symptoms. There is no known association between BPH and sexual activity.

Associated activity

Acuity of presentation

BPH is a slowly progressive condition, and the symptoms may develop over a period of months or years. The severity of symptoms may vary among individuals, and some may not experience any symptoms at all. The symptoms of BPH usually manifest as lower urinary tract symptoms (LUTS), which may include: 

• Urinary frequency: A need to urinate more often than normal, especially at night (nocturia). 
• Urgency: Urge to urinate that is sudden and strong. 
• Difficulty starting urination: Weak or intermittent urine stream, or difficulty initiating urination. 
• Incomplete emptying of the bladder: A feeling of incomplete emptying of the bladder after urination. 
• Urinary retention: Inability to urinate, or a complete inability to empty the bladder. 
• Urinary incontinence: Unintentional leakage of urine. 

Differential Diagnoses

• Prostate cancer: Prostate cancer can have similar symptoms to BPH, such as urinary urgency and frequency, weak urine flow, and difficulty urinating. 
• Urinary tract infections: They can cause similar urinary symptoms to BPH, but UTIs are usually associated with pain or burning during urination. 
• Bladder cancer: Bladder cancer can cause urinary symptoms such as blood in the urine, frequent urination, and pain during urination. 
• Neurogenic bladder: It is a condition that affects the nerves that control bladder function. It can cause urinary symptoms like those of BPH. 
• Urethral stricture: It is a narrowing of the urethra that can cause difficulty urinating, a weak urine stream, and urinary retention. 
• Chronic prostatitis: Chronic prostatitis can cause symptoms like BPH, such as pain during urination and a frequent need to urinate. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

• Patients may be advised to avoid drinking fluids before bed, caffeine, and alcohol to reduce urinary frequency. 
• They may be advised to empty their bladder regularly and take their time when urinating to ensure the bladder is completely emptied. 
• Exercises like Kegels, which strengthen the muscles of the pelvic floor, can also help. 

• Alpha blockers like tamsulosin, doxazosin, and terazosin can relax the muscles of the prostate and bladder neck to relieve urinary symptoms. 
• 5-alpha-reductase inhibitors like finasteride and dutasteride can shrink the prostate gland, but it may take several months for the effects to be noticed. 

• Transurethral resection of prostate (TURP): It is a common surgical procedure used to treat moderate to severe BPH. it involves removal of inner part of the prostate gland that is blocking urine flow. 
• Transurethral microwave thermotherapy (TUMT), high-intensity focused ultrasound (HIFU), and laser surgery are other minimally invasive procedures that can be used to treat BPH. 

• Watchful waiting involves monitoring the patient’s symptoms without immediate treatment. 
• Medical therapy can be initiated with alpha-blockers or 5-alpha-reductase inhibitors. 
• Combination therapy with both alpha-blockers and 5-alpha-reductase inhibitors may be recommended for patients with moderate to severe symptoms. 
• Surgical intervention may be considered if medical therapy is ineffective or if the patient has complications from BPH. 

Medication

Future Trends

Media Gallary

References

• www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems/benign-prostatic-hyperplasia-bph. 
• https://emedicine.medscape.com/article/437359-overview#a1.