What are the typical presentation, differential diagnosis (DDX), investigations (INVX), management (MX), and complications of Benign Prostatic Hyperplasia (BPH)?

Benign Prostatic Hyperplasia (BPH): Clinical Presentation, Diagnosis, Management, and Complications

BPH is characterized by lower urinary tract symptoms (LUTS) that can be effectively managed through a stepwise approach of watchful waiting, medical therapy, or surgical intervention based on symptom severity and the presence of complications.

Typical Presentation (Signs and Symptoms)

BPH presents with two main categories of symptoms:

Storage Symptoms

• Frequency
• Urgency
• Nocturia (nighttime urination)

Voiding Symptoms

• Incomplete emptying
• Intermittent stream
• Straining to urinate
• Weak urinary stream

The severity of symptoms is quantified using the International Prostate Symptom Score (IPSS) or American Urological Association Symptom Score, which classifies symptoms as:

• Mild (0-7 points)
• Moderate (8-19 points)
• Severe (20-35 points) 1

Differential Diagnosis (DDX)

Several conditions can mimic BPH symptoms:

• Prostate cancer
• Urinary tract infection
• Bladder cancer or carcinoma in situ
• Urethral stricture
• Bladder or urethral stones
• Neurological disorders affecting bladder function
• Detrusor overactivity or underactivity
• Medication side effects (anticholinergics, diuretics)

Investigations (INVX)

Recommended Tests

1. Detailed history including family history of prostate disease and assessment using IPSS 2
2. Physical examination including digital rectal examination (DRE) and focused neurological examination 2
3. Urinalysis to screen for hematuria and urinary tract infection 2
4. Serum PSA in selected patients with at least 10-year life expectancy or when PSA might change management of voiding symptoms 2

Optional Tests

1. Uroflowmetry before invasive therapy (at least 2 flow rates with >150ml voided volume) 1
2. Post-void residual urine measurement before invasive therapy 1
3. Frequency-volume charts (voiding diary) particularly for nocturia 1
4. Urine cytology in men with predominantly irritative symptoms 2
5. Transrectal or transabdominal ultrasound when minimally invasive or surgical interventions are considered 2

Not Recommended

• Filling cystometrography
• Upper urinary tract imaging (unless hematuria, UTI, renal insufficiency, history of urolithiasis or urinary tract surgery is present) 2

Management (MX)

Management depends on symptom severity:

1. Watchful Waiting

• Appropriate for mild symptoms or moderate-severe symptoms without complications
• Annual follow-up with repeat of initial evaluation
• Simple measures like decreasing fluid intake at bedtime and reducing caffeine/alcohol 2

2. Medical Therapy

Alpha Blockers (First-Line)

• Mechanism: Relax smooth muscle in prostate and bladder neck
• Options: Tamsulosin, alfuzosin, doxazosin, silodosin
• Benefits: Rapid symptom relief (within 3-5 days)
• Caution: Inform patients with planned cataract surgery about intraoperative floppy iris syndrome risk 1, 3

5-Alpha Reductase Inhibitors

• Mechanism: Shrink prostate by inhibiting conversion of testosterone to dihydrotestosterone
• Options: Finasteride, dutasteride
• Indications: Enlarged prostates (>30cc on imaging, PSA >1.5ng/mL, or palpable enlargement)
• Benefits: Reduce risk of acute urinary retention by 57% and BPH-related surgery by 55% 4
• Timeline: Effects take 3-6 months to develop

Combination Therapy

• Alpha blocker + 5-alpha reductase inhibitor for men with larger prostates and moderate-severe symptoms

3. Surgical Options

• Indicated when medical therapy fails, patient preference, or complications develop
• Options include:
  • Transurethral resection of prostate (TURP) - gold standard
  • Transurethral incision of prostate (TUIP)
  • Minimally invasive therapies (transurethral microwave thermotherapy, transurethral needle ablation)
  • Open prostatectomy (for very large prostates)

Complications of BPH

1. Acute urinary retention - sudden inability to urinate requiring catheterization
2. Chronic urinary retention with overflow incontinence
3. Recurrent urinary tract infections
4. Bladder stones
5. Renal insufficiency/failure from chronic obstruction
6. Hematuria from enlarged vessels in the prostate
7. Detrusor dysfunction from chronic obstruction

Treatment Evaluation and Follow-up

• Reassess IPSS at 2-4 weeks for alpha blockers and 3 months for 5-ARIs 1
• Use both IPSS and Global Subjective Assessment to evaluate treatment response
• Consider treatment changes if:
  • Patient reports dissatisfaction despite IPSS improvement
  • IPSS has not improved despite patient reporting satisfaction
  • IPSS has deteriorated 1

Common Pitfalls to Avoid

• Relying solely on IPSS without patient discussion
• Failing to verify patient understanding of IPSS questions (49% may misunderstand)
• Ignoring bother score and quality of life impact
• Overlooking non-BPH causes of symptoms 1
• Delaying treatment in patients with complications or severe symptoms
• Not offering PSA testing to appropriate patients

BPH management should be guided by symptom severity, prostate size, and presence of complications, with regular reassessment to ensure optimal outcomes.