What are the signs and symptoms of Benign Prostatic Hyperplasia (BPH)?

Signs and Symptoms of Benign Prostatic Hyperplasia (BPH)

BPH primarily presents with lower urinary tract symptoms (LUTS) that include both storage symptoms (urgency, frequency, nocturia) and voiding symptoms (weak stream, hesitancy, intermittency, straining, and sensation of incomplete emptying). 1, 2

Storage Symptoms

• Urgency: Sudden compelling desire to pass urine which is difficult to defer 1, 3
• Frequency: Need to urinate more often than usual during daytime 1, 2
• Nocturia: Need to wake up at night one or more times to urinate, often the most bothersome symptom 1, 4
• Incontinence: Involuntary leakage of urine, particularly urgency incontinence which may develop as a consequence of BPH 3, 5

Voiding Symptoms

• Weak urinary stream: Reduced force of urination 1, 2
• Hesitancy: Difficulty initiating urination 1, 6
• Intermittency: Urine flow that stops and starts during micturition 1, 2
• Straining: Need to push or strain to begin and maintain urination 1, 6
• Sensation of incomplete emptying: Feeling that the bladder is not completely empty after urination 1, 2

Pathophysiological Mechanisms

BPH contributes to urinary symptoms through two primary mechanisms:

• Static component: Direct bladder outlet obstruction from enlarged prostatic tissue 2, 7
• Dynamic component: Increased smooth muscle tone and resistance within the enlarged prostate gland 2, 8

Symptom Assessment

The American Urological Association Symptom Index (AUA-SI) or International Prostate Symptom Score (IPSS) is recommended for objective assessment of symptom severity 1:

• Mild symptoms: Score 0-7 1
• Moderate symptoms: Score 8-19 1
• Severe symptoms: Score 20-35 1

Complications of Untreated BPH

If left untreated, BPH can lead to:

• Acute urinary retention: Complete inability to void requiring urgent catheterization 7, 2
• Bladder stones: Formation of calculi in the bladder 1
• Recurrent urinary tract infections: Due to incomplete bladder emptying 6, 5
• Renal insufficiency: Rare but serious complication in advanced cases 1

Clinical Pearls

• BPH symptoms typically begin after age 40, with prevalence reaching 60% by age 60 and 80% by age 80 2
• Nocturia is often the most bothersome symptom and frequently the reason men seek medical attention 4
• Symptoms may fluctuate in severity over time and can significantly impact quality of life 2, 6
• The size of the prostate does not necessarily correlate with symptom severity 8
• Frequency-volume charts are particularly useful when nocturia is the predominant symptom 1

Common Pitfalls

• Not all LUTS in older men are due to BPH; conditions such as urinary tract infection, bladder cancer, neurological disorders, and diabetes can present with similar symptoms 9, 5
• Relying solely on prostate size to determine treatment approach is inadequate; symptom severity and bother should guide management decisions 8, 2
• Failing to assess post-void residual urine can miss important information about bladder function 1
• Overlooking the impact of medications (especially diuretics, anticholinergics, and decongestants) that may exacerbate LUTS 6

BPH symptoms significantly impact quality of life and should be systematically evaluated using validated questionnaires to guide appropriate management decisions 1, 2.