What are the differences in diagnosis and treatment between Benign Prostatic Hyperplasia (BPH) and prostatitis?

BPH versus Prostatitis: Diagnostic and Treatment Differences

BPH and prostatitis are fundamentally different conditions requiring distinct diagnostic approaches and treatments—BPH is a chronic structural enlargement causing obstructive symptoms in older men, while prostatitis is an inflammatory/infectious condition that can occur at any age with pain as a predominant feature.

Key Diagnostic Distinctions

Clinical Presentation

BPH presents with progressive obstructive and irritative voiding symptoms without pain, while prostatitis typically includes pelvic/perineal pain, dysuria, and systemic symptoms in acute cases 1.

• BPH symptoms: Weak stream, incomplete emptying, frequency, nocturia, urgency—quantified by IPSS/AUA Symptom Score 2, 3
• Prostatitis symptoms: Pelvic pain, painful urination, painful ejaculation, fever (in acute bacterial form), flu-like symptoms 1
• BPH typically affects men over 50 with gradually worsening symptoms 2
• Prostatitis can occur at any age and may have acute onset 1

Physical Examination Findings

Digital rectal examination (DRE) is mandatory for both conditions but reveals different findings 2, 1:

• BPH: Enlarged, smooth, firm, non-tender prostate 2
• Acute bacterial prostatitis: Tender, boggy, warm prostate; avoid vigorous prostatic massage as it may cause bacteremia 1
• Chronic prostatitis: May have normal or slightly tender prostate 1

Laboratory and Diagnostic Testing

The diagnostic workup differs significantly between these conditions:

For BPH 2, 3:

• Urinalysis (mandatory): Screen for hematuria and UTI—normal in uncomplicated BPH
• PSA measurement (recommended): Offered to patients with >10-year life expectancy; elevated PSA predicts prostate growth and BPH progression 2
• IPSS/AUA Symptom Score (mandatory): Quantifies symptom severity (mild <7, moderate 8-19, severe ≥20) 3
• Uroflowmetry and post-void residual: Optional but helpful for assessing obstruction 4
• Urine culture: Not routinely needed unless infection suspected 2

For Prostatitis 1:

• Urine culture (mandatory): Essential for diagnosing bacterial prostatitis
• Pre- and post-prostatic massage urine specimens: Differentiates bacterial prostatitis from other causes 1
• Urinalysis: May show pyuria and bacteriuria in bacterial forms 1
• PSA: May be elevated but not diagnostically useful; normalizes after treatment 1
• NIDDK-CPSI score: Specific symptom assessment for chronic prostatitis/chronic pelvic pain syndrome 5

Critical Diagnostic Pitfall

Do not confuse chronic prostatitis with BPH based solely on LUTS—both can present with urinary frequency and urgency, but prostatitis includes pain as a cardinal feature while BPH does not 6, 1. The differential diagnosis must exclude both conditions along with bladder cancer, urethral stricture, and neurogenic bladder 2, 1.

Treatment Approaches

BPH Treatment Algorithm 2

Treatment is stratified by symptom severity and bother level:

Mild Symptoms (IPSS <7) or Non-bothersome Symptoms:

• Watchful waiting is the standard approach 2
• Annual monitoring with repeat IPSS and DRE 2

Moderate to Severe Bothersome Symptoms (IPSS ≥8):

For small prostates (<30cc) 3:

• Alpha-blockers (alfuzosin, doxazosin, tamsulosin, terazosin) are first-line 2, 7
• Mechanism: Relax smooth muscle in prostate and bladder neck 7
• Follow-up at 1 and 3 months 3

For large prostates (>30cc) 3, 8:

• 5-alpha reductase inhibitors (finasteride, dutasteride) reduce prostate volume by 17.9% over 4 years 8
• Reduce risk of acute urinary retention by 57% and surgery by 55% 8
• Follow-up at 3 and 6 months due to delayed onset of action 3
• Combination therapy (alpha-blocker + 5-alpha reductase inhibitor) for optimal results 2

Surgical Options 2:

• TURP remains the benchmark for severe symptoms or complications (retention, renal insufficiency, recurrent UTI, bladder stones) 2
• Minimally invasive options: TUMT, laser procedures 2

Prostatitis Treatment Algorithm 1

Treatment depends on prostatitis classification:

Acute Bacterial Prostatitis:

• Fluoroquinolones or trimethoprim-sulfamethoxazole for 4-6 weeks 1
• Hospitalization with IV antibiotics for severe cases with sepsis 1
• Never perform vigorous prostatic massage 1

Chronic Bacterial Prostatitis:

• Prolonged antibiotic therapy (6-12 weeks) with fluoroquinolones 1
• Alpha-blockers may help voiding symptoms 1

Chronic Prostatitis/Chronic Pelvic Pain Syndrome:

• Alpha-blockers for voiding symptoms 1
• Anti-inflammatory agents (NSAIDs) 1
• Antibiotics have limited evidence but often tried empirically 1
• Bioregulatory peptides (vitaprost) show benefit in combination with alpha-blockers and antibiotics for BPH+CP overlap 5

Common Treatment Pitfalls

Do not treat presumed prostatitis with antibiotics without confirming bacterial infection—chronic pelvic pain syndrome (90% of chronic prostatitis cases) does not respond to antimicrobials 1. Conversely, do not assume all LUTS in older men are BPH—always exclude prostatitis, especially if pain is present 6, 1.

For patients with both BPH and chronic prostatitis, combination therapy with alpha-blockers, appropriate antibiotics (if bacterial), and bioregulatory peptides demonstrates superior symptom reduction compared to alpha-blockers alone 5.