Signs and Symptoms of Benign Prostatic Hyperplasia
BPH presents with two distinct symptom categories: voiding (obstructive) symptoms including hesitancy, weak stream, straining, and prolonged voiding; and storage (irritative) symptoms including frequency, urgency, nocturia, and urge incontinence—with storage symptoms typically being the most bothersome to patients. 1, 2
Voiding (Obstructive) Symptoms
These symptoms result from direct bladder outlet obstruction by enlarged prostatic tissue and increased smooth muscle tone within the gland: 1
- Urinary hesitancy - difficulty initiating urination 1, 2
- Weak urinary stream - reduced force of urine flow 1, 2
- Straining to void - need to apply abdominal pressure during urination 1, 2
- Prolonged voiding - extended time required to complete urination 1, 2
- Intermittency - stopping and starting during urination 2
Storage (Irritative) Symptoms
These symptoms arise from bladder dysfunction secondary to chronic obstruction and are typically more bothersome than voiding symptoms: 3
- Urinary frequency - voiding more than 8 times per 24 hours 1, 2
- Urgency - sudden compelling desire to void that is difficult to defer 1, 2
- Nocturia - waking at night to urinate 1, 2
- Urge incontinence - involuntary urine leakage associated with urgency 1, 2
- Reduced voiding volumes - small amounts per void 2
Post-Micturition Symptoms
- Post-void dribbling - continued urine leakage after completing urination 2
- Sensation of incomplete bladder emptying - feeling that the bladder has not fully emptied 1, 2
Critical Red Flag Symptoms Requiring Urgent Evaluation
The following symptoms indicate complications requiring immediate physician referral: 1
- Acute urinary retention - complete inability to void 1
- Recurrent urinary tract infections 1
- Gross hematuria - visible blood in urine 1, 4
- Renal insufficiency - elevated creatinine from chronic obstruction 1
- Palpable bladder on physical examination 1, 4
Important Clinical Caveats
- Symptom severity does not correlate with prostate size - men with large prostates may have minimal symptoms while those with modest enlargement may be severely symptomatic 3
- Symptoms fluctuate over time and tend to gradually worsen, though progression is not inevitable 3
- Lower limb edema is NOT a symptom of BPH - if present, evaluate for heart failure, renal disease, venous insufficiency, or medication side effects 5
- Storage symptoms without prostatic enlargement may indicate overactive bladder rather than BPH as the primary diagnosis 4
Symptom Quantification
The International Prostate Symptom Score (IPSS/AUA Symptom Score) should be used to objectively categorize symptom severity: 1, 4
- Mild symptoms: Score <7
- Moderate symptoms: Score 8-19
- Severe symptoms: Score ≥20
Assess symptom bother separately from severity—patients with severe symptoms who report minimal bother should not receive active treatment. 1