What is adenomatous hyperplasia (benign prostatic hyperplasia) and what are the recommended management options?

Adenomatous Hyperplasia (Benign Prostatic Hyperplasia)

Definition and Pathophysiology

Adenomatous hyperplasia, clinically known as benign prostatic hyperplasia (BPH), is a histologic diagnosis characterized by proliferation of glandular epithelial tissue, smooth muscle, and connective tissue within the prostatic transition zone. 1

• BPH develops from an imbalance between cellular growth and apoptosis, favoring increased cellular mass in the transition zone 2
• This histologic condition is ubiquitous in aging males, with prevalence increasing progressively: affecting 60% of men by age 60 and 80% by age 80 2, 3
• BPH itself does not require treatment and is not the target of interventions 1

Clinical Progression and Complications

BPH can lead to benign prostatic enlargement (BPE), which may cause bladder outlet obstruction at the bladder neck level (benign prostatic obstruction). 1, 2

• The obstruction occurs through two distinct mechanisms: the static component (physical tissue enlargement) and the dynamic component (increased smooth muscle tone and resistance) 2, 3
• This results in lower urinary tract symptoms (LUTS) including urinary hesitancy, incomplete bladder emptying, dribbling, prolonged urination, nocturia, urinary urgency, and urge incontinence 4
• Moderate-to-severe LUTS prevalence rises to nearly 50% by the eighth decade of life 1, 3

Management Algorithm

Initial Conservative Management

For men over age 45 presenting with LUTS attributed to BPH, initial management should include urinalysis to exclude infection and assessment with the International Prostate Symptom Score (IPSS) to quantify symptom severity. 2

• Digital rectal examination must be performed to assess prostate size and exclude nodules suggesting malignancy 2
• PSA measurement is essential in any elderly male with new-onset obstructive symptoms or hematuria to exclude malignancy 2
• Post-void residual (PVR) urine volume should be measured to assess for significant obstruction 2

Medical Therapy Escalation

For patients with worsening symptoms despite long-term alpha-blocker therapy, add a 5-alpha reductase inhibitor (5-ARI) to address both dynamic and static components of obstruction. 2

• Combination therapy of alpha-blockers and 5-ARIs is more effective than monotherapy, with 5-ARIs reducing prostate volume by approximately 18-25% over 6-12 months 2
• Re-evaluate at 4-12 weeks after initiating combination therapy with repeat IPSS score, PVR measurement, and uroflowmetry if available 2

Surgical Intervention Criteria

Refer for surgical intervention if symptoms continue to worsen or fail to improve after 6 months of combination therapy. 2

• Absolute indications for surgery include: renal insufficiency secondary to BPH, refractory urinary retention, recurrent urinary tract infections, and recurrent bladder stones. 2
• Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment 1
• Alternative minimally invasive surgical therapies (MIST) include holmium laser enucleation (HoLEP), photoselective vaporization (PVP), prostatic urethral lift (PUL), and prostate artery embolization (PAE) 1

Critical Diagnostic Pitfalls to Avoid

Do not assume all voiding dysfunction in elderly males is due to BPH, as detrusor underactivity from aging or diabetes can produce identical symptoms but requires different management. 2

• A maximum flow rate (Qmax) greater than 10 mL/second does not exclude obstruction; pressure-flow studies are indicated when the clinical picture is unclear 2
• The positive predictive value for obstruction is only 88% with Qmax under 10 mL/s and 76% with prostate volume over 40 mL 2
• Never attribute hematuria solely to BPH without excluding bladder stones, bladder cancer, or upper tract pathology, particularly in patients with risk factors like smoking or occupational exposures 2
• Detrusor overactivity with impaired contractility (DHIC) represents a particularly challenging scenario in elderly males with longstanding BPH, creating a mixed picture where both obstruction and impaired bladder contractility contribute to voiding dysfunction 2

Quality of Life Impact

Although LUTS/BPH is not often life-threatening, the impact on quality of life can be significant and should not be underestimated. 1

• Studies estimate that 90% of men between 45 and 80 years suffer some type of LUTS 1
• The increasing risk of complications such as acute urinary retention necessitates regular monitoring for men with risk factors for BPH progression 3