What is benign prostatic hyperplasia, its typical urinary symptoms in men over 50, and how should it be evaluated and treated?

Benign Prostatic Hyperplasia: Definition, Symptoms, Evaluation, and Treatment

What is BPH?

Benign prostatic hyperplasia is a noncancerous enlargement of the prostate gland caused by proliferation of both stromal and epithelial cells in the transitional zone, resulting in bladder outlet obstruction and lower urinary tract symptoms. 1, 2

• BPH is nearly ubiquitous in aging males, with prevalence reaching 60% by age 60 and 80% by age 80. 1
• The condition affects approximately 90% of men between 45 and 80 years of age with some type of lower urinary tract symptoms. 1
• Moderate-to-severe symptoms rise to nearly 50% by age 80, making this one of the most common conditions affecting older men. 1

Typical Urinary Symptoms in Men Over 50

BPH produces two distinct patterns of urinary symptoms through static (anatomic enlargement) and dynamic (smooth muscle tone) mechanisms of obstruction: 1

Voiding (Obstructive) Symptoms:

• Weak urinary stream 1, 3
• Urinary hesitancy 1, 3
• Intermittent stream 1
• Straining to void 1
• Prolonged urination 3, 4
• Sensation of incomplete bladder emptying 1, 3
• Inability to terminate micturition abruptly 3

Storage (Irritative) Symptoms:

• Urinary frequency 1, 2
• Urgency 1, 2
• Nocturia 1, 4
• Urge incontinence 4, 2

Post-Void Symptoms:

• Post-void dribbling 2

How to Evaluate BPH

Initial Required Evaluation

Every man presenting with lower urinary tract symptoms should undergo a focused initial assessment including medical history, digital rectal examination, International Prostate Symptom Score (IPSS), and urinalysis. 1

Specific elements to assess:

• Administer the IPSS or AUA Symptom Index to objectively quantify symptom severity and degree of bother—this score directly guides treatment decisions. 1, 5
• Perform digital rectal examination to estimate prostate size (critical for determining if 5-alpha reductase inhibitors will be effective), assess consistency, and screen for nodules suggesting malignancy. 1, 5
• Order urinalysis with dipstick to detect hematuria, pyuria, or infection that would alter management. 1, 5
• Measure serum PSA in men with ≥10-year life expectancy to exclude prostate cancer and predict BPH progression risk. 6, 1

Optional Objective Testing

• Consider post-void residual (PVR) measurement via bladder ultrasound to assess bladder emptying efficiency. 6, 1
• Consider uroflowmetry for objective assessment of voiding function, particularly if considering surgical intervention. 6, 1
• Have patients complete a 3-day frequency-volume chart (bladder diary) to quantify voiding patterns and differentiate nocturnal polyuria from bladder dysfunction. 1, 5

Critical Pitfall to Avoid

Do not initiate treatment without first documenting symptom severity with IPSS, as treatment indication depends on symptom bother, not just presence of symptoms. 1

How to Treat BPH

Treatment Algorithm Based on Symptom Severity

For men with mild symptoms (IPSS <8), watchful waiting with lifestyle modifications is the standard approach, as the risks of medical therapy outweigh benefits in this population. 6, 5

For men with moderate-to-severe symptoms (IPSS ≥8) who are bothered by them, alpha-blockers are first-line therapy, providing rapid symptom relief within 2-4 weeks regardless of prostate size. 6, 1, 5

First-Line Medical Therapy: Alpha-Blockers

Start an alpha-blocker immediately for symptomatic relief in all men with bothersome moderate-to-severe symptoms: 6, 5

• Tamsulosin 0.4 mg once daily is highly effective, requires no dose titration, and has minimal cardiovascular effects. 5
• Alfuzosin provides comparable efficacy with superior tolerability compared to older agents. 6, 5
• Doxazosin and terazosin are equally effective but require dose titration and carry higher risk of orthostatic hypotension. 5

Alpha-blockers work by relaxing prostatic smooth muscle, reducing the dynamic component of bladder outlet obstruction, with effects typically seen within 2-4 weeks. 6, 5

Counsel patients about orthostatic hypotension risk during initial doses and advise them to inform their ophthalmologist before cataract surgery due to intra-operative floppy iris syndrome risk. 5

When to Add 5-Alpha Reductase Inhibitors

Add finasteride 5 mg daily or dutasteride 0.5 mg daily to ongoing alpha-blocker therapy only when prostate volume exceeds 30-40 cc or PSA is elevated. 6, 5

Critical: Measure prostate volume before prescribing a 5-ARI; these agents provide no benefit for prostates <30 cc. 6, 5, 7

• 5-ARIs work by shrinking the prostate over 6-12 months by inhibiting conversion of testosterone to dihydrotestosterone. 6, 5
• Expect delayed therapeutic onset—wait 3-6 months before assessing efficacy. 6
• Do not use 5-ARIs as monotherapy for immediate symptom relief, as they take 6-12 months to work. 5

Combination Therapy for Long-Term Disease Control

For patients with moderate-to-severe symptoms AND prostate enlargement >30 cc, combination therapy (alpha-blocker plus 5-ARI) is recommended to address both dynamic and static components of obstruction. 6, 5

• Combination therapy reduces overall risk of progression by 67%, acute urinary retention by 79%, and need for surgery by 67%. 6
• Combination therapy is superior to monotherapy for preventing symptom progression over 4-5 years. 5
• The best-tested combination is doxazosin plus finasteride, though other alpha-blocker/5-ARI combinations are likely comparable. 6

Alternative First-Line Options

For patients with erectile dysfunction, PDE5 inhibitors can be started as initial therapy instead of alpha-blockers. 6

For patients with predominant storage symptoms and small prostates, consider antimuscarinic agents after excluding bladder outlet obstruction. 6

Lifestyle Modifications

• Restrict fluid intake before bedtime to reduce nocturia. 5
• Limit caffeine and alcohol intake. 5
• Reduce high-calorie bakery products, processed meats, and sugar-sweetened beverages while increasing fiber through whole grains, fruits, and vegetables. 5

Follow-Up Strategy

Reassess patients 4-12 weeks after initiating alpha-blocker therapy using IPSS to objectively measure treatment response. 6, 1

• For 5-ARIs, wait 3-6 months before assessing efficacy. 6
• Measure post-void residual if initial PVR was elevated. 5
• Once stable on treatment, follow-up intervals should be at least yearly, repeating the initial evaluation to detect symptom progression or complications. 6

When to Refer for Surgery

Transurethral resection of the prostate (TURP) remains the gold standard surgical approach for patients who fail medical therapy or develop complications. 6, 1, 7

Absolute indications requiring immediate urologic referral include: 6, 5

• Acute urinary retention requiring catheterization
• Refractory urinary retention
• Recurrent urinary tract infections despite appropriate antibiotics
• Recurrent gross hematuria after negative malignancy work-up
• Bladder stones
• Renal insufficiency attributable to bladder outlet obstruction
• Upper tract dilatation with hydronephrosis
• Persistent severe symptoms (IPSS >19) despite maximal medical therapy

Key Clinical Pitfalls to Avoid

• Do not prescribe 5-ARIs without documented prostate enlargement >30 cc—they are ineffective in small glands. 6, 5, 7
• Do not use 5-ARIs for immediate symptom relief—they require 6-12 months to achieve maximum benefit. 5
• Do not assume infection based solely on trace leukocytes in urinalysis—negative culture definitively excludes bacterial UTI. 1
• Do not overlook prostate cancer screening—PSA and DRE are essential in men over 50 to exclude malignancy as a cause of LUTS. 1
• If symptoms fail to improve or patients experience intolerable side effects after 2-3 months of alpha-blocker therapy or 6 months of finasteride, refer to urology for further evaluation and consideration of surgical intervention. 6, 3