Benign Prostatic Hyperplasia (BPH)

👴🏽 Benign Prostatic Hyperplasia (BPH)

NP Student Educational Guide

✅ Definition

Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland, commonly seen in aging men. It leads to lower urinary tract symptoms (LUTS) due to urethral compression and bladder outlet obstruction.

📊 Epidemiology

  • Very common in men >50 years old

  • ~50% of men by age 60

  • ~90% by age 85

  • Not all men with BPH develop symptoms

🧬 Pathophysiology

  • BPH involves hyperplasia of prostatic stromal and epithelial cells, mostly in the transition zone.

  • Androgens (especially dihydrotestosterone, DHT) drive prostate growth.

  • As the prostate enlarges, it compresses the urethra, leading to bladder outflow obstruction and urinary symptoms.

🚽 Clinical Presentation

LUTS = Lower Urinary Tract Symptoms
🔹 Voiding (Obstructive) Symptoms:

  • Weak urinary stream

  • Hesitancy

  • Straining

  • Incomplete emptying

  • Intermittency

  • Dribbling

🔹 Storage (Irritative) Symptoms:

  • Urgency

  • Frequency

  • Nocturia

  • Urge incontinence (less common)

📌 Hematuria or UTIs may occur with chronic retention.

📝 History & Physical Exam

🔍 History:

  • Symptom onset and severity

  • Impact on quality of life

  • Medication use (anticholinergics, decongestants)

  • Voiding pattern, nocturia, incontinence

👨🏽‍⚕️ Physical Exam:

  • Digital Rectal Exam (DRE):

    • Enlarged, smooth, firm, nontender prostate

    • Nodules → rule out prostate cancer

  • Abdominal exam for bladder distension

🧪 Diagnostic Workup

Test

Purpose

UA (Urinalysis)

Rule out UTI or hematuria

PSA (optional)

Screen for prostate cancer (controversial in BPH)

Serum creatinine

Check renal function if retention is suspected

Post-void residual (PVR)

Bladder scan or cath after voiding

IPSS (International Prostate Symptom Score)

Symptom assessment (mild, moderate, severe)

🛠 Management

🔹 1. Watchful Waiting

  • For mild symptoms (IPSS 0–7)

  • Lifestyle changes:

    • Limit fluids before bed

    • Avoid caffeine/alcohol

    • Timed voiding

    • Avoid decongestants and anticholinergics

🔹 2. Pharmacologic Therapy

Class

Example

Mechanism

Notes

Alpha-1 blockers

Tamsulosin, Terazosin

Relax prostate/bladder neck smooth muscle

Fast symptom relief in days

5-alpha reductase inhibitors

Finasteride, Dutasteride

Shrink prostate by blocking DHT

Takes months; ↓ PSA by 50%

Combination therapy

Tamsulosin + Finasteride

Dual benefit for larger prostates

Better long-term outcomes

Anticholinergics

Oxybutynin

Reduce bladder irritability

Use if irritative symptoms dominate

Beta-3 agonists

Mirabegron

Improve bladder capacity

Alternative to anticholinergics

⚠ Always assess post-void residual before starting anticholinergics — risk of retention.

🔹 3. Surgical Options

Consider if:

  • Failed medical therapy

  • Recurrent urinary retention

  • Recurrent UTIs or bladder stones

  • Hematuria or hydronephrosis from BPH

Procedures include:

  • TURP (transurethral resection of prostate) – gold standard

  • Laser therapy

  • UroLift or Rezum – newer, minimally invasive options

🚩 When to Refer to Urology

  • Gross hematuria

  • Elevated PSA

  • Abnormal DRE (nodules)

  • Recurrent urinary retention or UTIs

  • Renal impairment due to obstruction

  • Failure of medical management

👩‍⚕ NP’s Role

  • Identify symptoms early

  • Educate patients on lifestyle modifications

  • Initiate and monitor medication therapy

  • Monitor for complications (retention, hematuria)

  • Collaborate with urology when needed

🧠 Clinical Pearl

A sudden worsening of urinary symptoms in a man with BPH may be due to:

  • UTI

  • Medication side effects (antihistamines, anticholinergics)

  • Bladder stones

  • Prostate cancer