BPH

BPH (Benign Prostatic Hyperplasia) – NP Student Clinical Guide

πŸ“˜ What Is BPH?

Benign Prostatic Hyperplasia is a noncancerous enlargement of the prostate gland, common in aging men, which leads to lower urinary tract symptoms (LUTS) due to bladder outlet obstruction.

πŸ” Very common: >50% of men by age 60, up to 90% by age 85

🧠 Pathophysiology

  • Hyperplasia of both stromal and epithelial cells in the transitional zone of the prostate

  • Androgen (esp. dihydrotestosterone [DHT]) plays a key role

  • Enlargement compresses the urethra, leading to obstructive and irritative urinary symptoms

🚻 Clinical Presentation: LUTS (Lower Urinary Tract Symptoms)

β›” Obstructive (voiding) symptoms:

  • Hesitancy

  • Weak stream

  • Straining to void

  • Incomplete emptying

  • Post-void dribbling

  • Intermittency

πŸ’§ Irritative (storage) symptoms:

  • Frequency

  • Nocturia

  • Urgency

  • Urge incontinence

πŸ“Œ Note: BPH does not cause pain, hematuria, or infection β€” if these are present, think of other causes.

πŸ§ͺ Diagnosis

πŸ§‘β€βš• History:

  • Assess severity using the AUA Symptom Score (IPSS)

βœ‹ Physical Exam:

  • Digital Rectal Exam (DRE): smooth, enlarged, non-tender prostate

  • Rule out prostate cancer (nodules, asymmetry, induration)

🧾 Basic Workup:

Test

Purpose

UA (urinalysis)

Rule out infection or hematuria

PSA (prostate-specific antigen)

Optional β€” use shared decision-making

Serum creatinine

Optional β€” if concern for renal compromise

PVR (post-void residual)

Can be assessed via bladder scan

🎯 Treatment Strategy

Depends on:

  • Symptom severity

  • Degree of bother

  • Presence of complications (retention, infections, renal issues)

🟒 Watchful Waiting / Lifestyle (Mild Symptoms)

  • Limit evening fluids, caffeine, alcohol

  • Double voiding (try to urinate again shortly after first attempt)

  • Timed voiding

  • Avoid meds that worsen symptoms (e.g., anticholinergics, decongestants)

πŸ’Š Pharmacologic Therapy (Moderate to Severe Symptoms)

1. Alpha-1 Blockers (1st-line)

Examples

Tamsulosin, Terazosin, Doxazosin

MOA

Relax smooth muscle in prostate/bladder neck

Onset

Rapid (days to weeks)

SEs

Orthostatic hypotension, dizziness, retrograde ejaculation

2. 5-Alpha Reductase Inhibitors

Examples

Finasteride, Dutasteride

MOA

Shrinks prostate by blocking DHT

Best for

Larger prostates (>40 mL)

Onset

Slower (3–6 months)

SEs

Decreased libido, ED, gynecomastia

Bonus

Lowers PSA by ~50%

βœ… Combo therapy:

  • Alpha-blocker + 5ARI = superior in moderate-to-severe cases

3. Others:

  • PDE5 inhibitors (Tadalafil): Dual benefit for BPH + ED

  • Anticholinergics / Beta-3 agonists: If storage symptoms predominate β€” caution in high PVR

πŸ₯ When to Refer to Urology

  • Urinary retention

  • Recurrent UTIs

  • Hematuria

  • Elevated PSA or abnormal DRE

  • Bladder stones

  • Renal insufficiency

  • Failed medical therapy

πŸ”ͺ Surgical Options (for severe cases)

  • TURP (Transurethral Resection of the Prostate): Gold standard

  • Minimally invasive procedures:

    • UroLift

    • RezΕ«m

    • Laser ablation

🧠 Mnemonic: β€œFUNWISE” for BPH Symptoms

Letter

Stands for

F

Frequency

U

Urgency

N

Nocturia

W

Weak stream

I

Intermittency

S

Straining

E

Emptying incompletely

βœ… Summary Table

Feature

Description

Cause

Stromal/epithelial hyperplasia (DHT-driven)

Symptoms

Obstructive + Irritative LUTS

DRE

Enlarged, smooth, non-tender

Tests

UA, optional PSA, bladder scan

Treatment

Lifestyle β†’ meds β†’ surgery

Meds

Alpha-blockers, 5ARIs, PDE5 inhibitors

Refer

Retention, hematuria, abnormal DRE, failed meds