Benign prostatic hyperplasia BPH , also called prostate enlargement , is a noncancerous increase in size of the prostate gland. The cause is unclear. Treatment options including lifestyle changes, medications, a number of procedures, and surgery. About million men are affected globally.
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It is common for men to present to a general practitioner GP with symptoms suggestive of bladder outflow obstruction, which is often due to benign prostatic enlargement BPE. Benign and neoplastic conditions of the lower urinary tract. Other causes of lower urinary tract symptoms.
Prior pelvic surgery. Iatrogenic from medications. International guidelines highlight the importance of determining the severity of LUTS and identifying complicating factors such as urinary retention, macroscopic haematuria, urinary tract infection UTI or a personal or family history of prostate cancer.
Men may describe i voiding bladder emptying symptoms such as weak stream, hesitancy and intermittency of flow or ii storage bladder filling symptoms such as urgency, daytime frequency and nocturia. Urinary symptoms over the past month symptom score criteria. Incomplete emptying How often have you had a sensation of not emptying your bladder completely after you finished urinating?
Frequency How often have you had to urinate less than two hours after you finished urinating? Intermittency How often have you found you stopped and started again several times when you urinated? Urgency How often have you found it difficult to postpone urination? Straining How often have you had to push or strain to begin urination?
Nocturia How many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? Mixed — about equally satisfied and unsatisfied. If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? The aim of physical examination is to exclude a palpable bladder as well as phimosis, meatal stenosis or other pathology, including balanitis.
Initial investigations aim to exclude sinister causes of LUTS or complications of bladder outflow obstruction that require immediate treatment. Such investigations Table 3 include urinalysis to exclude haematuria, proteinuria and pyuria , serum creatinine and estimated glomerular filtration rate eGFR.
In patients with moderate-to-severe symptoms or an abnormal serum creatinine, a renal tract ultrasound will show bladder capacity and post-void urine residual volume, allow for assessment for hydronephrosis and provide an estimation of prostate volume. Follow up with imaging if abnormal eGFR. Can be useful as a follow-up test if renal impairment is suspected.
Bladder scanners are available for general practitioner use to calculate residual volume, but a formal ultrasound requires a radiology unit. Controversial; most guidelines recommend the use of serum PSA if prostate cancer diagnosis will influence management or if the test will assist in decision making. Some men are concerned that their urinary symptoms may be due to an underlying prostate cancer.
Prostate-specific antigen PSA testing remains controversial both in Australia and internationally. Treatment is mostly determined by bother of symptoms, effect on QoL or whether any complicating features are identified. A conservative approach, with reassurance and behavioural modification, can be considered in men with mild, non-bothersome LUTS and normal baseline investigations, as their risk of progression is low.
Men with bothersome symptoms in the absence of complicating factors are appropriate candidates for a trial of medical therapy. Combined therapy with a 5-alpha reductase inhibitor 5-ARI may further improve symptoms in men with large prostate volumes. Alpha-1 adrenoceptor blockade results in smooth muscle relaxation in the prostate and bladder neck.
Men should be warned of the side effects of alpha-adrenoceptor antagonists, including retrograde ejaculation higher with uroselective agents , erectile dysfunction, nasal congestion, hypotension, dizziness and tachycardia. Dutasteride inhibits type 1 and type 2 isoenzymes of 5-alpha reductase, as opposed to type 2 inhibition alone with finasteride.
Since , tamsulosin plus dutasteride has been available to GPs to prescribe as a combined formulation without specialist approval. Two randomised controlled trials of more than men compared combination therapy with monotherapy. Overall, combination therapy was superior to either alpha-adrenoceptor antagonist or 5-ARI therapy alone in improving LUTS and reducing progression. BPE and erectile dysfunction can occur concomitantly, and phosphodiesterase 5 PDE5 inhibitors eg sildenafil have been associated with some improvement in voiding symptoms.
There are numerous clinical indications for urological referral including urinary retention, evidence of hydronephrosis on ultrasound, symptoms refractory to medical management, recurrent UTIs, gross haematuria, bladder stones, renal insufficiency or large bladder diverticula. Transurethral incision of the prostate involves an incision of the bladder neck without removal of prostatic tissue. It is used for men with small prostates and has outcomes comparable with TURP. Uncomplicated LUTS and minimal bother warrant an initial conservative approach.
Men with more bothersome symptoms can be initially managed with an alpha-adrenoceptor antagonist, while an additional 5-ARI can be considered for men with larger prostates. Surgery is recommended for men who are bothered by symptoms and fail to respond to medical management or have complications such as hydronephrosis, recurrent UTIs, progressive deterioration of residual volume, macroscopic haematuria or very poor maximum velocity on uroflow studies.
Review and update of benign prostatic hyperplasia in general practice. Background Benign prostatic hyperplasia BPH is the most common benign tumour in men. Although men with BPH often need medical or surgical management from a urologist at some point throughout the timeline of their disease, most men are initially assessed and managed by a general practitioner GP in the primary healthcare setting.
Several changes in pharmaceutical agents and surgical intervention have occurred over the past decade. As a result, it is imperative that GPs remain up to date with assessment and management of BPH, are aware of new therapies and understand when to refer to a urologist. Table 1. The International Prostate Symptom Score 4 Urinary symptoms over the past month symptom score criteria Not at all Less than one time in five Less than half the time About half the time More than half the time Almost always 1.
Weak stream How often have you had a weak urinary stream? Management Treatment is mostly determined by bother of symptoms, effect on QoL or whether any complicating features are identified. Alpha-adrenoceptor antagonists Alpha-1 adrenoceptor blockade results in smooth muscle relaxation in the prostate and bladder neck. Combination therapy Since , tamsulosin plus dutasteride has been available to GPs to prescribe as a combined formulation without specialist approval.
Provenance and peer review: Not commissioned, externally peer reviewed. New York: McGraw-Hill, A practical approach to the management of lower urinary tract symptoms among men. Med J Aust ; 1 — Endotext: Benign prostate disorders. Benign prostatic hyperplasia: Diagnosis and treatment. Agency for Health Care Policy and Research. Guidelines on the management of non-neurogenic male lower urinary tract symptoms LUTS , incl.
The Netherlands: EAU, Can Urol Assoc J ;4 5 — Patient information sheet: Should I have prostate cancer screening? Available at www. PSA testing and early management of test-detected prostate cancer: Clinical practice guidelines. Self management for men with lower urinary tract symptoms: Randomised controlled trial. BMJ ; The impact of self-management of lower urinary tract symptoms on frequency-volume chart measures.
BJU Int ; 8 — Urologiia ; 5 —42, 44— Rev Urol ;5 Suppl 5:S12— Role of 5 alpha-reductase inhibitors in the management of prostate cancer. Clin Interv Aging ;1 4 — A review of the clinical efficacy and safety of 5alpha-reductase inhibitors for the enlarged prostate. Clin Ther ;29 1 — Dutasteride: A review of current data on a novel duel inhibitor of 5alpha reductase. Rev Urol ;7 4 — The different reduction rate of prostate-specific antigen in dutasteride and finasteride. Korean J Urol ;51 10 — Easier access to medicines for men with enlarged prostates following medicine reimbursement changes.
Clinical outcomes after combined therapy with dutasteride plus tamsulosin or either monotherapy in men with benign prostatic hyperplasia BPH by baseline characteristics: 4-year results from the randomized, double-blind Combination of Avodart and Tamsulosin CombAT trial. BJU Int ; 6 — BJU Int ; 3 — Efficacy and safety of a fixed-dose combination therapy of tamsulosin and tadalafil for patients with lower urinary tract symptoms and erectile dysfunction: Results of a randomized, double-blinded, active-controlled trial.
J Sex Med ;14 8 — Transurethral plasmakinetic resection of the prostate is a reliable minimally invasive technique for benign prostate hyperplasia: A meta-analysis of randomized controlled trials.
Asian J Androl ;17 1 — Trends in the surgical treatment of benign prostatic hyperplasia in a tertiary hospital. ANZ J Surg ;88 1—2 — Outcomes of transurethral resection and holimiun laser enucleation in more than 60 g of prostate: A prospective randomized study. Urol Ann ;9 1 — Minimally invasive surgical therapies for benign prostatic hypertrophy: The rise in minimally invasive surgical therapies.
Prostate Int ;5 2 — UroLift — FAQs. Prostatic urethral lift improves urinary symptoms and flow while preserving sexual function for men with benign prostatic hyperplasia: A systematic review and meta-analysis. Eur Urol ;67 4 — Five year results of the prospective randomized controlled prostatic urethral L.
Review and update of benign prostatic hyperplasia in general practice
COVID is an emerging, rapidly evolving situation. Get the latest public health information from CDC: www. Benign prostatic hyperplasia—also called BPH—is a condition in men in which the prostate gland is enlarged and not cancerous. Benign prostatic hyperplasia is also called benign prostatic hypertrophy or benign prostatic obstruction. The prostate goes through two main growth periods as a man ages.
Benign prostatic hyperplasia
It is common for men to present to a general practitioner GP with symptoms suggestive of bladder outflow obstruction, which is often due to benign prostatic enlargement BPE. Benign and neoplastic conditions of the lower urinary tract. Other causes of lower urinary tract symptoms. Prior pelvic surgery.
Benign Prostatic Hyperplasia
Benign prostatic hyperplasia and lower urinary tract symptoms. N Engl J Med [Internet]. Simon HB. Prostate enlargement: Benign prostatic hyperplasia.