Definition
A.Benign prostatic hyperplasia (BPH) is enlargement of the prostate gland that constricts the urethra causing urinary symptoms. BPH is not believed to be a risk factor for prostate cancer. BPH occurs primarily in the central or transitional zone of the prostate, while prostate cancer originates primarily in the peripheral part of the prostate.
B.The voiding dysfunction that results from prostate enlargement and bladder outlet obstruction (BOO) are termed lower urinary tract symptoms (LUTS).
Incidence
A.BPH increases progressively with age. The prevalence of prostatic hyperplasia increases from 8% in men aged 31 to 40 years to 40% to 50% in men aged 51 to 60 years to over 80% in men older than 80 years.
Pathogenesis
A.The exact cause is unknown; BPH may be a response to the androgen hormone. The process of aging and the presence of circulating androgens are required for the development of BPH. Hyperplasia, in which the normally thin and fibrous outer capsule of the prostate becomes spongy and thick, and the contraction of muscle fibers cause pressure on the urethra. This pressure requires the bladder musculature to work harder to empty urine.
Predisposing Factors
A.Advancing age.
B.Race: African American men younger than 65 years of age may need treatment more often than White men.
C.Genetic predisposition: Increases with a positive family history of BPH having moderate to severe LUTS.
D.Obesity.
E.Diabetes.
F.High levels of alcohol consumption.
G.Physical inactivity.
Common Complaints
The clinical manifestations of BPH are LUTS that typically appear slowly and progress gradually over a period of years:
A.Difficulty starting urine flow.
B.Dribbling.
C.Bladder that does not feel it completely empties.
D.Frequency of urination.
Other Signs and Symptoms
A.Obstructive symptoms:
1.Hesitancy.
2.Diminution in size and force of urinary stream.
3.Stream interruption (double voiding).
4.Urinary retention.
5.Straining/Valsalva maneuver to fully empty the bladder.
B.Irritative voiding symptoms:
1.Urgency.
2.Frequency.
3.Nocturia.
4.Painless hematuria: An early symptom; may also indicate malignancy.
C.Severe late symptoms with untreated BPH:
1.Acute urinary retention.
2.Recurrent urinary tract infections (UTIs).
3.Hydronephrosis.
4.Loss of renal concentrating ability.
5.Systemic acidosis and renal failure.
Subjective Data
A.Have the patient complete the American Urologic Association Symptom Score (AUASS) assessment tool at each visit to track symptoms. The AUASS (see Table 15.1) is used to assess the severity of symptoms of BPH.
B.Review the onset, duration, and course of symptoms. The AUASS assessment tool can be used to quantitatively assess BPH symptoms over time.
C.Does the patient have signs of a UTI?
D.Is there any blood in the urine or pain in the bladder region? (Evaluate bladder tumor or calculi.)
E.Does the patient have new symptoms such as bone or back pain, loss of appetite, or weight loss (rules out cancer)?
F.Review the patient’s history for medical illness, including diabetes and neurologic problems.
G.Review previous urinary problems, surgeries, infections, treatments, success of treatments, and testing.
H.Review the patient’s history of sexual dysfunction and any new sexual partners (sexually transmitted infections [STIs]).
I.Review the patient’s history of urethral trauma, urethritis, or urethral instrumentation that could have led to urethral stricture.
J.Review medications, both prescription and over-the-counter (OTC) drugs, including sinus or cold products, anticholinergic drugs (for impaired bladder function), and sympathomimetic drugs (to increase outflow resistance).
K.Review family history of BPH and prostate cancer.
L.Review fluid intake, especially caffeinated/carbonated drinks.
M.Evaluate how bothersome the symptoms are to the patient’s quality of life:
1.How often does he have interrupted sleep to get up to go to the bathroom?
2.How often does he urinate?
3.Does he have to wear an absorptive underwear pad?
Physical Examination
A.Check temperature (if indicated), blood pressure (BP), and weight (if indicated).
B.Inspect:
1.Evaluate general appearance for discomfort or acute discomfort with urinary retention.
2.Consider having the patient void: Normal urination for a man is the ability to empty the bladder of 300 mL of urine in 12 to 15 seconds.
3.Examine the urethral meatus for discharge.
4.Retract foreskin (if present) and assess for hygiene and smegma.
5.Check the shaft of the penis, glans, and prepuce for lesions.
6.Check inguinal and femoral areas for bulges or hernias; have the patient bear down and cough and reexamine him.
7.Perform a neurological examination (evaluate sensory and motor deficits).
C.Palpate:
1.Palpate the abdomen for masses or bladder distension.
2.Palpate lymph nodes in the groin for enlargement.
3.Check costovertebral angle (CVA) tenderness.
4.Palpate the testes and epididymides for inflammation, tenderness, and masses.
5.Palpate the scrotum for hydrocele or varicocele.
D.Digital rectal exam (DRE): Use the index finger of the dominant hand for the DRE:
1.Note sphincter tone, nodules or masses, and tenderness. Decreased anal sphincter tone or the lack of muscle reflex may indicate an underlying neurological disorder.
2.Palpate the two lateral lobes of the prostate gland and its median sulcus for irregularities, nodules, induration, swelling, or tenderness just above the prostate anteriorly; determine whether the rectum lies adjacent to the peritoneal cavity. If possible, palpate this region for peritoneal masses and tenderness.
Diagnostic Tests
A.Urinalysis: Evaluate for infection and hematuria.
B.Urine culture if indicated (patients with BPH are more susceptible to UTIs).
C.Optional studies:
1.Prostate-specific antigen (PSA): Reference ranges vary by age and ethnicity and may be elevated with BPH.
2.Urodynamic testing, including maximal urinary flow rate.
3.Postvoid residual (PVR; as shown by in—out catheterization, radiography, or ultrasound).
4.Cystourethroscopy (assists in planning for surgical therapy).
D.The American Urological Association (AUA) recommends that the routine measurement of serum creatinine levels is not indicated in the initial evaluation.
Differential Diagnoses
A.BPH: Classifications of BPH from the score of the AUA symptom assessment tool:
1.Mild = total AUASS 0 to 7.
2.Moderate = total AUASS 8 to 19.
3.Severe = total AUASS 20 to 35.
B.Other obstructive causes: Prostate cancer, urethral obstruction, urethral stricture, and vesical neck obstruction.
C.Neurogenic bladder.
D.Cystitis.
E.Prostatitis.
F.Bladder calculi.
Plan
A.General interventions:
1.Have the patient complete a 24-hour voiding chart with assessment of frequency and volume.
2.Any patient with other than mild symptoms needs referral to a urologist to discuss treatment options (surgery or drugs).
3.Monitor the patient with mild symptoms every 3 to 6 months to determine the progression of symptoms. Imaging studies are not routinely necessary in typical cases of BPH unless there is hematuria, an elevated creatinine, or another indication.
4.Treat concurrent UTI and STIs.
B. 
See Section III: Patient Teaching Guide Benign Prostatic Hyperplasia (BPH)
:
1.Patients should be instructed about the hypotensive effect, asthenia, nasal congestion, and effect on ejaculation of the long-acting alpha-1-antagonists. The hypotensive effects can be potentiated by concomitant use of phosphodiesterase-5 (PDE-5) inhibitors sildenafil (Viagra), stendra (Avanafil), tadalafil (Cialis), or vardenafil (Levitra).
2.Alpha-1-antagonists have been associated with intraoperative floppy iris syndrome. Patients need to discuss using these meds with their ophthalmologist prior to eye surgery (i.e., cataract).
C.Pharmaceutical therapy:
1.Four long-acting alpha-1-antagonists are Food and Drug Administration (FDA) approved for treatment of BPH:
a.Terazosin (Hytrin) initial: 1 mg at bedtime, increasing as needed; most patients require 10 mg/d. If no response after 4 to 6 weeks of 10 mg/d, may increase to 20 mg/d. Side effect increases hypotensive effect with PDE-5 inhibitor. Terazosin requires dose titration to minimize side effects.
b.Doxazosin (Cardura) goal: 4–8 mg/d; maximum dose 8 mg/d. Start 1 mg/d in the morning or evening; may be increased to 2 mg/d. Thereafter titrate upwards, if needed, over several weeks, balancing therapeutic benefit with doxazosin-induced postural hypotension. Side effect increases hypotensive effect with PDE-5 inhibitor. Doxazosin requires dose titration to minimize side effects.
c.Tamsulosin (Flomax): 0.4 mg/d; dose may be increased after 2 to 4 weeks to 0.8 mg/d. Side effect decreases ejaculate volume. Tamsulosin capsules are not intended for use as an antihypertensive.
d.Alfuzosin (Uroxatral): 10 mg/d; it generally does not cause ejaculation problems. Dosage adjustment in renal impairment: Bioavailability and maximum serum concentrations are increased by 50% with mild, moderate, or severe renal impairment.