Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia
- Glenn R Cunningham, MD
Glenn R Cunningham, MD
- Distinguished Professor Emeritus, Department of Medicine
- Baylor College of Medicine
- Dov Kadmon, MD
Dov Kadmon, MD
- Professor of Urology
- Baylor College of Medicine
Benign prostatic hyperplasia (BPH) is a common disorder that increases in frequency progressively with age in men older than 50 years (figure 1). The clinical manifestations and the diagnostic approach to patients suspected of having BPH will be reviewed here. The epidemiology, pathogenesis and treatment of this disorder, and lower urinary tract symptoms in men and acute urinary retention are discussed separately. (See "Epidemiology and pathogenesis of benign prostatic hyperplasia" and "Medical treatment of benign prostatic hyperplasia" and "Transurethral procedures for treating benign prostatic hyperplasia" and "Lower urinary tract symptoms in men" and "Acute urinary retention".)
The prevalence of moderate-to-severe lower urinary tract symptoms (LUTS) and decreased peak urinary flow rates increases with age, and there is a modest correlation among LUTS, peak flow rates, and prostate volume. (See "Epidemiology and pathogenesis of benign prostatic hyperplasia", section on 'Prevalence' and "Lower urinary tract symptoms in men", section on 'Prevalence'.)
In a small percentage of men, untreated BPH can cause acute urinary retention, recurrent urinary tract infections, hydronephrosis, and even renal failure. It is estimated that a 60 year old man with moderate-to-severe symptoms would have a 13.7 percent chance of developing acute urinary retention in the following 10 years. Age, symptoms, urinary flow rate, and prostate volume are risk factors for acute urinary retention at least in population-based studies, though not in all clinical trials . Men with symptomatic BPH who are not treated have about a 2.5 percent per-year risk of developing acute urinary retention [2,3]. (See "Acute urinary retention".)
The natural history of BPH has been examined both in population-based studies and by looking at outcomes in the placebo arms of clinical trials. However, studies have found that outcomes among patients in the placebo arms of clinical trials may not accurately reflect outcomes in the general population . In clinical trials, measurements of LUTS and peak urine flow tend to show a regression to the mean; whereas, this is not seen with measurements of prostate volume and PSA . A systematic review of the placebo arms of 16 randomized trials of medical treatment lasting for one to four years found that the risk of surgery ranged from 1 to 10 percent, and the risk of acute urinary retention ranged from 0.4 to 6.0 percent . Patients experience some progression in symptoms, increase in prostate volume, and decrease in peak urine flow rate that can result in a need for invasive treatment.
Men may or may not have progressive symptoms. In one study, for example, about one-third of men had a 50 percent reduction in the severity of their symptoms of urinary obstruction when followed with no treatment for 2.5 to 5 years after symptom onset . On the other hand, many men have progressive disease that eventually requires treatment . In a prospective study of 1057 men, over 30 years of follow-up, 527 (50 percent) were given a diagnosis of BPH and 110 (10 percent) underwent prostatectomy . The Health Professionals Follow-up Study provides the largest and longest evaluation of LUTS in men ages 40 to over 75 . Participants completed and mailed the International Prostate Symptom Score (IPSS) (table 1) every two years from 1992 to 2008. The study found that progression rates rise steeply as men age. Investigators in the Florey Adelaide Male Ageing Study conducted a five-year follow-up of 780 men between the ages of 35 and 80 years at baseline . They found that storage and voiding lower urinary tract symptoms progressed in 39.8 and 32.3 percent, and improved in 33.1 and 23.4 percent, respectively. Older age, previous diagnosis of BPH or erectile dysfunction, and lower high-density lipoprotein (HDL) cholesterol, testosterone, and income predicted progression of LUTS. Increased physical activity and use of an alpha-blocker and/or a 5-alpha-reductase inhibitor improved symptoms.
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- NATURAL HISTORY
- Prostate cancer
- CLINICAL MANIFESTATIONS
- DIAGNOSTIC APPROACH
- American Urologic Association symptom score
- Physical examination
- RECOMMENDED TESTS
- Serum creatinine
- Serum prostate specific antigen
- OPTIONAL TESTS
- Maximal urinary flow rate
- Post-void residual urine volume
- Urine cytology
- NOT RECOMMENDED TESTS
- Pressure-flow studies
- Intravenous urography
- Ultrasonography and plain abdominal radiographs
- Newer technologies
- SUMMARY AND RECOMMENDATIONS