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Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia

Glenn R Cunningham, MD
Dov Kadmon, MD
Section Editor
Michael P O'Leary, MD, MPH
Deputy Editor
Howard Libman, MD, FACP


Benign prostatic hyperplasia (BPH) is a common disorder that increases in prevalence with age (figure 1). The clinical manifestations and the diagnostic approach to patients suspected of having BPH will be addressed here.

The epidemiology, pathogenesis, and treatment of this disorder 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".)

Lower urinary tract symptoms (LUTS) in men and acute urinary retention are also discussed elsewhere. (See "Lower urinary tract symptoms in men" and "Acute urinary retention".)


Asymptomatic BPH — Benign prostatic hyperplasia (BPH) is a histologic diagnosis that becomes more prevalent with age (figure 1), but some men with BPH are asymptomatic [1]. The correlation between symptoms and the presence of prostatic enlargement on physical examination or by transrectal ultrasonographic assessment of prostate size is poor.

Typical presentation — Approximately 50 percent of men at age 50 and up to 80 percent of men at age 80 have lower urinary tract symptoms (LUTS) attributable to BPH [2,3]. Common manifestations include:

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Literature review current through: Nov 2017. | This topic last updated: Oct 31, 2017.
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  1. Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol 1984; 132:474.
  2. Roehrborn C, McConnell J. Etiology, pathophysiology, epidemiology and natural history of benign prostatic hyperplasia. In: Campbell's Urology, 8th ed, Walsh P, Retik A, Vaughan E, Wein A (Eds), Saunders, Philadelphia 2002. p.1297.
  3. Egan KB. The Epidemiology of Benign Prostatic Hyperplasia Associated with Lower Urinary Tract Symptoms: Prevalence and Incident Rates. Urol Clin North Am 2016; 43:289.
  4. Platz EA, Joshu CE, Mondul AM, et al. Incidence and progression of lower urinary tract symptoms in a large prospective cohort of United States men. J Urol 2012; 188:496.
  5. Arrighi HM, Metter EJ, Guess HA, Fozzard JL. Natural history of benign prostatic hyperplasia and risk of prostatectomy. The Baltimore Longitudinal Study of Aging. Urology 1991; 38:4.
  6. Martin S, Lange K, Haren MT, et al. Risk factors for progression or improvement of lower urinary tract symptoms in a prospective cohort of men. J Urol 2014; 191:130.
  7. Marshall LM, Holton KF, Parsons JK, et al. Lifestyle and health factors associated with progressing and remitting trajectories of untreated lower urinary tract symptoms among elderly men. Prostate Cancer Prostatic Dis 2014; 17:265.
  8. Isaacs JT. Importance of the natural history of benign prostatic hyperplasia in the evaluation of pharmacologic intervention. Prostate Suppl 1990; 3:1.
  9. Emberton M, Fitzpatrick JM, Garcia-Losa M, et al. Progression of benign prostatic hyperplasia: systematic review of the placebo arms of clinical trials. BJU Int 2008; 102:981.
  10. Barry M, Roehrborn C. Management of benign prostatic hyperplasia. Annu Rev Med 1997; 48:177.
  11. Marberger MJ, Andersen JT, Nickel JC, et al. Prostate volume and serum prostate-specific antigen as predictors of acute urinary retention. Combined experience from three large multinational placebo-controlled trials. Eur Urol 2000; 38:563.
  12. O'Leary MP, Wei JT, Roehrborn CG, et al. Correlation of the International Prostate Symptom Score bother question with the Benign Prostatic Hyperplasia Impact Index in a clinical practice setting. BJU Int 2008; 101:1531.
  13. Pienta KJ, Esper PS. Risk factors for prostate cancer. Ann Intern Med 1993; 118:793.
  14. Schenk JM, Kristal AR, Arnold KB, et al. Association of symptomatic benign prostatic hyperplasia and prostate cancer: results from the prostate cancer prevention trial. Am J Epidemiol 2011; 173:1419.
  15. Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013; 64:118.
  16. McConnell JD, Barry MJ, Bruskewitz RC. Benign prostatic hyperplasia: diagnosis and treatment. Agency for Health Care Policy and Research. Clin Pract Guidel Quick Ref Guide Clin 1994; :1.
  17. McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol 2011; 185:1793.
  18. Nickel JC, Méndez-Probst CE, Whelan TF, et al. 2010 Update: Guidelines for the management of benign prostatic hyperplasia. Can Urol Assoc J 2010; 4:310.
  19. Parsons JK, Carter HB, Partin AW, et al. Metabolic factors associated with benign prostatic hyperplasia. J Clin Endocrinol Metab 2006; 91:2562.
  20. Bang WJ, Lee JY, Koo KC, et al. Is type-2 diabetes mellitus associated with overactive bladder symptoms in men with lower urinary tract symptoms? Urology 2014; 84:670.
  21. Leissner KH, Tisell LE. The weight of the human prostate. Scand J Urol Nephrol 1979; 13:137.
  22. Mohr DN, Offord KP, Melton LJ 3rd. Isolated asymptomatic microhematuria: a cross-sectional analysis of test-positive and test-negative patients. J Gen Intern Med 1987; 2:318.
  23. Ezz el Din K, Koch WF, de Wildt MJ, et al. The predictive value of microscopic haematuria in patients with lower urinary tract symptoms and benign prostatic hyperplasia. Eur Urol 1996; 30:409.
  24. Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 1989; 141:243.
  25. Roehrborn CG, Boyle P, Gould AL, Waldstreicher J. Serum prostate-specific antigen as a predictor of prostate volume in men with benign prostatic hyperplasia. Urology 1999; 53:581.
  26. Hochberg DA, Armenakas NA, Fracchia JA. Relationship of prostate-specific antigen and prostate volume in patients with biopsy proven benign prostatic hyperplasia. Prostate 2000; 45:315.
  27. Mao Q, Zheng X, Jia X, et al. Relationships between total/free prostate-specific antigen and prostate volume in Chinese men with biopsy-proven benign prostatic hyperplasia. Int Urol Nephrol 2009; 41:761.
  28. Coley CM, Barry MJ, Fleming C, Mulley AG. Early detection of prostate cancer. Part I: Prior probability and effectiveness of tests. The American College of Physicians. Ann Intern Med 1997; 126:394.
  29. Gormley GJ, Stoner E, Bruskewitz RC, et al. The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group. N Engl J Med 1992; 327:1185.
  30. Barry MJ, Fowler FJ Jr, O'Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol 1992; 148:1549.
  31. Wadie BS, Ibrahim EH, de la Rosette JJ, et al. The relationship of the International Prostate Symptom Score and objective parameters for diagnosing bladder outlet obstruction. Part I: when statistics fail. J Urol 2001; 165:32.
  32. Barry MJ, Fowler FJ, Chang Y, et al. The American Urological Association symptom index: does mode of administration affect its psychometric properties? J Urol 1995; 154:1056.
  33. Lepor H, Nieder A, Feser J, et al. Total prostate and transition zone volumes, and transition zone index are poorly correlated with objective measures of clinical benign prostatic hyperplasia. J Urol 1997; 158:85.
  34. Kojima M, Naya Y, Inoue W, et al. The American Urological Association symptom index for benign prostatic hyperplasia as a function of age, volume and ultrasonic appearance of the prostate. J Urol 1997; 157:2160.
  35. van Venrooij GE, van Melick HH, Eckhardt MD, Boon TA. Diagnostic and predictive value of voiding diary data versus prostate volume, maximal free urinary flow rate, and Abrams-Griffiths number in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology 2008; 71:469.
  36. Bright E, Cotterill N, Drake M, Abrams P. Developing and validating the International Consultation on Incontinence Questionnaire bladder diary. Eur Urol 2014; 66:294.
  37. DiMare JR, Fish SR, Harper JM, et al. Residual urine in normal male subjects. J Urol 1963; 96:180.
  38. Wasson JH, Reda DJ, Bruskewitz RC, et al. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. N Engl J Med 1995; 332:75.
  39. Corica FA, Jacobsen SJ, King BF, et al. Prostatic central zone volume, lower urinary tract symptom severity and peak urinary flow rates in community dwelling men. J Urol 1999; 161:831.
  40. Marks LS, Roehrborn CG, Andriole GL. Prevention of benign prostatic hyperplasia disease. J Urol 2006; 176:1299.
  41. Lieber MM, Rhodes T, Jacobson DJ, et al. Natural history of benign prostatic enlargement: long-term longitudinal population-based study of prostate volume doubling times. BJU Int 2010; 105:214.
  42. Stravodimos KG, Petrolekas A, Kapetanakis T, et al. TRUS versus transabdominal ultrasound as a predictor of enucleated adenoma weight in patients with BPH: a tool for standard preoperative work-up? Int Urol Nephrol 2009; 41:767.
  43. Dicuio M, Vesely S, Knutson T, et al. Is it possible to predict post-residual voided urine by bladder scan before uroflowmetry--a useful and timesaving test to reduce the number of non--evaluable uroflow measurements? Arch Ital Urol Androl 2010; 82:100.
  44. Simon RM, Howard LE, Moreira DM, et al. Does Peak Urine Flow Rate Predict the Development of Incident Lower Urinary Tract Symptoms in Men with Mild to No Current Symptoms? Results from REDUCE. J Urol 2017; 198:650.
  45. McLoughlin J, Gill KP, Abel PD, Williams G. Symptoms versus flow rates versus urodynamics in the selection of patients for prostatectomy. Br J Urol 1990; 66:303.