Benign Prostatic Hypertrophy Clinical Presentation

  • Author: Levi A Deters, MD; Chief Editor: Edward David Kim, MD, FACS   more...
 
Updated: Oct 7, 2011
 

History

The diagnosis of benign prostatic hyperplasia (BPH) can often be suggested on the basis of the history alone. Special attention to the following features is essential to making the correct diagnosis:

  • Onset and duration of symptoms
  • General health issues (including sexual history)
  • Fitness for any possible surgical interventions
  • Severity of symptoms and how they are affecting quality of life
  • Medications
  • Previously attempted treatments

Symptoms often attributed to BPH can be caused by other disease processes, and a history and physical examination are essential in ruling out other etiologies of (lower urinary tract symptoms (LUTS) (see Diagnostic Considerations).

When the prostate enlarges, it may act like a "clamp on a hose," constricting the flow of urine. Nerves within the prostate and bladder may also play a role in causing the following common symptoms:

  • Urinary frequency - The need to urinate frequently during the day or night (nocturia), usually voiding only small amounts of urine with each episode
  • Urinary urgency - The sudden, urgent need to urinate, owing to the sensation of imminent loss of urine without control
  • Hesitancy - Difficulty initiating the urinary stream; interrupted, weak stream
  • Incomplete bladder emptying - The feeling of persistent residual urine, regardless of the frequency of urination
  • Straining - The need strain or push (Valsalva maneuver) to initiate and maintain urination in order to more fully evacuate the bladder
  • Decreased force of stream - The subjective loss of force of the urinary stream over time
  • Dribbling - The loss of small amounts of urine due to a poor urinary stream

A sexual history is important, as epidemiologic studies have identified LUTS as an independent risk factor for erectile dysfunction and ejaculatory dysfunction.[1]

Next

Physical Examination

Conduct a focused physical examination to assess the suprapubic area for signs of bladder distention and a neurological examination for sensory and motor deficits.

The digital rectal examination (DRE) is an integral part of the evaluation in men with presumed BPH. During this portion of the examination, prostate size and contour can be assessed, nodules can be evaluated, and areas suggestive of malignancy can be detected. The normal prostate volume in a young man is approximately 20 g.

A more precise volumetric determination can be made using transrectal ultrasonography (TRUS) of the prostate.

Decreased anal sphincter tone or the lack of a bulbocavernosus muscle reflex may indicate an underlying neurological disorder.

The prostate is examined using the index finger of the dominant hand. The finger is placed through the anus after relaxation of the anal sphincter, and the prostate is palpated circumferentially (analogous to a windshield wiper movement).

In general, an estimation of the number of index finger pads that one can sweep over the rectal surface of the prostate during DRE is a useful way for nonurologist examiners to communicate estimated gland size. Anecdotally, each fingerbreadth correlates to approximately 15-20 g of tissue. For example, one can report the prostate size as "2-3 fingerbreadths wide" when charting in the medical record or communicating with a colleague. Most asymptomatic men have glands of 2 fingerbreadths or less.

In addition, pelvic floor tone, the presence or absence of fluctuance (ie, prostate abscess), and pain sensitivity of the gland (prostatodynia/prostatitis) can be assessed.

Previous
Next

Complications

Complications related to bladder outlet obstruction (BOO) secondary to BPH include the following:

  • Urinary retention
  • Renal insufficiency
  • Recurrent urinary tract infections
  • Gross hematuria
  • Bladder calculi
  • Renal failure or uremia (rare in current practice)
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Levi A Deters, MD  Staff Physician, Department of Urology, Dartmouth Hitchcock Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Raymond A Costabile, MD  Jay Y Gillenwater Professor of Urology and Vice Chairman, Senior Associate Dean for Clinical Strategy, University of Virginia Health System

Raymond A Costabile, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Andrology, American Urological Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Raymond J Leveillee, MD, FRCS(Glasg)  Professor of Clinical Urology, Radiology and Biomedical Engineering, Department of Urology, University of Miami Miller School of Medicine; Chief, Division of Endourology/Laparoscopy and Minimally Invasive Surgery, Department of Urology, Jackson Memorial Hospital

Raymond J Leveillee, MD, FRCS(Glasg) is a member of the following medical societies: American Urological Association, Endourological Society, Sigma Xi, and Society of Laparoendoscopic Surgeons

Disclosure: ACMI/Gyrus Honoraria Speaking and teaching; Boston Scientific Honoraria Speaking and teaching; Applied Medical Honoraria Speaking and teaching; Intuitive Surgical Honoraria Speaking and teaching; Intio Grant/research funds Other

Charles R Moore, MD  Endourology Fellow, Department of Urology, University of Miami School of Medicine

Charles R Moore, MD, is a member of the following medical societies: Alpha Omega Alpha and American Urological Association

Disclosure: Nothing to disclose.

Vipul R Patel, MD  Consulting Surgeon, Global Robotics Institute, Florida Hospital Celebration Health

Vipul R Patel, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, Endourological Society, Ohio State Medical Association, and Society of Laparoendoscopic Surgeons

Disclosure: Intuitive Surgical Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

Edward David Kim, MD, FACS  Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Vincent G Bird, MD, to the development and writing of the source article.

References

  1. Seftel AD, Rosen RC, Rosenberg MT, Sadovsky R. Benign prostatic hyperplasia evaluation, treatment and association with sexual dysfunction: practice patterns according to physician specialty. Int J Clin Pract. Apr 2008;62(4):614-22. [Medline].

  2. McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC, Donnell RF, et al. Update on AUA Guideline on the Management of Benign Prostatic Hyperplasia. J Urol. Mar 17 2011;[Medline].

  3. Carballido J, Fourcade R, Pagliarulo A, et al. Can benign prostatic hyperplasia be identified in the primary care setting using only simple tests? Results of the Diagnosis IMprovement in PrimAry Care Trial. Int J Clin Pract. Sep 2011;65(9):989-996. [Medline].

  4. American Cancer Society. 2009. American Cancer Society - Learn About Prostate Cancer. Available at http://www.cancer.org/docroot/lrn/lrn_0.asp. Accessed 1/29/2009.

  5. McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline. No. 8, AHCPR Publication No. 94-0582. Rockville, Md: Agency for Healthcare Policy and Research,. Public Health Service, US Department of Health and Human Services, 1994.

  6. AUA Clinical Guidelines - Management of BPH ('03/Updated '06). Available at http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=bph. Accessed 1/29/2009.

  7. Emberton M, Cornel EB, Bassi PF, Fourcade RO, Gómez JM, Castro R. Benign prostatic hyperplasia as a progressive disease: a guide to the risk factors and options for medical management. Int J Clin Pract. Jul 2008;62(7):1076-86. [Medline].

  8. Hellstrom WJ, Sikka SC. Effects of acute treatment with tamsulosin versus alfuzosin on ejaculatory function in normal volunteers. J Urol. Oct 2006;176(4 Pt 1):1529-33. [Medline].

  9. Cantrell MA, Bream-Rouwenhorst HR, Steffensmeier A, Hemerson P, Rogers M, Stamper B. Intraoperative floppy iris syndrome associated with alpha1-adrenergic receptor antagonists. Ann Pharmacother. Apr 2008;42(4):558-63. [Medline].

  10. Bell CM, Hatch WV, Fischer HD, Cernat G, Paterson JM, Gruneir A, et al. Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery. JAMA. May 20 2009;301(19):1991-6. [Medline]. [Full Text].

  11. Nickel JC, Gilling P, Tammela TL, Morrill B, Wilson TH, Rittmaster RS. Comparison of dutasteride and finasteride for treating benign prostatic hyperplasia: the Enlarged Prostate International Comparator Study (EPICS). BJU Int. Aug 2011;108(3):388-94. [Medline].

  12. Thompson IM, Goodman PJ, Tangen CM, Lucia MS, Miller GJ, Ford LG, et al. The influence of finasteride on the development of prostate cancer. N Engl J Med. Jul 17 2003;349(3):215-24. [Medline].

  13. Andriole GL, Bostwick DG, Brawley OW, Gomella LG, Marberger M, Montorsi F, et al. Effect of dutasteride on the risk of prostate cancer. N Engl J Med. Apr 1 2010;362(13):1192-202. [Medline].

  14. Madersbacher S, Marszalek M, Lackner J, Berger P, Schatzl G. The long-term outcome of medical therapy for BPH. Eur Urol. Jun 2007;51(6):1522-33. [Medline].

  15. Montorsi F, Roehrborn C, Garcia-Penit J, Borre M, Roeleveld TA, Alimi JC, et al. The effects of dutasteride or tamsulosin alone and in combination on storage and voiding symptoms in men with lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH): 4-year data from the Combination of Avodart and Tamsulosin (CombAT) study. BJU Int. Feb 23 2011;[Medline].

  16. McConnell JD, Bruskewitz R, Walsh P, et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group. N Engl J Med. Feb 26 1998;338(9):557-63. [Medline].

  17. McConnell JD, Roehrborn CG, Bautista OM, Andriole GL Jr, Dixon CM, Kusek JW. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. Dec 18 2003;349(25):2387-98. [Medline].

  18. Roehrborn CG. Alfuzosin 10 mg once daily prevents overall clinical progression of benign prostatic hyperplasia but not acute urinary retention: results of a 2-year placebo-controlled study. BJU Int. Apr 2006;97(4):734-41. [Medline].

  19. Vallancien G, Emberton M, Alcaraz A, Matzkin H, van Moorselaar RJ, Hartung R. Alfuzosin 10 mg once daily for treating benign prostatic hyperplasia: a 3-year experience in real-life practice. BJU Int. Apr 2008;101(7):847-52. [Medline].

  20. Montorsi F, Roehrborn C, Garcia-Penit J, et al. The effects of dutasteride or tamsulosin alone and in combination on storage and voiding symptoms in men with lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH): 4-year data from the Combination of Avodart and Tamsulosin (CombAT) study. BJU Int. May 2011;107(9):1426-31. [Medline].

  21. Roehrborn CG, Siami P, Barkin J, Damião R, Major-Walker K, Morrill B. The effects of dutasteride, tamsulosin and combination therapy on lower urinary tract symptoms in men with benign prostatic hyperplasia and prostatic enlargement: 2-year results from the CombAT study. J Urol. Feb 2008;179(2):616-21; discussion 621. [Medline].

  22. Barry MJ, Meleth S, Lee JY, et al. Effect of Increasing Doses of Saw Palmetto Extract on Lower Urinary Tract Symptoms: A Randomized Trial. JAMA. Sep 28 2011;306(12):1344-1351. [Medline].

  23. Sildenafil [package insert]. New York, NY: Pfizer Inc.; 2002.

  24. Vardenafil [package insert]. Pittsburgh, Pa: Bayer Pharmaceuticals Corporation/GlaxoSmithKline; 2003.

  25. Tadalafil [package insert]. Indianapolis, IN: Lilly ICOS LLC; 2005.

  26. Mulhall JP, Guhring P, Parker M, Hopps C. Assessment of the impact of sildenafil citrate on lower urinary tract symptoms in men with erectile dysfunction. J Sex Med. Jul 2006;3(4):662-7. [Medline].

  27. Sotelo R, Spaliviero M, Garcia-Segui A, et al. Laparoscopic retropubic simple prostatectomy. J Urol. Mar 2005;173(3):757-60. [Medline].

  28. Malek RS, Kuntzman RS, Barrett DM. Photoselective potassium-titanyl-phosphate laser vaporization of the benign obstructive prostate: observations on long-term outcomes. J Urol. Oct 2005;174(4 Pt 1):1344-8. [Medline].

  29. Kuntz RM. Laser treatment of benign prostatic hyperplasia. World J Urol. Jun 2007;25(3):241-7. [Medline].

  30. Elzayat EA, Habib EI, Elhilali MM. Holmium laser enucleation of the prostate: a size-independent new "gold standard". Urology. Nov 2005;66(5 Suppl):108-13. [Medline].

  31. Barry MJ, Cockett AT, Holtgrewe HL, et al. Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia. J Urol. Aug 1993;150(2 Pt 1):351-8. [Medline].

  32. Kristal AR, Arnold KB, Schenk JM, Neuhouser ML, Goodman P, Penson DF. Dietary patterns, supplement use, and the risk of symptomatic benign prostatic hyperplasia: results from the prostate cancer prevention trial. Am J Epidemiol. Apr 15 2008;167(8):925-34. [Medline].

  33. Arai Y, Fukuzawa S, Terai A, Yoshida O. Transurethral microwave thermotherapy for benign prostatic hyperplasia: relation between clinical response and prostate histology. Prostate. Feb 1996;28(2):84-8. [Medline].

  34. Gallegos PJ, Frazee LA. Anticholinergic therapy for lower urinary tract symptoms associated with benign prostatic hyperplasia. Pharmacotherapy. Mar 2008;28(3):356-65. [Medline].

 
Previous
Next
 
Normal prostate anatomy. The prostate is located at the apex of the bladder and surrounds the proximal urethra.
Benign prostatic hyperplasia (BPH) diagnosis and treatment algorithm.
Basic management of lower urinary tract symptoms (LUTS) in men
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.