eMedicine Specialties > Urology > Benign Prostatic Hypertrophy

Prostate Hyperplasia, Benign

Author: 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
Coauthor(s): Vipul R Patel, MD, Consulting Surgeon, Global Robotics Institute, Florida Hospital Celebration Health; Vincent G Bird, MD, Assistant Professor of Clinical Urology, University of Miami, Miller School of Medicine; Consulting Staff, Department of Urology, Division of Endourology/Laparoscopy and Minimally Invasive Surgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital; Charles R Moore, MD, Fellow, Department of Urology, University of Miami
Contributor Information and Disclosures

Updated: Jun 8, 2009

Introduction

Background

Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate. Cellular accumulation and gland enlargement may result from epithelial and stromal proliferation, impaired preprogrammed cell death (apoptosis), or both. BPH involves the stromal and epithelial elements of the prostate arising in the periurethral and transition zones of the gland. The hyperplasia presumably results in enlargement of the prostate that may restrict the flow of urine from the bladder.

BPH is considered a normal part of the aging process in men and is hormonally dependent on testosterone and dihydrotestosterone (DHT) production. An estimated 50% of men demonstrate histopathologic BPH by age 60 years. This number increases to 90% by age 85 years; thus, increasing gland size is considered a normal part of the aging process.

The voiding dysfunction that results from prostate gland enlargement and bladder outlet obstruction (BOO) is termed lower urinary tract symptoms (LUTS). It has also been commonly referred to as prostatism, although this term has decreased in popularity. These entities overlap; not all men with BPH have LUTS, and, likewise, not all men with LUTS have BPH. Approximately half of men diagnosed with histopathologic BPH demonstrate moderate-to-severe LUTS. Clinical manifestations of LUTS include urinary frequency, urgency, nocturia (getting up at night during sleep to urinate), decreased or intermittent force of stream, or a sensation of incomplete emptying. Complications occur less commonly but may include acute urinary retention (AUR), impaired bladder emptying, or the need for corrective surgery.

Prostate volume may increase over time in men with BPH. In addition, peak urinary flow, voided volume, and symptoms may worsen over time in men with untreated BPH. The risk of AUR and the need for corrective surgery increases with age.

Benign prostatic hyperplasia (BPH) diagnosis and ...

Benign prostatic hyperplasia (BPH) diagnosis and treatment algorithm.

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Benign prostatic hyperplasia (BPH) diagnosis and ...

Benign prostatic hyperplasia (BPH) diagnosis and treatment algorithm.

Pathophysiology

The prostate is a walnut-sized gland that forms part of the male reproductive system. It is located in front of the rectum and just below the urinary bladder. It is in continuum with the urinary tract and connects directly with the penile urethra. It is therefore a conduit between the bladder and the urethra. The gland is composed of several zones or lobes that are enclosed by an outer layer of tissue (capsule). These include the peripheral, central, anterior fibromuscular stroma, and transition zones. BPH originates in the transition zone, which surrounds the urethra. Microscopically, BPH is characterized as a hyperplastic process. The hyperplasia results in enlargement of the prostate that may restrict the flow of urine from the bladder, resulting in clinical manifestations of BPH. The prostate enlarges with age in a hormonally dependent manner. Notably, castrated males (ie, who are unable to make testosterone) do not develop BPH.

Benign prostatic hyperplasia. The prostate is loc...

Benign prostatic hyperplasia. The prostate is located at the apex of the bladder and surrounds the proximal urethra.

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Benign prostatic hyperplasia. The prostate is loc...

Benign prostatic hyperplasia. The prostate is located at the apex of the bladder and surrounds the proximal urethra.

The traditional theory behind BPH is that, as the prostate enlarges, the surrounding capsule prevents it from radially expanding, potentially resulting in urethral compression. However, obstruction-induced bladder dysfunction contributes significantly to LUTS. The bladder wall becomes thickened, trabeculated, and irritable when it is forced to hypertrophy and increase its own contractile force. This increased sensitivity (detrusor instability), even with small volumes of urine in the bladder, is believed to contribute to urinary frequency and LUTS. The bladder may gradually weaken and lose the ability to empty completely, leading to increased residual urine volume and, possibly, acute or chronic urinary retention.

The main function of the prostate gland is primarily secretory; it produces alkaline fluid that comprises approximately 70% of the seminal volume. The secretions produce lubrication and nutrition for the sperm. The alkaline fluid in the ejaculate results in liquefaction and helps to neutralize the acidic vaginal environment. The prostatic urethra is a conduit for semen and prevents retrograde ejaculation (ie, ejaculation resulting in semen being forced backwards into the bladder) by closing off the bladder neck during sexual climax. Ejaculation involves a coordinated contraction of many different components, including the smooth muscles of the seminal vesicles, vasa deferentia, ejaculatory ducts, and the ischiocavernosus and bulbocavernosus muscles.

Frequency

United States

As many as 14 million men in the United States have symptoms of BPH.

International

Worldwide, approximately 30 million men have symptoms related to BPH.

Mortality/Morbidity

In the past, chronic end-stage BOO often led to renal failure and uremia. Although this complication is much less common now, chronic BOO secondary to BPH may lead to urinary retention, renal insufficiency, recurrent urinary tract infections, gross hematuria, and bladder calculi.

Race

The prevalence of BPH in white and African-American men is similar. However, BPH tends to be more severe and progressive in African-American men, possibly because of higher testosterone levels, 5-alpha-reducatase activity, androgen receptor expression, and growth factor activity in this population. The increased activity leads to an increased rate of prostatic hyperplasia and subsequent enlargement and its sequelae.

Sex

BPH occurs only in males. Women do not have prostate glands.

Age

BPH is a common problem that affects the quality of life (QOL) in approximately one third of men older than 50 years. BPH is histologically evident in up to 90% of men by age 85 years.

Clinical

History

The diagnosis of benign prostatic hyperplasia (BPH) can often be suggested based on history alone. Special attention to the onset and duration of symptoms, general health issues (including sexual history), fitness for any possible surgical intervention, severity of symptoms and how they are affecting QOL, medications, and previously attempted treatments is essential to making the correct diagnosis. 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 LUTS (See Other Problems to be Considered).

When the prostate enlarges, it may act similar to 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 quickly 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

Epidemiologic studies have identified LUTS as an independent risk factor for erectile dysfunction and ejaculatory dysfunction.1

Physical

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 adult male is approximately 20 g.
  • A more precise volumetric determination can be made using transrectal ultrasonography (TRUS) of the prostate.
  • Anal sphincter tone or lack of it may indicate an underlying neurological disorder.
  • 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.
  • 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).

More on Prostate Hyperplasia, Benign

Overview: Prostate Hyperplasia, Benign
Differential Diagnoses & Workup: Prostate Hyperplasia, Benign
Treatment & Medication: Prostate Hyperplasia, Benign
Follow-up: Prostate Hyperplasia, Benign
Multimedia: Prostate Hyperplasia, Benign
References
Further Reading
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Further Reading

Additional resources on benign prostatic hyperplasia (BPH) are available at Medscape's Benign Prostatic Hyperplasia Resource Center.

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Keywords

benign prostatic hyperplasia, BPH, benign prostatic hypertrophy, benign prostate hyperplasia, benign prostate hypertrophy, prostatism, prostatic hypertrophy, enlarged prostate, bladder outlet obstruction, BOO, testosterone, dihydrotestosterone, DHT, obstruction-induced bladder dysfunction, acute urinary retention, AUR, frequent urination, nocturia, lower urinary tract symptoms, LUTS, prostatectomy, transurethral resection of the prostate, TURP, transurethral incision of the prostate, TUIP, transurethral microwave therapy, TUMT, transurethral needle ablation of the prostate, TUNA, water-induced thermotherapy, WIT, digital rectal examination, DRE, prostate-specific antigen, PSA

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Contributor Information and Disclosures

Author

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; LMA suisse Grant/research funds Consulting; Pluromed Grant/research funds Consulting

Coauthor(s)

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

Vincent G Bird, MD, Assistant Professor of Clinical Urology, University of Miami, Miller School of Medicine; Consulting Staff, Department of Urology, Division of Endourology/Laparoscopy and Minimally Invasive Surgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital
Vincent G Bird, MD is a member of the following medical societies: American Urological Association, Endourological Society, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Charles R Moore, MD, Fellow, Department of Urology, University of Miami
Charles R Moore, MD is a member of the following medical societies: Alpha Omega Alpha and American Urological Association
Disclosure: Nothing to disclose.

Medical 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, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Martin I Resnick, MD †, Former Lester Persky Professor and Chair, Department of Urology, Former Professor, Department of Oncology, Case Western Reserve University School of Medicine
Martin I Resnick, MD † is a member of the following medical societies: American College of Surgeons, American Federation for Medical Research, American Institute of Ultrasound in Medicine, American Medical Association, American Society for Bone and Mineral Research, American Society for Reproductive Medicine, American Society of Andrology, American Surgical Association, American Urological Association, Association for Academic Surgery, Endocrine Society, National Kidney Foundation, Ohio Urological Society, and Pan American Medical Association
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

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, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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