Medscape is available in 5 Language Editions – Choose your Edition here.


Benign Prostatic Hypertrophy Workup

  • Author: Levi A Deters, MD; Chief Editor: Edward David Kim, MD, FACS  more...
Updated: Oct 12, 2015

Approach Considerations

The American Urological Association (AUA) has issued a Guideline on the Management of Benign Prostatic Hyperplasia (BPH), which the AUA validated in 2014. The guideline includes an algorithm for the diagnosis and basic treatment of lower urinary tract symptoms (LUTS), which is presented below.[1]

Basic management of lower urinary tract symptoms ( Basic management of lower urinary tract symptoms (LUTS) in men

The Diagnosis Improvement in PrimAry Care Trial (D-IMPACT), a prospective, multicenter study in three European countries, identified simple tests for primary care practitioners to diagnose BPH in men who present with LUTS. D-IMPACT found that a diagnostic algorithm including only the objective variables of age, International Prostate Symptom Score (IPSS) and prostate-specific antigen level (PSA),  allows accurate diagnosis of BPH in approximately three-quarters of patients who report LUTS.[3]



Examine the urine using dipstick methods and/or via centrifuged sediment evaluation to assess for the presence of blood, leukocytes, bacteria, protein, or glucose.


Urine Culture

This may be useful to exclude infectious causes of irritative voiding and is usually performed if the initial urinalysis findings indicate an abnormality.


Prostate-Specific Antigen

Although BPH does not cause prostate cancer, men at risk for BPH are also at risk for prostate cancer and should be screened accordingly. Screening for prostate cancer remains controversial and should done after an informed discussion between the physician and patient.

The 2010 update of the American Cancer Society (ACS) guideline for early detection of prostate cancer stresses the importance of involving men in the decision whether to test for prostate cancer. The ACS notes that PSA testing may reduce the likelihood of dying from prostate cancer but poses serious risks, particularly of treatment of prostate cancer that would not have caused ill effects if left undetected.[4]

The ACS recommends that men receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening. After this discussion, if the patient wishes to proceed with screening (ie, prostate-specific antigen [PSA] testing and digital rectal examination [DRE] for prostate cancer), the ACS recommends proceeding with screening at the following ages:

  • Starting at age 50 years in men who are expected to live at least 10 more years
  • Starting at age 45 years in men at high risk for prostate cancer (African-Americans and men with a close relative with prostate cancer)

A physician should discuss the risks and benefits of PSA screening with the patient. Notably, men with larger prostates may have slightly higher PSA levels.


Electrolytes, BUN, and Creatinine

These evaluations are useful screening tools for chronic renal insufficiency in patients who have high postvoid residual (PVR) urine volumes. A routine serum creatinine measurement is not indicated in the initial evaluation of men with lower urinary tract symptoms (LUTS) secondary to BPH.[1]



Ultrasonography (abdominal, renal, transrectal) and intravenous urography are useful for helping determine bladder and prostate size and the degree of hydronephrosis (if any) in patients with urinary retention or signs of renal insufficiency. Generally, they are not indicated for the initial evaluation of uncomplicated LUTS.

A systematic review concluded that patients with suspected large postvoid residual volumes should undergo a bladder scan for urine volume to assess for bladder outlet obstruction. Urine volumes measured by bladder scanning correlated highly with urine volumes measured by bladder catheterization.  Symptoms alone proved insufficient for diagnosis, although an International Prostate Symptom Score f of 20 or greater increased the likelihood of bladder outlet obstruction.[5]

Transrectal ultrasonography (TRUS) of the prostate is recommended in selected patients, to determine the dimensions and volume of the prostate gland. The success of certain minimally invasive treatments may depend on the anatomical characteristics of the gland. In patients with elevated PSA levels, TRUS-guided biopsy may be indicated.

Imaging of the upper tracts is indicated in patients who present with concomitant hematuria, a history of urolithiasis, an elevated creatinine level, high PVR volume, or history of upper urinary tract infection.

Other imaging studies, such as CT scanning and MRI, have no role in the evaluation and treatment of uncomplicated BPH.


American Urological Association Guidelines

The American Urological Association (AUA) has developed rigorous clinical practice guidelines for BPH.[6] The AUA guidelines were based on the 1994 evidence-based guidelines for the diagnosis and treatment of BPH originally created under the auspices of the United States Department of Health and Human Services Agency for Health Care Policy and Research.[7] The AUA updated its guidelines in 2006 and 2010, and reviewed and confirmed their validity in 2014.[6]

The AUA 2010 guideline update lowered the age of the Index Patient from age 50 years or older to age 45 years or older. Two algorithms were published: the algorithm for diagnosis and basic management of LUTS in the Approach section above, and an algorithm for detailed management of bothersome LUTS that persists after basic management, shown below.[1]

Benign prostatic hyperplasia (BPH) diagnosis and t Benign prostatic hyperplasia (BPH) diagnosis and treatment algorithm.

These panels have established the following categories to classify diagnostic tests and studies. A recommended test is one that should be performed on every patient, whereas an optional test is of proven value in selected patients.

Recommended tests

A medical history should be taken to qualify and quantify voiding dysfunction. Identification of other causes of voiding dysfunction and medical comorbidities are essential to properly assess the condition and to determine conditions that may complicate treatment.

The physical examination consists of a focused physical examination and a neurologic examination. The physical examination includes a DRE to measure prostate size and to assess for abnormalities. The neurological examination is geared toward lower-extremity neurologic and muscular function, as well as anal sphincter tone. Examination of the phallus and foreskin occasionally reveals meatal stenosis, unretractable foreskin, penile ulcers, or foreign bodies such as warts.

PSA testing should be offered to any patient with a 10-year life expectancy in whom the diagnosis of prostate cancer would change management.

The severity of BPH can be determined with the International Prostate Symptom Score (IPSS)/American Urological Association Symptom Index (AUA-SI) plus a disease-specific quality of life (QOL) question. The AUA-SI for BPH is a set of 7 questions that has been adopted worldwide and yields reproducible and quantifiable information regarding symptoms and response to treatment. Questions concern incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia.

The IPSS uses the same 7 questions as the AUA-SI, with the addition of an eighth question, known as the bother score, which is designed to assess perceived disease-specific QOL. The AUA-SI/IPSS questionnaire is available online. Based on the sum of the score for all 8 questions, patients are classified as 0-7 (mildly symptomatic), 8-19 (moderately symptomatic), or 20-35 (severely symptomatic).

Optional tests

Flow rate is useful in the initial assessment and to help determine the response to treatment. It may be performed prior to embarking on any active treatments, including medical treatment.

A maximal flow rate (Qmax) is the single best measurement, but a low Qmax does not help differentiate between obstruction and poor bladder contractility. For more detailed analysis, a pressure flow study (urodynamic testing) is required. A Qmax value of greater than 15 mL/s is considered by many to be normal. A value of less than 7 mL/s is widely accepted as low.

The results of flow rate measurements are somewhat effort- and volume-dependent. Therefore, the best plan to make a reasonable determination of significance is to obtain at least 2 tracings with at least 150 mL of voided volume each time.

Obtain postvoid residual urine in order to gauge the severity of bladder decompensation. It can be obtained invasively with a catheter or noninvasively with a transabdominal ultrasonic scanner. A high PVR (ie, 350 mL) may indicate bladder dysfunction and/or bladder outlet obstruction and may predict a poor response to treatment.

Although pressure flow studies are somewhat invasive, requiring catheterization of the urethra and placement of a transrectal pressure transducer, the findings may prove useful for evaluating for bladder outlet obstruction (BOO).

Urodynamic studies are the only way to help distinguish poor bladder contraction ability (detrusor underactivity) from outlet obstruction. BOO is characterized by high intravesical voiding pressures (>60 cm water) accompanied by low urine flow rates (Qmax < 15 mL/s).

Cytologic examination of the urine may be considered in patients with predominantly irritative voiding symptoms. Risk factors for bladder cancer (smoking, previous bladder cancer) should alert the physician to consider this noninvasive test.

Tests that are not recommended

Routine measurement of serum creatinine is not indicated in the initial evaluation of men with LUTS secondary to BPH.


Endoscopy of the Lower Urinary Tract

Cystoscopy may be indicated in patients scheduled for invasive treatment or in whom a foreign body or malignancy is suspected. In addition, endoscopy may be indicated in patients with a history of sexually transmitted disease (eg, gonococcal urethritis), prolonged catheterization, or trauma. Findings may suggest urethral stricture as the cause of BOO, instead of BPH.

Flexible cystoscopy can be easily performed in several minutes in an office-based setting using topical gel-based intraurethral anesthesia without sedation. The appearance of the gland alone on cystoscopy cannot make the diagnosis of obstruction but can help the clinician decide on treatment modalities if intervention is warranted.


Histologic Findings

BPH is characterized by a varying combination of epithelial and stromal hyperplasia in the prostate. Some cases demonstrate an almost pure smooth-muscle proliferation, although most demonstrate a fibroadenomyomatous pattern of hyperplasia.

In the bladder, obstruction leads to smooth-muscle-cell hypertrophy. Biopsy specimens of trabeculated bladders demonstrate evidence of scarce smooth-muscle fibers with an increase in collagen.

Contributor Information and Disclosures

Levi A Deters, MD Attending Physician, Spokane Urology

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, Society of Laparoendoscopic Surgeons

Disclosure: Received honoraria from ACMI/Gyrus for speaking and teaching; Received honoraria from Boston Scientific for speaking and teaching; Received honoraria from Applied Medical for speaking and teaching; Received honoraria from Intuitive Surgical for speaking and teaching; Received grant/research funds from Intio for other.

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, Society of Laparoendoscopic Surgeons

Disclosure: Received honoraria from Intuitive Surgical for speaking and teaching; Received honoraria from Pfizer for speaking and teaching.

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, Phi Beta Kappa

Disclosure: Nothing to disclose.

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, American Urological Association

Disclosure: Nothing to disclose.

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: Received salary from Medscape for employment. for: Medscape.

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, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.


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.

  1. 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. 2011 Mar 17. [Medline].

  2. 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. 2008 Apr. 62(4):614-22. [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. 2011 Sep. 65(9):989-996. [Medline].

  4. [Guideline] American Cancer Society recommendations for prostate cancer early detection. American Cancer Society. January 6, 2025; Accessed: July 24, 2015.

  5. D'Silva KA, Dahm P, Wong CL. Does this man with lower urinary tract symptoms have bladder outlet obstruction?: The Rational Clinical Examination: a systematic review. JAMA. 2014 Aug 6. 312 (5):535-42. [Medline].

  6. [Guideline] American Urological Association Guideline: Management of Benign Prostatic Hyperplasia (BPH). American Urological Association. Available at 2014; Accessed: July 24, 2015.

  7. 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.

  8. 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. 2008 Jul. 62(7):1076-86. [Medline].

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

  10. 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. 2008 Apr. 42(4):558-63. [Medline].

  11. 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. 2009 May 20. 301(19):1991-6. [Medline]. [Full Text].

  12. 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. 2011 Aug. 108(3):388-94. [Medline].

  13. 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. 2003 Jul 17. 349(3):215-24. [Medline].

  14. 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. 2010 Apr 1. 362(13):1192-202. [Medline].

  15. Azoulay L, Eberg M, Benayoun S, Pollak M. 5α-Reductase Inhibitors and the Risk of Cancer-Related Mortality in Men With Prostate Cancer. JAMA Oncol. 2015 Jun 1. 1 (3):314-20. [Medline].

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

  17. 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. 2011 Feb 23. [Medline].

  18. 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. 1998 Feb 26. 338(9):557-63. [Medline].

  19. 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. 2003 Dec 18. 349(25):2387-98. [Medline].

  20. 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. 2006 Apr. 97(4):734-41. [Medline].

  21. 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. 2008 Apr. 101(7):847-52. [Medline].

  22. 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. 2011 May. 107(9):1426-31. [Medline].

  23. 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. 2008 Feb. 179(2):616-21; discussion 621. [Medline].

  24. 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. 2011 Sep 28. 306(12):1344-1351. [Medline].

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

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

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

  28. 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. 2006 Jul. 3(4):662-7. [Medline].

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

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

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

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

  33. 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. 1993 Aug. 150(2 Pt 1):351-8. [Medline].

  34. Crane M. FDA OKs New Device to Treat BPH. Medscape Medical News. Available at Accessed: September 23, 2013.

  35. 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. 2008 Apr 15. 167(8):925-34. [Medline].

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

  37. Ben-Zvi T, Hueber PA, Liberman D, Valdivieso R, Zorn KC. GreenLight XPS 180W vs HPS 120W Laser Therapy for Benign Prostate Hyperplasia: A Prospective Comparative Analysis After 200 Cases in a Single-center Study. Urology. 2013 Apr. 81(4):853-8. [Medline].

  38. Bird ST, Delaney JA, Brophy JM, Etminan M, Skeldon SC, Hartzema AG. Tamsulosin treatment for benign prostatic hyperplasia and risk of severe hypotension in men aged 40-85 years in the United States: risk window analyses using between and within patient methodology. BMJ. 2013 Nov 5. 347:f6320. [Medline]. [Full Text].

  39. Boggs W. Increased Risk of Severe Hypotension in Men Treated With Tamsulosin. Medscape Medical News. Available at Accessed: December 7, 2013.

  40. Boggs W. Prostatic Urethral Lift Relieves Symptoms of Benign Prostatic Hyperplasia. Medscape Medical News. Available at Accessed: July 16, 2013.

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

  42. Roehrborn CG, Gange SN, Shore ND, Giddens JL, Bolton DM, Cowan BE, et al. Multi-Center Randomized Controlled Blinded Study of the Prostatic Urethral Lift for the Treatment of LUTS Associated with Prostate Enlargement Due to BPH: The L.I.F.T. Study. J Urol. 2013 Jun 10. [Medline].

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 © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.