Benign Prostatic Hyperplasia (BPH) Clinical Presentation

Updated: Mar 22, 2023
  • Author: Levi A Deters, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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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 and recommending treatment choices:

  • 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 DDx/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. [6]


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. 

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 non-urologist examiners to communicate estimated gland size. 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.  Anecdotally, each fingerbreadth correlates to approximately 15-20 g of tissue. The normal prostate volume in a young man is approximately 20 g.

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.

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



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

  • Urinary retention
  • Kidney insufficiency
  • Recurrent urinary tract infections
  • Gross hematuria
  • Bladder calculi
  • Kidney failure or uremia (rare in current practice)