Sections

Presentation

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 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

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)

Differential Diagnoses

[Guideline] Parsons JK, Dahm P, Köhler TS, Lerner LB, Wilt TJ. Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2020. J Urol. 2020 Oct. 204 (4):799-804. [QxMD MEDLINE Link]. [Full Text].
Nimeh T, Magnan B, Almallah YZ. Benign Prostatic Hyperplasia: Review of Modern Minimally Invasive Surgical Treatments. Semin Intervent Radiol. 2016 Sep. 33 (3):244-50. [QxMD MEDLINE Link].
Franco JVA, Tesolin P, Jung JH. Update on the management of benign prostatic hyperplasia and the role of minimally invasive procedures. Prostate Int. 2023 Mar. 11 (1):1-7. [QxMD MEDLINE Link]. [Full Text].
Kopp W. Diet-Induced Hyperinsulinemia as a Key Factor in the Etiology of Both Benign Prostatic Hyperplasia and Essential Hypertension?. Nutr Metab Insights. 2018. 11:1178638818773072. [QxMD MEDLINE Link]. [Full Text].
Egan KB. The Epidemiology of Benign Prostatic Hyperplasia Associated with Lower Urinary Tract Symptoms: Prevalence and Incident Rates. Urol Clin North Am. 2016 Aug. 43 (3):289-97. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[Guideline] American Cancer Society recommendations for prostate cancer early detection. American Cancer Society. Available at http://www.cancer.org/cancer/prostatecancer/moreinformation/prostatecancerearlydetection/prostate-cancer-early-detection-acs-recommendations. February 24, 2023; Accessed: March 22, 2023.
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. [QxMD MEDLINE Link].
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.
Yoo S, Oh S, Park J, Cho SY, Cho MC, Jeong H, et al. The impacts of metabolic syndrome and lifestyle on the prevalence of benign prostatic hyperplasia requiring treatment: historical cohort study of 130 454 men. BJU Int. 2019 Jan. 123 (1):140-148. [QxMD MEDLINE Link].
Sebastianelli A, Gacci M. Current Status of the Relationship Between Metabolic Syndrome and Lower Urinary Tract Symptoms. Eur Urol Focus. 2018 Jan. 4 (1):25-27. [QxMD MEDLINE Link].
Zhou B, Wang P, Xu WJ, Li YM, Tong DL, Jiang J, et al. Correlations of glucose metabolism, insulin resistance and inflammatory factors with symptom score of patients with benign prostatic hyperplasia. Eur Rev Med Pharmacol Sci. 2018 Aug. 22 (16):5077-5081. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Jung JH, Kim J, MacDonald R, Reddy B, Kim MH, Dahm P. Silodosin for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev. 2017 Nov 22. 11:CD012615. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Pande S, Hazra A, Kundu AK. Evaluation of silodosin in comparison to tamsulosin in benign prostatic hyperplasia: a randomized controlled trial. Indian J Pharmacol. 2014 Nov-Dec. 46 (6):601-7. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Dimitropoulos K, Gravas S. Fixed-dose combination therapy with dutasteride and tamsulosin in the management of benign prostatic hyperplasia. Ther Adv Urol. 2016 Feb. 8 (1):19-28. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Dong Y, Hao L, Shi Z, Wang G, Zhang Z, Han C. Efficacy and safety of tadalafil monotherapy for lower urinary tract symptoms secondary to benign prostatic hyperplasia: a meta-analysis. Urol Int. 2013. 91 (1):10-8. [QxMD MEDLINE Link].
Zhang Z, Li H, Zhang X, Dai Y, Park HJ, Jiann BP, et al. Efficacy and safety of tadalafil 5 mg once-daily in Asian men with both lower urinary tract symptoms associated with benign prostatic hyperplasia and erectile dysfunction: A phase 3, randomized, double-blind, parallel, placebo- and tamsulosin-controlled study. Int J Urol. 2018 Oct 25. [QxMD MEDLINE Link].
Sildenafil [package insert]. New York, NY: Pfizer Inc. 12/2017. Available at [Full Text].
Vardenafil [package insert]. Whippany, NJ: Bayer HealthCare Pharmaceuticals Inc/GlaxoSmithKline. April 2014. Available at [Full Text].
Tadalafil [package insert]. Indianapolis, IN: Lilly USA LLC. October 2011. Available at [Full Text].
Sharma M, Chadha R, Dhingra N. Phytotherapeutic Agents for Benign Prostatic Hyperplasia: An Overview. Mini Rev Med Chem. 2017. 17 (14):1346-1363. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Damiano R, Cai T, Fornara P, Franzese CA, Leonardi R, Mirone V. The role of Cucurbita pepo in the management of patients affected by lower urinary tract symptoms due to benign prostatic hyperplasia: A narrative review. Arch Ital Urol Androl. 2016 Jul 4. 88 (2):136-43. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Kuntz RM. Laser treatment of benign prostatic hyperplasia. World J Urol. 2007 Jun. 25(3):241-7. [QxMD MEDLINE Link].
Castellani D, Pirola GM, Rubilotta E, Gubbiotti M, Scarcella S, Maggi M, et al. GreenLight Laser™ Photovaporization versus Transurethral Resection of the Prostate: A Systematic Review and Meta-Analysis. Res Rep Urol. 2021. 13:263-271. [QxMD MEDLINE Link]. [Full Text].
Scoffone CM, Cracco CM. Which is the Best Laser for Treatment of Benign Prostatic Hyperplasia?. Eur Urol Open Sci. 2023 Feb. 48:34-35. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Gupta N, Rogers T, Holland B, Helo S, Dynda D, McVary KT. Three-Year Treatment Outcomes of Water Vapor Thermal Therapy Compared to Doxazosin, Finasteride and Combination Drug Therapy in Men with Benign Prostatic Hyperplasia: Cohort Data from the MTOPS Trial. J Urol. 2018 Aug. 200 (2):405-413. [QxMD MEDLINE Link].
Lim Ng K, Barber N. Prostatic hydroablation (Aquablation): A new effective ultrasound guided robotic waterjet ablative surgery for treatment of benign prostatic hyperplasia. Arch Esp Urol. 2019 Oct. 72 (8):786-793. [QxMD MEDLINE Link].
Nguyen DD, Barber N, Bidair M, Gilling P, Anderson P, Zorn KC, et al. Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue trial (WATER) vs WATER II: comparing Aquablation therapy for benign prostatic hyperplasia in 30-80 and 80-150 mL prostates. BJU Int. 2020 Jan. 125 (1):112-122. [QxMD MEDLINE Link]. [Full Text].
Crane M. FDA OKs New Device to Treat BPH. Medscape Medical News. Available at http://www.medscape.com/viewarticle/810981. September 13, 2013; Accessed: February 19, 2021.
Yu H, Isaacson AJ, Burke CT. Review of Current Literature for Prostatic Artery Embolization. Semin Intervent Radiol. 2016 Sep. 33 (3):231-5. [QxMD MEDLINE Link].
Mirakhur A, McWilliams JP. Prostate Artery Embolization for Benign Prostatic Hyperplasia: Current Status. Can Assoc Radiol J. 2017 Feb. 68 (1):84-89. [QxMD MEDLINE Link].
Jung JH, McCutcheon KA, Borofsky M, Young S, Golzarian J, Kim MH, et al. Prostatic arterial embolisation for men with benign prostatic hyperplasia: a Cochrane review. BJU Int. 2023 Jan. 131 (1):32-45. [QxMD MEDLINE Link].
Sotelo R, Spaliviero M, Garcia-Segui A, et al. Laparoscopic retropubic simple prostatectomy. J Urol. 2005 Mar. 173(3):757-60. [QxMD MEDLINE Link].
John H, Wagner C, Padevit C, Witt JH. From open simple to robotic-assisted simple prostatectomy (RASP) for large benign prostate hyperplasia: the time has come. World J Urol. 2021 Jul. 39 (7):2329-2336. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].

Media Gallery

Benign prostatic hyperplasia. Normal prostate anatomy is shown. The prostate is located at the apex of the bladder and surrounds the proximal urethra.
Benign prostatic hyperplasia (BPH) diagnosis and treatment algorithm.
Benign prostatic hyperplasia. Basic management of lower urinary tract symptoms (LUTS) in men.

of 3

Author

Levi A Deters, MD Attending Physician, Spokane Urology

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, 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, The Scientific Research Honor Society, Society of Laparoscopic and Robotic 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.

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.

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 Laparoscopic and Robotic Surgeons

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

Chief Editor

Edward David Kim, MD, FACS Professor of Urology, Department 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 Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Antares.

Acknowledgements

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.

Benign Prostatic Hyperplasia (BPH) Clinical Presentation

History

Physical Examination

Complications

References

Tables

Contributor Information and Disclosures

What would you like to print?