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COPYRIGHT 2008 American Academy of Family Physicians
Benign prostatic hyperplasia is a common condition affecting older men. Typical presenting symptoms include urinary hesitancy, weak stream, nocturia, incontinence, and recurrent urinary tract infections. Acute urinary retention, which requires urgent bladder catheterization, is relatively uncommon. Irreversible renal damage is rare. The initial evaluation should assess the frequency and severity of symptoms and the impact of symptoms on the patient's quality of life. The American Urological Association Symptom Index is a validated instrument for the objective assessment of symptom severity. The initial evaluation should also include a digital rectal examination and urinalysis. Men with hematuria should be evaluated for bladder cancer. A palpable nodule or induration of the prostate requires referral for assessment to rule out prostate cancer. For men with mild symptoms, watchful waiting with annual reassessment is appropriate. Over the past decade, numerous medical and surgical interventions have been shown to be effective in relieving symptoms of benign prostatic hyperplasia. Alpha blockers improve symptoms relatively quickly. Although 5-alpha reductase inhibitors have a slower onset of action, they may decrease prostate size and alter the disease course. Limited evidence shows that the herbal agents saw palmetto extract, rye grass pollen extract, and pygeum relieve symptoms. Transurethral resection of the prostate often provides permanent relief. Newer laser-based surgical techniques have comparable effectiveness to transurethral resection up to two years after surgery with lower perioperative morbidity. Various outpatient surgical techniques are associated with reduced morbidity, but symptom relief may be less durable.
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Benign prostatic hyperplasia (BPH) is a common condition in older men. Histologically, it is characterized by the presence of discrete nodules in the periurethral zone of the prostate gland. (1) Clinical manifestations of BPH are caused by extrinsic compression of the prostatic urethra leading to impaired voiding. Chronic inability to completely empty the bladder may cause bladder distension with hypertrophy and instability of the detrusor muscle. Some patients with BPH present with hematuria. Because the severity of symptoms does not correlate with the degree of hyperplasia, and other conditions can cause similar symptoms, the clinical syndrome that often accompanies BPH has been described as lower urinary tract symptoms.
The prevalence of BPH increases with age. One study suggests that the prevalence is 20 percent in 40-year-old men and increases to 90 percent in men in their seventies. (2) The most common lower urinary tract symptoms are hesitancy, weak stream, nocturia, and incontinence. BPH may also be complicated by recurrent urinary tract infections (UTIs) (3) or bladder stones. (4) It is estimated that one half of all men with histologic BPH experience moderate to severe lower urinary tract symptoms. (5) Acute urinary retention (the complete inability to void), which requires urgent bladder catheterization, is uncommon with an annual risk of less than 1 percent; irreversible renal insufficiency is rare. (6,7) Therefore, management decisions should be based on the presence and severity of symptoms.
Diagnosis
HISTORY AND PHYSICAL EXAMINATION
In men with bothersome lower urinary tract symptoms, a history should be performed to establish the severity of symptoms, evaluate for causes other than BPH (Table 1), and identify contraindications to potential therapies. The American Urological Association (AUA) Symptom Index (Figure 1) is a validated seven-question instrument that can be used to objectively assess the severity of BPH. (6)
Several classes of medications may cause or exacerbate lower urinary tract symptoms, and comorbidities may contribute to these symptoms (Table 2). Previous surgical procedures may increase the risk of urethral strictures or other anatomic abnormalities. Black men and first-degree relatives of patients with prostate cancer have an increased risk of prostate cancer. (1)
Symptomatic men should have a digital rectal examination to assess the size and contour of the prostate. (6) Prostate volume predicts the response to finasteride (Proscar) therapy. Finasteride is more effective if the prostate volume is greater than 40 mL (8) (the normal prostate volume is 20 to 30 mL). A palpable nodule suggests prostate cancer and requires biopsy. Abnormal sphincter tone suggests a neurologic abnormality, which may contribute to urinary symptoms. (6) Cognitive or ambulatory impairment may exacerbate incontinence problems.
LABORATORY STUDIES
The AUA recommends urinalysis for all men presenting with...
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