Benign Prostatic Hyperplasia

can lead to bladder outlet obstruction in some patients, which may cause urinary retention (acute or chronic), recurrent UTIs, hydronephrosis, or renal injury

Risks 

1. Established non-modifiable risk factors

Factor	Strength of evidence	Key points
Age ≥ 40 y	High	Prevalence rises from ~20 % at 40–49 y to >70 % at >70 y.
Androgens (DHT exposure)	High	Prostate growth is androgen-dependent; men with lifelong 5-α-reductase deficiency do not develop BPH.
Family history / genetics	Moderate	Twin & cohort data show 39–72 % heritability and ~4-fold risk in first-degree relatives, particularly with early-onset disease.
Ethnicity	Low–moderate	Earlier onset and larger prostates in African-Caribbean men; Asian cohorts report lower surgical intervention rates.

2. Probable modifiable risk factors

Factor	Evidence	Mechanism / notes
Obesity (↑ BMI & visceral fat)	Moderate (meta-analysis of 22 206 men)	↑ oestrogen, insulin, chronic inflammation → larger transition-zone volume.
Metabolic syndrome	Moderate; effect size ~ +4–5 mL prostate volume	Insulin-IGF axis, sympathetic over-activity.
Type 2 diabetes / poor glycaemic control	Moderate; systematic review shows higher IPSS & larger prostates in diabetics	Hyperinsulinaemia & microvascular injury may drive prostatic stromal growth.
Physical inactivity	Consistent observational signal	Regular moderate–vigorous activity appears protective (↓ LUTS, smaller volumes).

3. Factors with conflicting / limited evidence

Factor	Current consensus
Alcohol	Light–moderate intake (<2 standard drinks/day) often shows a lower BPH risk; heavy use may worsen storage LUTS.
Caffeine	Not a causal risk factor, but it can transiently aggravate urgency/frequency; no clear link to prostate growth.
Dietary micronutrients	Older case-control work suggested β-carotene & vitamin A benefit, but large prospective cohorts and RCTs have not confirmed a protective effect. High-dose vitamin C data are inconsistent; one Italian study found lower surgical BPH with higher dietary (not supplemental) vitamin C and iron.
NSAIDs	Three small RCTs showed only modest IPSS (≈ -3 points) and Qmax (<1 mL/s) gains; cardiovascular/GI risks outweigh routine use.
Inflammation / prostatitis	Chronic histological inflammation is common in resected tissue, but it is still unclear whether it is initiator, by-product or epiphenomenon. Long-term anti-inflammatories are not guideline-endorsed therapy.

4. Factors not convincingly associated

• High-dose vitamin C supplements (≥ 1 g/d) – no RCT benefit
• Smoking – inconsistent data for BPH (but does worsen nocturia)
• High dietary dairy or red meat per se – signals disappear after BMI adjustment
• Statin use – initially thought protective; recent prospective data show neutrality.

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Differentials

Differential diagnoses for lower urinary tract symptoms (LUTS)
Benign and neoplastic conditions of the lower urinary tract	Neurological  conditions	Other causes of lower urinary tract symptoms
– Urinary tract infection – Prostatitis – Bladder calculi – Interstitial cystitis – Urethral stricture – Phimosis – Overactive bladder syndrome – Prostate cancer – Urothelial carcinoma of the bladder including carcinoma in situ – Urethral cancer	– Parkinson’s disease – Stroke/cerebrovascular accident – Multiple sclerosis – Cerebral atrophy – Head injury – Spinal cord injury/surgery or degenerative disc disease – Prior pelvic surgery	– Polyuria from renal or cardiac dysfunction – Nocturnal polyuria and sleep apnoea – Iatrogenic from medications

History

Lower urinary tract symptoms (LUTS)

Ask about:

1. Voiding:
   1. poor flow (slow, weak, or intermittent stream)
   2. hesitancy
   3. straining
   4. terminal dribbling
   5. pain or discomfort (dysuria)
2. Storage:
   1. frequency
   2. urgency
   3. nocturia
   4. overflow incontinence
3. Post-urination:
   1. Sensation of incomplete bladder emptying
   2. Post-urination dribbling

International prostate symptoms score (IPSS)

1. Total score:
   1. 0-7 Mildly symptomatic
   2. 8-19 moderately symptomatic
   3. 20-35 severely symptomatic

symptoms that may indicate other diagnoses

1. haematuria
2. constitutional symptoms
3. neurological symptoms
4. Sexual dysfunction
5. Family history of urological cancer

Aggravating or contributing factors:

1. Caffeine and alcohol consumption
2. Constipation
3. Medications (e.g., diuretics, anticholinergics, antidepressants)
4. Co-morbidities (e.g., diabetes, neurological disorders, known renal insufficiency, heart failure)

Consider asking the patient to complete a bladder diary (especially if predominant obstructive symptoms or nocturia)

• Bladder diary
  • Advise the patient to use a bladder diary for at least 3 days, and to include:
  • volume and timing of each void.
  • fluid intake.
  • episodes of incontinence or use of pads.
  • Lower urinary tract symptoms (LUTS).
  • activity at the time of symptoms

Consider other causes of LUTS

1. UTI
2. Prostatitis
3. Urolithiasis
4. Overactive bladder (e.g., neurogenic bladder)
5. Penile pathology (e.g., urethral strictures, phimosis)
6. Medications e.g., diuretics, anticholinergics, antidepressants
7. Complication from urological procedures
8. Urological cancer (rare) e.g., bladder, prostate

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Examine the patient

follow recommended protocol for genital examination and consider a chaperone.

1. Check vital signs and record BMI.
2. Examine abdomen:
   1. Check for palpable masses or enlarged organs (e.g., palpable bladder).
   2. Check for tenderness.
3. Examine external genitalia (testes, foreskin, urethral orifice)
   1. Phimosis
   2. meatal stenosis
   3. balanitis

Performing a Digital Rectal Examination (DRE)

Steps for DRE

1. Check Perianal Sensation and Sphincter Tone
   • Assess neurological function by checking perianal sensation.
   • Evaluate the sphincter tone by asking the patient to squeeze the anal muscles.
2. Assess Prostate
   • Size: Note if the prostate feels enlarged.
   • Consistency: Determine if the prostate is smooth or irregular.
   • Symmetry: Check if both lobes of the prostate feel similar.
   • Nodularity: Identify any nodules or irregularities.
   • Findings: An enlarged, smooth, and non-tender prostate can indicate benign prostatic hyperplasia (BPH).

Evidence-Based Recommendations

Cancer Council Recommendation

• Routine Screening: DRE is not recommended as a routine addition to PSA testing for asymptomatic men in primary care settings.
• Referral Assessment: DRE remains important when referred to a urologist or specialist for further assessment before considering a biopsy.

Practice Points

• Consent and Sensitivity: Acknowledge the possibility of past sexual abuse when obtaining consent for a DRE. Explain the procedure clearly and empathetically.
• Communication Example:
  • “I need to perform a rectal exam. I understand this is undignified for anyone, but it can be especially difficult if you have had a bad experience in this area. By that, I mean if anyone has ever touched your anus when you didn’t want them to…”
  • Respond accordingly based on the patient’s response.

Awareness of Sexual Abuse in Male Children

• Prevalence: Approximately 7.5% of males in Australia experience sexual assault as children.
• Perpetrators: The majority of sexual abuse cases are perpetrated by family members.

Additional Assessments

Focused Neurological Examination of the Lower Limbs

• Strength: Assess muscle strength in various muscle groups.
• Sensation: Check for any sensory deficits.
• Reflexes: Test deep tendon reflexes (e.g., knee jerk, ankle jerk).
• Coordination: Evaluate coordination and gait if necessary.

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Investigations:

1. Arrange:
   1. Prostate-specific antigen (PSA)
      1. following discussion of benefits and risks with the patient.
   2. ELFTs
   3. Glucose- exclude diabetes
   4. Urinalysis/MCS
      1. Exclude leucocytosis, haematuria, proteinuria, pyuria and glycosuria
      2. Follow up with urine culture if abnormality on urinalysis
   5. Serum creatinine/ estimated glomerular filtration rate (eGFR)
      1. Exclude
         1. renal injury from primary renal dysfunction 
         2. high-pressure bladder outflow obstruction
      2. Follow up with imaging if abnormal eGFR. 
      3. Can be useful as a follow-up test if renal impairment is suspected
   6. Urinary tract ultrasound
      1. Size, 
      2. residual volume
      3. exclude hydronephrosis
      4. excludes stones/large tumours
      5. bladder wall thickening/trabeculation
   7. Prostate-specific antigen (PSA)
      1. If suspect prostate cancer (e.g. based on prostate examination)
      2. Controversial; most guidelines recommend the use of serum PSA if prostate cancer diagnosis will influence management or if the test will assist in decision making
      3. As part of screening of prostate cancer, after discussion of pros and cons
      4. Routine PSA screening is not necessary for patients with BPH. 
      5. Patients with LUTS are not at increased risk of having prostate cancer

8. Other PSA tests
   1. PSA velocity or doubling time:
      1. if the PSA level doubles in 12-months it may indicate prostate cancer or prostatitis.
      2. An elevated PSA and a stable velocity suggest BPH.
      3. Free-to-total PSA ratio:
         1. high ratio (> 25%) suggests BPH
         2. low ratio (< 10%) suggests prostate cancer
      4. Prostate Health Index (PHI):
         1. not covered by the MBS, PHI thought to be more specific for diagnosing prostate cancer than PSA level alone; 
         2. good quality evidence lacking & not recommended in Australian prostate cancer testing.

• N.b. BPH is not a risk factor for prostate cancer

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Treatment

1. If malignancy excluded trial therapy – but should be followed up for progression of symptoms
2. Observation and review
   1. for mild or low impact symptoms
   2. Optimise through reassurance, education, periodic monitoring and lifestyle modifications.
   3. Consider adjustment of medication (e.g. timing of diuretic).
3. Lifestyle – limit evening fluid intake
   • ↓ ing diuretics – caffeine and alcohol intake
   • ↓ bladder irritants (acidic, spicy foods)
   • ↓evening fluid intake
   • ↓ constipation
   • limiting perineal trauma (e.g., bicycle riding, long-distance driving)

Alpha blockers

1. Tamsulosin, silosdosin, alfuozin
2. usually first line, reasonable to start in GP
3. More useful for voiding symptoms
4. SE’s – dizziness, nasal congsetion, anejaculation

5-alpha reductase inhibitors

1. Finasteride, duasteride
2. Can be added onto a-blockers
3. Help to reduce prostate volume over 6-12 months
4. SE’s – gynaecomastia, loss of libido, erectile dysfunctoin

Duodart – combination

1. Better for patients with large prostates (> 30 ml)
2. 5ARI can affect sexual function so consider carefully in sexually active men.

Anticholinergics

1. Oxybutynin
2. Solifenacin
3. Darifenacin 
4. For signfiicant storage symptoms, treat detrusor overactivity
5. Side effects include dry mouth, dry eyes and/or constipation.

Beta-3 adrenergic agonist

1. Mirabegron.
2. Requires blood pressure monitoring within first week 

PDE5 inhibitors

1. daily dosing, useful in concurrent ED

Voiding techniques

1. relaxed or double voiding (e.g., sitting down to urinate).
2. urethral milking to reduce dribbling.
3. techniques to control frequency and urgency (e.g., penile squeeze, pelvic floor (Kegel) exercises, distraction techniques).
4. techniques to increase bladder capacity (bladder retraining) e.g., resisting urgency, aiming to prolong times between voids.

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Urologist referral Treatment

• acute urology assessment:
  • If acute urinary retention
• non-acute urgent urology assessment:
  • Abnormal USS suggestive of urinary tract tumour
  • Elevated post-void residuals and hydronephrosis on USS and/or altered renal function
  • Severe irritative symptoms and any of the following:
    • haematuria 
    • suspicion of malignancy
  • Acute urinary retention post IDC insertion
  • New elevated PSA> 10ng/ml
• non-acute urology assessment:
  • recurrent UTI > 1 per year
  • bladder outlet obstruction with post-void residual volume > 200 mL on ultrasound.
  • severely symptomatic or incontinent.
  • If moderate-to-severe symptoms (IPSS > 15 with quality of life score > 4), and unable to tolerate or poor response to medical treatment over 6 months
  • Associated Neurological condition (e.g. Parkinson’s disease, Multiple sclerosis)

Surgical

1. TURP, TUIP, Green light laser, Urolift
2. Complications
   1. UTIs
   2. Urinary retention
   3. Bladders stones
   4. Bilateral hydroneprhosis
   5. Incontinence

QLD Health Minimum referral criteria For LUTS

Category 1 (appointment within 30 calendar days) If you feel your patient meets Category 1 criteria, please mark “urgent” on your referral	– Abnormal USS suggestive of urinary tract tumour – Elevated post-void residuals and hydronephrosis on USS and/or altered renal function – Severe irritative symptoms and any of the following:haematuria , suspicion of malignancy – Acute urinary retention post IDC insertion – New elevated PSA> 10ng/ml
Category 2 (appointment within 90 calendar days)	– USS suggestive of bladder outlet obstruction – Bladder stones – Recurrent UTI (> 1 per year) – Elevated post-void residuals > 200ml – Suspected or proven urethral stricture – Acute change in long-term catheter – Persistent or progressive symptoms despite maximal medical management – Incontinence – Elevated PSA < 10ng/ml – Suspected or symptomatic benign prostatic hypertrophy or prostatomegaly
Category 3 (appointment within 365 calendar days)	No category 3 criteria

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Prognosis of Untreated BPH

• LUTS worsen over time with increasing voiding difficulty.
• Complications may include:
  • Urinary retention
  • Recurrent UTIs
  • Hematuria
• Observational data:
  • 31% required further treatment by 48 months
  • 5% developed acute retention
• Incidence of retention increases with age:
  • From 3/1000 (40–49 years) to 35/1000 (70–79 years)
• Risk factors for progression:
  • Prostate volume >30 g
• Preventive pharmacotherapy:
  • 5α-reductase inhibitors ↓ retention and surgery need
  • α-blockers do not delay progression

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⚠️ Common Complications

• Voiding and structural
  • Acute or chronic urinary retention
  • Incomplete bladder emptying
  • Decompensated bladder
  • Detrusor underactivity
  • Weak/intermittent stream
  • Bladder calculi
  • Suprapubic distension
• Renal
  • Hydronephrosis
  • Renal failure
• Infectious
  • UTIs (due to stasis)
• Hematuria
  • Due to increased vascularity of enlarged prostate
  • Finasteride reduces bleeding risk
• Postoperative
  • Incontinence (transient or rarely permanent)
  • Management:
    • Kegels, pads, anticholinergics, PT
    • Male slings, AUS in refractory cases
• Catheter-related
  • Failed TWOC
  • Long-term complications (UTIs, blockage, hematuria)

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🧠 Deterrence and Patient Education

• Lifestyle modifications:
  • Weight loss
  • Diabetic control
  • Caffeine and fluid timing management
  • E.g., dose furosemide 6–8 hrs before bedtime to reduce nocturia
• Catheter care:
  • Hygiene and infection prevention
  • Nurse-led education
• Shared decision-making:
  • Discuss risks of progression
  • Options: watchful waiting, medical therapy, surgery

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💡 Clinical Pearls and Considerations

• Use IPSS/AUA scores, DRE, PSA, PVR for assessment.
• DRE asymmetry → suspicious for malignancy.
• Bladder scans essential in primary care for PVR assessment.
• Renal ultrasound:
  • Indicated in unexplained renal failure/retention
• Persistent hydronephrosis despite catheter → consider malignancy.
• Pharmacotherapy:
  • α-blockers: symptomatic relief; trial 72 hrs for acute retention
  • 5-ARIs: require ≥6 months for effect
  • Anticholinergics/β3 agonists: only if PVR is low
• Procedural cautions:
  • Avoid clamping catheter if >1500 mL drained (risk of diuresis)
  • Record post-catheter volume → prognosticate bladder recovery
• Procedures for refractory/fragile patients:
  • Prostatic artery embolisation (select centres)
  • Suprapubic catheter preferred over long-term urethral catheter