Benign prostatic hyperplasia

Microscopic benign prostatic hyperplasia (BPH) develops in most Western men, many of whom will develop measurable enlargement of the prostate. Lower urinary tract symptoms (LUTS), in association with prostatic enlargement, are common, especially with increasing age. About 50% of symptomatic men have measurable BPH/enlargement. A focused history and examination (with frequency/volume chart), simple tests (urine dipstick, creatinine) and assessment of voiding function (flow rate, ultrasound) help make the diagnosis, and a prostate-specific antigen (PSA) test should be considered. LUTS can be stratified according to severity by scoring systems (international prostate symptom score). Lifestyle advice can lessen mild symptoms. Medical therapy with α blockers should be offered initially to men with moderate to severe LUTS, and if the PSA is greater than 1.4 ng/ml or the prostate is estimated to be greater than 30 g, a 5-α reductase inhibitor should be offered alone or in combination with α blocker. Anticholinergics should be considered if there are concurrent storage symptoms. Severely symptomatic or obstructed men do best with a surgical technique chosen according to prostate size, that is transurethral incision of the prostate if small, transurethral resection of the prostate (TURP) or holmium laser enucleation (HoLEP) if 30–100 cm3 or open prostatectomy if large (>100 cm3). Pressure–flow studies can improve the accuracy of diagnosis and the selection of candidates for surgery, but most symptomatic men respond well to treatment. Outcomes for obstructed or moderate to severely symptomatic men are good, but the medical alternatives should always be discussed. 5-α reductase inhibitor therapy offers the opportunity to slow the development of further BPH instead of, or after, surgical treatment.