Benign prostatic hyperplasia

Microscopic benign prostatic hyperplasia (BPH) develops in most western men. Many such men will develop measurable enlargement of the prostate gland due to a complex interplay of hormonal and dietary influences. Urinary symptoms, in association with prostatic enlargement, affect 25% of the male population, increasing to 43% of the male population aged >60 years. About 50% of symptomatic men have measurable BPH/enlargement. Dietary, hormonal, cardiac, renal and habitual factors contribute to urinary symptoms in both sexes, particularly as they age. A focused history and examination, simple tests (prostate-specific antigen, creatinine) and assessment of voiding function (flow rate, ultrasound) help make the diagnosis. Many can be stratified according to the severity of their symptoms by scoring systems (International Prostate Symptom Score). Lifestyle advice can lessen mild symptoms, medical therapy (with alpha blockers, 5-alpha reductase inhibitors or a combination of both) are most appropriate for mild or moderate symptoms and may help severe symptoms. Severely symptomatic or obstructed men do best with a surgical technique chosen according to prostate size i.e. bladder neck incision/transurethral incision of the prostate if small, transurethral resection of the prostate 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. Impotence and significant incontinence are no more common with surgery than with conservative management. 5-alpha reductase inhibitor therapy offers the opportunity to prevent the development of further BPH instead of, or after, surgical treatment.