BENIGN PROSTATIC HYPERPLASIA: OVERVIEW AND MEDICAL MANAGEMENT

Dr. Saleh Mohammad Shoaib, Assistant Surgeon, Fakirhat UHC, Bagerhat

DMC (K – 67), MD resident (Phase – A, Neurology, NINS), Mob: 01757370094

1.1. GENERAL • Post–micturition dribbling not a consequence of BOO and not

usually improved by prostatectomy.
• Prostate enlargement > bladder outlet obstruction (BOO) > lower
urinary tract symptoms (LUTS). • Prostatic volume and symptoms tend to increase over time.

• BPH with age. Appx. 50% develop it by age 60 and appx. 90% by • Erectile dysfunction is commonly associated with LUTS.
age 85.
• Ask about medications (diuretics, anticholinergics, tricyclics,
• S. testosterone slowly (but significantly) ↓with age; however, opiates) and lifestyle factors (caffeine, alcohol, excess liquid intake).
oestrogen levels do not ↓ equally. According to this theory, the
• Ask about symptoms and detect IPSS score.
prostate enlarges because of relatively  oestrogenic effects.

1.2. PATHOPHYSIOLOGY OF LUTS

• Bladder outlet obstruction.

• Bladder dysfunction:  filling pressures →  bladder wall

hypertrophy, trabeculation, poor compliance (↓ smooth muscle, 
collagen), detrusor overactivity (sensitivity to small urine volumes),
and eventually, incomplete voiding.

• α –1–adrenergic receptor stimulation in prostatic smooth muscle

and the bladder neck →  smooth muscle tone → LUTS.

1.3. CLINICAL FEATURES

1.3.1. VOIDING/OBSTRUCTIVE LUTS

1. Hesitancy (worsened if the bladder is very full)

2. Poor flow (unimproved by straining)

3. Intermittent stream – stops and starts

4. Dribbling (including after micturition)

5. Sensation of poor bladder emptying

6. Episodes of near retention

• Maintain self–completed voiding diary.
7. Double voiding (urinating a second time within 2 hours)

8. Straining to urinate
1.4. COMPLICATIONS

• Bladder dysfunction
1.3.2. STORAGE/IRRITATIVE LUTS
• Post–void residual urine volumes
1. Frequency
• Acute urinary retention
2. Urgency
• Recurrent UTIs
3. Urge incontinence
• Obstructive nephropathy
4. Nocturnal incontinence (enuresis)
• Bladder stones

• Haematuria

1.5. DIFFERENTIAL DIAGNOSIS

• Prostate: Prostate cancer, prostatitis, prostatodynia.

• Bladder: Overactive bladder, bladder dysfunction (e.g.

neurological disorder like DM, cauda equina syndrome, multiple
sclerosis), tumour, stone, foreign body (e.g. stent).

• Urethra: stricture (previous trauma, STD).

1.6. PHYSICAL EXAMINATION

• Abdomen: Bladder may be palpable

• Digital rectal examination (DRE): Prostate: Size, consistency,

contour, surface texture. Pain. Sphincter tone (↓ if underlying
neurological disorder). Normal prostate volume is appx. 20g (appx. 2
index fingers across).

• Neurological examination: Cauda equina sydrome? Spinal cord

lesion?

• BP: may be elevated if chronic retention and obstructive uropathy.

1.7. INVESTIGATIONS

• Urine: R/E, stain and C/S.

• PSA:

 BPH does not cause prostate cancer. But, Male at risk for BPH are
also at risk for prostate cancer.

 PSA levels correlate with prostate volume, so PSA is less specific • Upper tract imaging: If haematuria, stones,↓eGFR, large residual
for cancer in an individual with BPH. volume, upper tract infection.

 Predicts treatment response.
• Measurement is recommended in many guidelines.
• Helpful if treatment with an 5α–reductase inhibitor is being
considered, as it should reduce PSA by ~50% by 6 months.
• eGFR: Do if high residual volume.
• Uroflometry: Maximal flow rate (Qmax): >15mL/s is normal. Flow
pattern: Differentiates BOO from detrusor dysfunction.
• Urodynamics (pressure flow studies): Invasive (urethral catheter
and transrectal probe). Differentiates BOO from detrusor
dysfunction (BOO:  voiding pressures (>60cmH2O) and ↓Qmax
(<15mL/s)).

• USG: Prostate and bladder volumes may predict response to

treatment. Exclude hydronephrosis if retention or ↓ eGFR.

• Transrectal ultrasound (TRUS): Desirable prior to surgery and 5α–

reductase inhibitors. Consider if  PSA.
  Modify diuretic therapy

 ↓ Caffeine and alcohol

 Void prior to bedtime, travel, or meetings

 Improve glycaemic control in diabetic patients

2. Failed lifestyle measures, or moderate to severe symptoms (IPSS

score ≥ 8): treat with drug therapy (along with lifestyle measures).

• A 3 – 6 point reduction in IPSS score can be expected (appx. 60%

men improve).

1.8.2. INDICATIONS FOR SURGERY

 Acute urinary retention

 Recurrent macroscopic haematuria

 Recurrent UTIs

 Obstructive nephropathy

 Failure of medical therapy

1.8.3. DRUG THERAPY

1. α–1 RECEPTOR BLOCKADE

• α–1–adrenergic receptor–mediated smooth muscle tone in both

prostate and bladder neck contribute to LUTS. There are several
receptor subtypes, with the α–1a receptor most relevant in prostatic
tissue.

• Flexible cystoscopy: If atypical features (e.g. haematuria), prior to
invasive treatment, or if an alternative diagnosis (e.g. stricture) is
being considered.
1.8. MANAGEMENT
1. Patients with minor symptoms (IPSS score <7), no complications,
and an acceptable quality of life: manage with adaptive lifestyle
measures and watchful waiting.
• α–1a–receptor blockade → ↓smooth muscle tone in prostate and
bladder neck → relief of LUTS
• α–1a–receptor blockade rapidly improve symptoms (within days)
but do not demonstrably ↓ the overall risk of acute retention or
requirement for surgery.
• S/E: postural hypotension, dizziness, ejaculatory disorder, nasal
congestion (less with selective α–1a blockers)

• Reassess at least annually. A. SELECTIVE α–1a–RECEPTOR BLOCKERS

1.8.1. LIFESTYLE MEASURES •Require less dose titration, have fewer side effects, daily taken 30
minutes after a meal:
 ↓ Liquid intake (particularly night–time)
 Tamsulosin 0.4mg orally once daily or
 Alfuzosin 10mg orally once daily
B. NON – SELECTIVE α–1–RECEPTOR BLOCKERS
•Effective, less expensive but require more careful dose titration,
to be given at bedtime:
 Doxazosin: start at 1 mg at bedtime for 7 days, then 2 mg at
bedtime for 7 days, then continue at 4 mg at bedtime. Max. 8 mg at
bedtime.
 Terazosin: Start at 1 mg at bedtime for 3 days, then 2 mg at
bedtime for 11 days, then continue at 5 mg at bedtime. Max. 10 mg
at bedtime.
 Prazosin: short–acting, requires dose titration and twice daily
dosing. Start at 1 mg at bedtime, slowly up–titrate to 1 – 5 mg twice
daily.
2. 5–α–REDUCTASE INHIBITORS
• Inhibit 5–α–reductase → block prostatic conversion of
testosterone to DHT →  testosterone level →  reduction in size of
the gland and improvement in symptoms.
• Reduces prostate volume.
• Greatest benefit in those with higher initial prostate volume (> 40
g on DRE or USG) or progression of symptoms despite on α–
blocker.
• Peak effect is delayed for 3 – 6 months. Continue long term.
•↓ incidence of acute retention and the requirement for surgery.
• Examples: Finasteride 5mg PO OD, Dutasteride 0.5mg PO OD.
• Side effects: ↓ libido, erectile dysfunction, ejaculatory disorder,
gynaecomastia.
• Often better tolerated than α–blockers.
• May ↓ PSA by 50% (caution! when interpreting measurements)
COMBINATION THERAPY
• Since α–blockers provide rapid symptomatic relief of LUTS and 5–
α–reductase inhibitors gradually reduce gland growth, concomitant
use makes good sense, particularly where initial prostate volumes
are high.
• Combination → ↓ progression, improved symptoms (and IPSS
score), ↓ risk of retention, and ↓ requirement for surgery.
• Withdrawal of the α–blocker may be possible after 6 months.
3. DETRUSOR MUSCLE RELAXANTS
• May be beneficial where storage LUTS (urgency, frequency,
nocturia, small urine volumes, urge incontinence) dominate
symptoms without significant obstruction or a residual volume (=
overactive bladder without BOO)
• Examples:
Anticholinergics: oxybutynin, tolterodine, solifenacin, and
darifenacin.
β–3 agonist: Mirabegron
• Generally effective and well–tolerated, although dry mouth
common.
• May worsen obstructive (voiding) symptoms, increase residual
volumes, and precipitate urinary retention, especially when
administered despite presence of BOO.
• NEVER prescribe them in presence of BOO (if you have to
prescribe, be very much cautious, consult a urologist before
prescribing).
4. PHOSPHODIESTERASE–5 ENZYME INHIBITORS
• Sildenafil or tadalafil may improve mild to moderate LUTS (nitric
oxide may mediate relaxation of the prostatic urethra).
• Useful in coexisting BPE and erectile dysfunction (ED commonly
associated with LUTS).
• Potential interaction between α–blockers and PDE–5 inhibitors
causing postural hypotension.
 Tadalafil: Improves urinary function in 2 – 4 weeks after initiating
treatment at 5 mg once daily, with minimal adverse effects.
 1.8.4. DRUGS FOR BPH

Starting Typical
Group Name Cost Comment
dose dose
Selective α– Tamsulosin (Maxrin, 0.4 mg OD 0.4 or 0.8 0.4 mg cap = 10 tk • S/E: postural hypotension, dizziness,
1a blockers Uroflo, Uromax, mg OD ejaculatory disorder, nasal congestion.
Uropass) • Take 30 min after meal.
Alfuzosin (Alfumax–ER, 10 mg OD 10 mg OD 10 mg tab = 10 tk • Rapidly improve symptoms (within days)
Uriten)
Silodosin (Rapiflo, 4 mg OD 4 – 8 mg 4 mg cap = 12 tk
Flowrap, Siloflo) OD 8 mg cap = 24 tk
st
Non – Doxazosin 1 mg at 1 – 8 mg • S/E: 1 dose syncope; postural hypotension,
selective α– bedtime OD dizziness, palpitations, headache, weakness,
1– blockers Terazosin (Terazon) 1 mg at 1 – 10 mg 2 mg tab = 5 tk drowsiness, sexual dysfunction.
bedtime OD 5 mg tab = 8 tk • Initiate at bedtime.
Prazosin (Prazopress + 1 mg at 1 – 5 mg 1 mg/4 tk • Useful in BPH with HTN.
ER, Alphapress) bedtime BD 2 mg/6 tk
2.5 mg ER/10 tk
5 mg ER/15 tk
5–α– Finasteride (Pronor) 5 mg OD 5 mg OD 5 mg tab = 10 tk • S/E: ↓ libido, erectile dysfunction, ejaculatory
reductase Dutasteride (Dutamax, 0.5 mg OD 0.5 mg OD 0.5 mg cap = 12 tk failure, gynaecomastia
inhibitors Urodart) • Useful if prostate size > 30 – 40 g
• Reduces prostate volume and serum PSA
level.
• Peak effect is delayed for 3 – 6 months.
Continue long term.
PDE–5 Tadafalil (Tada, Adafil, 5 mg OD 5 mg OD 5 mg tab = 18 tk • Useful in BPH with erectile dysfunction.
inhibitors Edysta, Intimate, Tiagra) 10 mg tab = 35 tk • Adverse effects minimal at this dose
20 mg tab = 60 tk • Take at same time everyday
• Caution! do not take with α–1a blockers →
large fall in BP + postural hypotension
Combination Tamsulosin + 0.4 + 0.5 0.4 + 0.5 0.4/0.5 mg cap = 15 • Take orally 30 min after same meal everyday
Dutasteride mg OD mg OD tk • Give if LUTS + prostate size > 30 ml
(Combomax, Maxrin D, • Acute relief of LUTS + long term reduction of
Uromax–D, Uropass–D) prostate size → excellent combination!
st
All drugs oral until otherwise stated. Prices are for 1 brand name inside bracket.

OD = once daily, BD = twice daily

1.8.5. DIFFERENCES BETWEEN α–1a BLOCKERS AND 5– 1.8.6. DIFFERENCES BETWEEN SELECTIVE AND NON –
α–REDUCTASE INHIBITORS SELECTIVE α–1a BLOCKERS

5–α–reductase Selective α–1a Non selective α–1

Factors α–1a blockers Factors
inhibitors blockers blockers
Relief of LUTS Rapid. Within days. Slow. Peak effect Dose titration less more
delayed for 3 – 6 Side effects fewer more
months. To be taken 30 minutes after at bedtime
Effect on smooth Tone decreased No effect meal
muscle tone Frequency once daily Prazosin: twice daily
Effect on prostate No effect Reduces prostate
size volume
Effect on PSA level No effect Reduces PSA 1.9. LOCATION AND ACTION OF α–1 RECEPTORS
Use with PDE–5 Danger! BP↓! No problemo
inhibitors Postural
Location Action Result
hypotension!
Pupil Radial muscle Mydriasis
contraction
Arterioles Constriction  Peripheral
resistance →  BP
Veins Constriction  Venous return →
 Cardiac output
Salivary glands Viscous secretion Salivation
(except parotid)
Pilomotor muscles Contraction Horripilation, “Chill  Bladder training
bumps”
GIT smooth muscles Relaxation GIT relaxation  Pelvic floor muscle therapy + biofeedback electrodes (abdominal,
GIT sphincter Constriction anal, vaginal)
Urinary bladder Constriction Urinary retention
sphincter 2. DETRUSOR MUSCLE RELAXANTS
Male sex organ Sphincter Urinary retention
contraction
Ejaculation
A. ANTICHOLINERGICS
Spleen capsule Contraction
Liver Glycogenolysis Hyperglycemia • Inhibit involuntary detrusor muscle contraction e.g. tolterodine,
Pregnant uterus Contraction oxybutynin and solifenacin.
Pancreas (acini, Decrease pancreatic
islets) secretion • S/E: dry mouth, constipation, blurred vision, confusion (caution in
elderly!).

1.10. COMBINATION OF α–1a BLOCKERS AND 5–α– • Contraindications: BOO, narrow angle glaucoma

REDUCTASE INHIBITORS: EXCELLENT! B. β–3 ADRENERGIC AGONISTS

α–1a blockers (e.g. Tamsulosin) causes acute relief of LUTS by
• Inhibit involuntary detrusor muscle contraction e.g. Mirabegron.
reduction of smooth muscle tone in prostate and bladder neck,
whereas 5–α–reductase inhibitors (e.g. Dulasteride) cause long Name Dose (mg/d) Cost
term reduction of prostate size → excellent combination! Tolterodine (Tab. Ucol 2) 2–4 2 mg/3 tk
Solifenacin (Tab. Solider, 5 – 10 5 mg/15 tk
1.11. COMBINATION OF α–1a BLOCKERS AND PDE–5 Utrobin) 10 mg/30 tk
INHIBITORS: DANGER! Mirabegron (Tab. Mirabeg, M – 25 – 50 25 mg/30 tk
beg) 50 mg ER/55 tk
Propantheline (Tab. Prokind) 10 – 15 15 mg/8 tk
This combination may cause a larger reduction in BP than when
using either agent alone. However, these two classes may be safely
used in combination if they are initiated and titrated in a stepwise
2.3. DETRUSOR MUSCLE RELAXANTS IN BOO: DANGER!
fashion.
Detrusor muscle relaxants (i.e. anticholinergics and β–3 agonists) →
2. THE OVERACTIVE BLADDER relaxes detrusor muscle and constricts bladder sphincter →
worsening of obstructive (voiding) symptoms, increase residual
• Urinary urgency (+ incontinence) dominates, usually with
volumes, and precipitate urinary retention.
frequency (≥ 8x in a 24h period) and sometimes with nocturia (≥ 3x
at night).
So, NEVER prescribe them in presence of BOO (if you have to
prescribe, be very much cautious, consult a urologist before
• Urgency: sudden, overwhelming desire to pass urine.
prescribing).
• Detrusor overactivity: present.
3. EXAMPLES OF PRESCRIBING IN BPH
2.1. INVESTIGATIONS
[A/M = after meal]
• Exclude UTI always: Urine R/E, C/S.
Example 1 – BPH (prostate < 30 g): A 67 y old male presented with
• Bladder diary, symptom questionnaires (like IPSS). hesitancy, poor flow. IPSS 5. Investigations confirm BPH with
prostate size appx. 25 g.
• USG with PVR• Urodynamics (differentiates detrusor overactivity
from BOO) + cystoscopy if needed. Management:

Adaptive lifestyle measures: ↓ Liquid intake (particularly night–

2.2. MANAGEMENT
time), modify diuretic therapy, ↓ caffeine and alcohol, void prior to
bedtime, travel, or meetings, improve glycaemic control if diabetic.
1. LIFESTYLE MODIFICATIONS
Watchful waiting. Annual reassessment.
 Modify amount and timing of fluid intake
Or, Drugs: 1. Cap. Uromax 0.4 mg 0 + 0 + 1 (30 min A/M) upto 1 + 0
 Absorbent pads/diapers if incontinence
+ 1 if needed – cont.
 Double void techniques if residual volume
Example 2 – BPH (prostate > 30 g): A 77 y old male presented with Management:
hesitancy, poor flow, lower abdominal distension. IPSS 8.
Investigations confirm BPH with prostate size appx. 45 g. Investigate cause.

Management: Reassurance.

Adaptive lifestyle measures. Drugs: Tab. U–col 2 1 + 0 + 1 – cont. or

Consider if surgery needed. Tab. Solider 5 1 + 0 + 1 – cont. or

Drugs: 1. Cap. Combomax 0 + 0 + 1 (30 min A/M) – cont. Tab. M – beg 25/50 0 + 0 + 1 – cont. or

Example 3 – BPH with HTN: A 80 y old male having BPH is Tab. Prokind 15 0 + 0 + 1 – cont.
hypertensive for 4 years. Prostate size appx. 45 g.
Example 7 – Overactive bladder with BOO: A 67 y old male presents
Management: with poor flow, hesitancy, straining to micturate, incomplete
voiding. He also has urgency and frequency of micturition. Imaging
Adaptive lifestyle measures. shows enlarged prostate. Urodynamic studies show severe bladder
outlet obstruction (flow severely reduced, pressure very high).
Consider if surgery needed.
Management:
Drugs: 1. Tab. Prazopress 1 mg 0 + 0 + 1 at bedtime, slowly up –
titrate to 5 ER 1 + 0 + 1 – cont. Adaptive lifestyle measures.

2. Cap. Urodart 0.5 mg 0 + 1 + 0 – cont. Consider if surgery needed.

Give other drugs for HTN. Drugs: 1. Cap. Combomax 0 + 0 + 1 (30 min A/M) – cont.

Example 4 – BPH with erectile dysfunction: A 52 y old male Example 8 – Iatrogenic acute urinary retention: The same patient
diagnosed as BPH also have erectile dysfunction. It is hampering his from example 7 was prescribed Tab. Utrobin (Solifenacin) 10 mg 0 +
family life. 0 + 1. Thereafter he developed inability to micturate, lower
abdominal pain and distension.
Management:
Management:
Adaptive lifestyle measures.
Urinary catheterization.
Consider if surgery needed.
Consider surgery.
Drugs: 1. Tab. Tada 5 mg 0 + 1 + 0 – cont.
Avoid detrusor relaxants in future.
2. Cap. Urodart 0.5 mg 0 + 1 + 0 – cont.

Example 5 – Iatrogenic: A 68 y old male diagnosed as BPH was

prescribed Cap. Rapiflo (Silodosin) 8 mg OD plus Tab. Tada (Tadalafil)
10 mg OD. After starting taking drugs, he developed dizziness and
vertigo. BP was 60/40, HR – 140/m. Pulse – feeble, periphery – cold.

Management:

Urgent admission in medicine ward/HDU/ICU.

Give fluids and Dopamine/Noradrenaline in drip until stable.

Consider discharge when stable.

Drugs on discharge: Cap. Rapiflo 4 mg 0 + 0 + 1 slowly up – titrate to

8 0 + 0 + 1 – cont.

Example 6 – Overactive bladder without BOO: A 60 y male presents

with urgency, frequency of micturition and nocturia. There are no
obstructive symptoms. Urine R/E reveals no pus cell. Urine C/S
reveals no organism.