Benign Prostatic Hypertrophy

Benign prostatic hypertrophy (BPH) is growth of the prostate with normal aging and causes symptoms, because the prostate blocks the flow of urine through the prostate as the urine exits the bladder. The name BPH indicates enlargement of the prostate, but men may suffer symptoms even with smaller prostates as they age. Other terms that describe the same process include: lower urinary tract symptoms (LUTS), bladder outlet obstruction (BOO) and benign prostatic enlargement (BPE).

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Diagnosis and Treatment of Benign Prostatic Hypertrophy

As men age and the prostate continues to enlarge, symptoms typically slowly progress, and men can develop retention of urine, bleeding, urinary infections, stones in the bladder and even kidney problems. Evaluation and management of these symptoms begin with an assessment of the urinary symptoms and quality of life. In the past treatment was often based on relieving serious problems, such as kidney failure, inability to urinate (retention), bleeding, recurrent infections and bladder stones. These are still indications for aggressive treatment but are less frequently encountered. In modern practice the level of bother from the symptoms most often drives treatment decision-making.

Diagnostic Tests

There are other medical conditions that can mimic the symptoms of BPH. Poor bladder function from diabetes, cerebrovascular accidents, pelvic surgery or other neurologic diseases must be evaluated and ruled out as contributing factors before pursuing surgical treatment. This often leads to testing the bladder function, pressure generated with urination and flow rate, which are all evaluated with a test called a cystometrogram (CMG). Prostatitis is a common urologic finding that requires different treatment aimed at the inflammation and pain as well as the problems the condition can cause with urinary flow. Prostate cancer usually does not cause problems with urinary flow but is often checked in men with urinary symptoms by a prostate exam and blood test called a prostate-specific antigen (PSA). Bladder cancer can sometimes cause frequent and urgent urination but usually does not lead to obstruction of urinary flow. If your urologist is worried about bladder cancer, the evaluation will likely include a cystoscopy where the inside of the bladder is inspected with a small flexible scope similar to a catheter. Infections and ureter and bladder stones may also create LUTS and a simple urine analysis will help identify these and guide evaluation and treatment of the underlying problem.

In addition to the above tests, your urologists may wish to check post void residual urine volumes (PVR) to determine complete bladder emptying as well as urinary flow rates to determine the strength of the stream. These are both painless tests that are done during your office visit. As bladder blockage becomes more severe, the PVR may increase and flow rates may decrease. These tests can help follow symptoms over time for progression or response to treatment.


Medical therapy relies on three different types of medications used alone or in combination. Alpha blockers are medications that relax the prostate and bladder opening so the urine can flow more freely. These are typically well tolerated and offer quick improvement in symptoms. Five alpha reductase inhibitors shrink the prostate and work slowly over a four to six month period. These work best for patients with large prostates. Anticholinergic medications help treat bladder over activity and the frequency and urgency that many patients experience with prostate enlargement. These are often used when symptoms of frequency and urgency do not improve after other medical or surgical management and when PVR is reasonably low.

Recently, the phosphdiesterase inhibiting drugs have been shown to improve symptom scores in men being treated for both erectile dysfunction and BPH. Exactly how these drugs improve LUTS is not currently known; but for patients with both problems, this is a new option for medical management.

Surgical Management

Surgical management relies on opening the urethra where it runs through the prostate. This can be done with a variety of different procedures including:

  • TUIP (transurethral incision of the prostate). Relaxing incisions are made in the prostate using a small scope; typically used for small prostates
  • TUMT (transurethral microwave therapy). Destroys prostate tissue with heat delivered by a catheter
  • Vaporization of the prostate. Using either laser energy or electrical energy to destroy tissue using a small scope under direct vision
  • TURP (transurethral resection of the prostate). Removal of prostatic tissue using electrical energy through a small scope
  • HoLEP (holmium laser enucleation of the prostate). Using a laser to carve out the prostate in larger portions and then remove them from the bladder with a morcellating device
  • Simple prostatectomy. Removing prostate tissue through an incision in the lower abdomen; typically used for very large prostates

The risks, benefits and indications for each of these procedures are slightly different, and your surgeon will discuss which is best for you. Often, surgeon experience with one technique will also help select the procedure with the lowest risk of complication and best outcome.

In general risks for surgery for BPH include bleeding, urinary tract infection, abnormal healing with scar tissue formation in the urethra and bladder opening, erectile dysfunction, retrograde ejaculation (where semen flows backward into the bladder with orgasm) and incontinence (leaking urine without control). Complications are not common and most surgeries work very well to increase the strength of men’s urinary flow and relieve the symptoms of frequency and urgency of urination. Surgery is a very good option for men that do not tolerate medicines because of side effects or men for whom the medicines are not strong enough to relieve the symptoms of the problem.