March 20, 2023

Waking up to urinate at night, frequent urination at daytime, urinary urgency, and inability to control urination are some of the symptoms caused by benign prostatic hyperplasia (BPH).
These so-called lower urinary tract symptoms or LUTS occur because the one-way flow of urine from the urinary bladder is disrupted by the enlarged prostate leading to urinary bladder wall irritation. Other LUTS are voiding symptoms and these are slow stream or reduced force of urine, splitting or spraying of the urine stream, exerting effort or straining to void, or delay in initiating voiding (hesitancy), and dribbling.
BPH is the term used to refer to an increase in the amount of cells, smooth muscle, and connective tissue inside the prostate. It occurs in males starting at age 40 to 45 years. One study has shown that it occurs in 60 percent of males at 60 years old, and in 80 percent at 80 years old. BPH can cause benign prostatic enlargement and eventually benign obstruction of the urinary bladder outlet. In others, it can be asymptomatic.
There are no typical or specific tests for BPH although it can cause higher levels of the blood test prostate specific antigen. A physical examination finding with direct rectal examination or DRE would reveal a prostate that is symmetrically enlarged, smooth, and non-tender. It does not cause pain when palpated with the examining finger.
Transrectal ultrasound is not necessary in diagnosing BPH but can assess the total volume of the prostate. It has been shown that the mildness or severity of symptoms is not clinically correlated with the size of the prostate on physical examination or ultrasound studies.
Direct visualization with urethroscopy or cystoscopy by a urologist is done when stricture or scarring in the urethra or bladder neck is suspected. Prostate biopsy is advised if there is reason to suspect cancer of the prostate as suggested by abnormal DRE finding or high level and increasing trend in prostate specific antigen.
Urinalysis is done in the evaluation of BPH to identify presence of infection, glucose, or proteinuria. Presence of blood in the urine will guide further work up for other causes like cancer. Urine culture is requested if the physician suspects presence of infection. Serum creatinine will assess kidney function. Prostate size above 35 grams by ultrasound correlates with prostate specific antigen level greater than 1.5 ng/dl and this information will guide the physician a urologist in drug therapy with 5-alpha reductase inhibitor and follow up.
Complications of untreated BPH include acute urinary retention or the sudden inability to urinate. In chronic cases with prolonged disturbance or obstruction to the normal flow of urine, there could be increased risk of urinary tract infections, urinary bladder stones, and kidney damage.
BPH is not a risk factor for prostate cancer. Immediate consult with a urologist should be done if symptoms are severe, DRE is abnormal (prostate is asymmetric and nodular not smooth), there is blood in the urine, PSA is high, there is incontinence or pain on urination, age less than 45 years, the urinary bladder is palpable, or urine volume that remains in the bladder after voiding is more than 250 ml.
Lower urinary tract symptoms, however, should not be readily attributed to benign enlargement of the prostate. Medical consult with a physician will entail exclusion of other causes like scarring of the urethra the passageway of urine from the urinary bladder, contracture of the urinary bladder wall, prostatic or bladder cancer, and UTI. The doctor also has to identify other illnesses that can worsen or imitate the symptoms of BPH like heart disease and diuretic use, diseases of the nervous system such as Parkinson’s disease, and high or frequent intake of fluids.

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