Dr Roger Henderson Gives Nine Top Tips on the Assessment, Diagnosis, and Treatment of Benign Prostatic Hyperplasia in Primary Care

Gerry Gajadharsingh writes:

“Apologies for the length of this blog but read on you may find it interesting!

Lower urinary tract symptoms (LUTS) are extremely common in men over a certain age and often very distressing for them and their partners.

Below is an excellent article from a urologist regarding the symptoms, assessment, diagnosis and treatment of one of the most common causes of LUTS, benign prosthetic hyperplasia (BHP) an enlarged prostate.

It has been estimated that 50% of the male population aged 51–60 years has pathological BPH, increasing to 90% of men aged over 80 years. Around 90% of men aged 45–80 years’ experience some type of LUTS.

The most common LUT symptoms are either:

Voiding symptoms include hesitancy, intermittency, weak stream, straining, incomplete emptying, and post-void dribbling. 

Storage symptoms include urinary frequency, nocturia, and urgency. 

Perhaps inevitably the urologist has focus on medical interventions, mostly in the form of medication which is the usual first line interventions from GPs and urologists. However, towards the end there is a section on lifestyle advice I think is also useful.

Interestingly, the most common first line drugs tend to be alpha blockers.

The prostate gland and bladder neck contain alpha-1 adrenergic receptors. When these receptors are activated by norepinephrine, a neurotransmitter, it causes the smooth muscle to contract.

Alpha blockers block messages from the autonomic nervous system going to the bladder and urinary tract and sometimes the prostate depending on the medication and causes the smooth muscles in these structures to relax.

So called selective alpha 1-blockers relieve the symptoms of BPH by blocking alpha-1 adrenergic receptors in the prostate and bladder neck, resulting in muscle relaxation and improved urinary flow. They are a cornerstone in the medical management of BPH due to their effectiveness and relatively favourable side effect profile. A common side-effect is also lowering of blood pressure which can be a positive side-effect if you tend to have high blood pressure. However, Dizziness, headaches, fatigue, and hypotension (low blood pressure) are some common side effects due to the systemic vasodilatory effect of these drugs.

Therefore, my suggestion regarding lifestyle, is the use of other techniques such as optimising breathing patterns as a way of calming down the excessive stimulation in the stress part of the autonomic nervous system.

There is some evidence suggesting that individuals with Type A personalities may be more susceptible to lower urinary tract symptoms (LUTS). Type A personality traits include being highly competitive, aggressive, impatient, and having a strong sense of urgency. Here are several factors and mechanisms that could explain this association:

Stress and Psychological Factors

  1. Increased Stress Levels:
    • Type A individuals often experience higher levels of stress due to their driven and competitive nature. Chronic stress can affect the autonomic nervous system, which controls the bladder and urinary functions.
  2. Cortisol and Sympathetic Nervous System Activation:
    • High stress levels can lead to elevated cortisol and increased sympathetic nervous system activity, potentially exacerbating urinary symptoms like urgency and frequency.

Behavioural Patterns

  1. Fluid Intake and Bathroom Habits:
    • Type A individuals might consume more caffeine and other stimulants to maintain their high energy levels, which can irritate the bladder and lead to increased urinary frequency.
    • They may also have irregular bathroom habits, either delaying urination due to busy schedules or going more frequently due to heightened sensitivity to bodily sensations.

Physiological and Hormonal Factors

  1. Impact of Stress on the Body:
    • Chronic stress can lead to inflammation and changes in the pelvic floor muscles, potentially contributing to LUTS.
    • Hormonal fluctuations associated with stress might also affect bladder function.

Evidence from Studies

  1. Research Findings:
    • Some studies have shown a correlation between Type A personality traits and the prevalence of LUTS. For instance, research has indicated that men with Type A personality traits report higher rates of LUTS, including symptoms such as urgency, frequency, and nocturia.
  2. Psychosomatic Links:
    • The psychosomatic connection suggests that psychological factors like stress and anxiety, more common in Type A individuals, can manifest as physical symptoms, including LUTS.

Practical Implications

  1. Management of Stress:
    • Stress management techniques, such as relaxation exercises, mindfulness, breathing and cognitive-behavioural therapy, could potentially alleviate some LUTS in Type A individuals by reducing overall stress levels.
  2. Lifestyle Adjustments:
    • Encouraging Type A individuals to adopt healthier lifestyle practices, such as regular exercise, proper hydration, and avoidance of bladder irritants (e.g., caffeine, alcohol), can help mitigate LUTS.

While the exact mechanisms linking Type A personality traits to LUTS are not fully understood, it is clear that stress and behavioural factors play significant roles. Addressing these aspects can be beneficial in managing and reducing LUTS in individuals with Type A personalities.”

Medscape

Dr Roger Henderson

The benign enlargement of the prostate gland that occurs normally with increasing age, known as benign prostatic hyperplasia (BPH), is so common as to be normal in most men. The prostate is a hormone-dependent gland, and BPH does not occur in individuals who have been castrated.

The term ‘prostatic hypertrophy’ is often used to describe BPH, but this is technically inaccurate because hypertrophy pertains to enlargement without an increase in component numbers (such as increasing muscle fibre bulk).‘Hyperplasia’ is more accurate, as it refers to an increase in the number of components typically seen in glandular enlargement.

It is important to note that, although BPH causes LUTS (lower urinary tract symptoms), these symptoms should not be viewed as synonymous with BPH. The current European Association of Urology (EAU) guideline recommends that other possible causes of LUTS should always be thoroughly investigated and considered. This article provides nine top tips to remember when assessing, diagnosing, and treating BPH in primary care practice.

  1. Understand That BPH Is Common and Significantly Impacts Individuals

It has been estimated that 50% of the male population aged 51–60 years has pathological BPH, increasing to 90% of men aged over 80 years. Around 90% of men aged 45–80 years’ experience some type of LUTS. A 2017 study investigating the global burden of LUTS suggestive of BPH estimated that the lifetime prevalence of BPH is 26.2%, with prevalence increasing with age.

The prostate gland doubles in size every 4.5 years between the ages of 31 and 50 years, with the rate of growth then slowing. Healthcare professionals should not only consider the occurrence and impact of BPH in terms of possible LUTS, but also in terms of direct medical costs, loss of normal daily functioning, and reduced quality-of-life measures for both the individual and their partner.

  1. Assess Symptom Severity as Part of the Initial Patient Assessment

The International Prostate Symptom Score is a self-administered questionnaire involving eight questions (seven scoring symptom severity and one scoring quality of life) that can be useful in clinician–patient discussion. This is a free tool for individual clinicians to use and should be completed during the initial evaluation of the patient, as the results can ascertain the degree of symptom severity.

An IPSS score of 0 would be considered asymptomatic, with a score of 1–7 being mild, a score of 8–19 indicating moderate symptoms, and a score of 20–35 indicating severe symptoms. Although the quality-of-life question may not capture the exact impact of BPH symptoms on quality of life, it can serve as a valuable starting point for consultations.

By using the patient’s age, their IPSS score, and prostate-specific antigen (PSA) testing, GPs can accurately diagnose BPH in approximately three-quarters of men who spontaneously report LUTS.

 Typical International Prostate Symptom Score Questions

 On a scale of 0–5, during the last month or so, how often have you…

  1. Had a sensation of not emptying your bladder completely after urinating?
  2. Had to urinate again <2 hours after you have urinated?
  3. Stopped and started several times when you urinated?
  4. Found it difficult to postpone urination?
  5. Had a weak urinary stream?
  6. Had to push or strain to urinate?
  • 0 points = not at all
  • 1 point = less than 1 time in 5
  • 2 points = less than half the time
  • 3 points = about half the time
  • 4 points = more than half the time
  • 5 points = almost always.

During the last month…

  1. How many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?
  • 0 points = none
  • 1 point = one time
  • 2 points = two times
  • 3 points = three times
  • 4 points = four times
  • 5 points = five times or more.

Quality of life due to urinary symptoms

  1. If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?
  • 0 = delighted
  • 1 = pleased
  • 2 = mostly satisfied
  • 3 = mixed, or about equally satisfied and dissatisfied
  • 4 = mostly dissatisfied
  • 5 = unhappy
  • 6 = terrible.
  1. Consider Key Symptoms of Voiding and Storage in a Medical History

Taking a detailed medical history is important when assessing BPH, and clinicians should look for voiding and storage symptoms in particular.

Voiding symptoms include hesitancy, intermittency, weak stream, straining, incomplete emptying, and post-void dribbling.

Storage symptoms include urinary frequency, nocturia, and urgency.

It can be useful to ask the patient to complete a frequency/volume chart for 3 days or more if they report significant nocturia because this can be a useful tool in detecting polyuria, which may then be targeted for reduction by limiting fluid and/or caffeine intake.

  1. When Conducting a Physical Examination, Include a Digital Rectal Examination

As part of the physical examination, a digital rectal examination (DRE) should be carried out to determine anal sphincter tone, estimate the size of the prostate, and assess for prostate nodules or rectal masses by examining the prostate’s symmetry, firmness, and tenderness. It can also be helpful to check the pelvic floor muscles to assess for dysfunction, especially in men presenting with pain as their primary complaint. Clinicians should not forget to palpate the bladder and inspect the external meatus. The prostate gland should be smooth and firm (not hard), with a clearly defined median sulcus; a hard, nodular gland with no palpable sulcus suggests malignancy.

  1. Undertake Necessary Routine Investigations for BPH

In the initial assessment of BPH, it is important that clinicians conduct dipstick urinalysis and collect a midstream specimen of urine (MSU) to check for glycosuria, proteinuria, haematuria, and infection. Routine blood tests include a full blood count, urea and electrolytes, creatinine, liver function, and PSA. It should be remembered that normal PSA levels alter with age; although there is debate about whether to test for PSA in men over 70 years old or for whom life expectancy is below 10–15 years, both the American Urological Association (AUA) and EAU guidelines suggest that serum PSA can be helpful for treatment options (primarily as a rough indicator/surrogate for prostate size).

Although using a combination of DRE and PSA testing may be the best initial way to distinguish between a benign and a malignant prostate gland, the evidence for this approach is poor. Clinicians should inform patients before testing that there is debate regarding the morbidity and mortality reduction of prostate cancer with PSA testing. Gentle DRE is unlikely to raise PSA test results.

  1. Do Not Delay Referral to Urology, When Appropriate

In 2023, NICE updated its guidance on suspected cancer recognition and referral. The guidance highlights that clinicians should refer people with possible symptoms of prostate cancer, recommending PSA testing and DRE to assess for prostate cancer in men with:

  • LUTS, such as nocturia, urinary frequency, hesitancy, urgency, or retention
  • erectile dysfunction
  • visible haematuria.

Referral should be made if a patient has:

  • a prostate that feels malignant on DRE
  • PSA levels above the threshold defined for their age in the guidance
  • age 45 years or over with visible haematuria that is either unexplained or persists or recurs after successful treatment of urinary tract infection (UTI)
  • age 60 years or over with:
    • unexplained nonvisible haematuria, and
    • either dysuria or a raised white blood cell count
  • age 60 years or over with recurrent or persistent unexplained UTI.

Further Investigations in Secondary Care

Other investigations that are typically carried out in secondary care include the assessment of urine flow rate, which serves as a baseline before embarking on any treatment. Imaging may also be necessary if there is any suggestion of urinary tract obstruction, and ultrasound examination of the prostate may assist in the choice of medical therapy for a patient. Because DRE is unreliable in estimating prostate size and serum PSA is not accurate, the AUA guideline recommends prostate imaging, particularly before surgical interventions; prostate size may inform the intervention considered.

  1. Discuss and Offer a Wide Range of Medical Treatments

Alpha-Blockers as Initial Therapy

It is standard practice to offer an alpha-blocker as initial therapy for most patients; phosphodiesterase-5 (PDE-5) inhibitors are a viable alternative or adjunct, particularly in patients who also have erectile dysfunction (for which they are a first-line treatment option). Long-acting alpha-1 blockers include terazosin, doxazosin, and tamsulosin, and alfuzosin is a short-acting alpha-1 blocker that is available as a modified-release formulation. Alpha-blockers work quickly and are usually well tolerated, although there is an increased risk of falling and fracture in men taking them, as well as an increased risk of hypotension and head trauma. Because of the increased risk of intraoperative floppy iris syndrome, it is recommended that alpha-blockers are not initiated in those planning to undergo cataract surgery, and that patients are informed of the associated risk.

5-Alpha-Reductase Inhibitors

Five-alpha-reductase inhibitors, such as dutasteride or finasteride, can be used as initial monotherapy in patients with large prostates and are effective in reducing prostate size, lowering acute urinary retention risk, and reducing the need for invasive surgery. Owing to their slow-action onset, they should be continued for many years (if tolerated). In patients with large prostates and symptom progression, 5-alpha-reductase inhibitors can be added to alpha-blocker therapy. Patients should be advised that 5-alpha-reductase inhibitors have the potential to impair sexual function.

Phosphodiesterase-5 Inhibitors

PDE-5 inhibitors may improve LUTS, erectile function, and quality of life. Tadalafil is currently the only PDE-5 inhibitor that is licensed for both BPH and erectile dysfunction. PDE-5 inhibitors in combination with alpha-blockers have been shown to improve flow rate compared with alpha-blockers alone, and the AUA recommends low-dose daily 5 mg tadalafil with alpha-blockers for the treatment of LUTS in BPH.

Anticholinergic Therapy and Beta-3 Adrenergic Agonists

Anticholinergic therapy such as oxybutynin or solifenacin—alone or in combination with an alpha-blocker—may help to reduce symptoms in men with moderate-to-severe LUTS and bladder storage symptoms. Beta-3 adrenergic agonists such as mirabegron can also be offered to patients with moderate-to-severe, predominantly storage LUTS, in combination with an alpha-blocker.

For further information on contraindications, cautions, drug interactions, and adverse effects, consult the Electronic Medicines Compendium or the British National Formulary.

  1. Consider No Treatment and Lifestyle Changes as Treatment Options

In people with minimal symptoms (that is, with an IPSS score under 7), ‘watchful waiting’—involving careful, regular monitoring of any symptoms—may be a preferred treatment option, provided that prostate cancer and other diagnoses that may cause LUTS and require additional tests have been excluded. Reassurance, monitoring, and education are essential if this approach is taken.

Treatment options for patients with bothersome, moderate (an IPSS score of 8–19), and severe (an IPSS score of 20–35) symptoms of BPH also include ‘watchful waiting’ as well as lifestyle modification and medical, minimally invasive, or surgical therapies. Lifestyle changes, such as those seen in Box 2, may be sufficient to treat patients with mild symptoms that do not bother them unduly.

Lifestyle Changes Suggested for Patients with Non-Bothersome Symptoms

  • Fluid restriction, particularly to reduce urinary frequency at inconvenient times (e.g. prior to bedtime)
  • Bladder retraining (i.e. timed or organised voiding)
  • Avoidance and treatment of constipation
  • Avoidance of food and drink that could have diuretic effects, e.g. caffeinated beverages, alcohol, and spicy foods
  • Avoidance or monitoring of certain drugs that can exacerbate symptoms (e.g. antihistamines, antidepressants, diuretics, decongestants), or substituting them for alternatives with fewer urinary effects
  • Pelvic floor physical therapy (e.g. Kegel exercises, urge suppression), particularly when the patient has:
    • suspected nonrelaxing pelvic floor dysfunction (which causes LUTS, pelvic and or genital pain, bowel and sexual dysfunction, etc.)
    • overactive bladder and/or urinary incontinence
  • Weight loss
  • Prevention/treatment of conditions association with the metabolic syndrome, e.g. type 2 diabetes.

LUTS=lower urinary tract symptoms

Monitoring Treatment

Regardless of the treatment pathway taken, there should be regular review of the patient to assess progress, symptoms, and potential adverse effects. This is because of the natural tendency for symptoms of BPH to worsen over time.

  1. Be Aware That Surgical Treatment Options Are Developing Rapidly

Surgery is typically reserved for men with a large prostate gland causing symptoms, or for whom medical treatment has failed. Patients should be referred to a urologist for surgery for LUTS/BPH if they have BPH complications (such as renal insufficiency, recurrent bladder stones or UTIs, gross recurrent haematuria, or urinary retention), have refractory responses to medication, do not wish to take medication, or experience unacceptable side effects.

There are various surgical treatment options, including:

  • transurethral resection of the prostate (TURP)—this is the standard procedure for men with prostate sizes 30–80 g and bothersome LUTS due to BPH. This procedure is also the historical standard against which all other surgical approaches are compared. However, there is an increased risk of bleeding compared with other procedures, along with unwanted sexual side effects
  • simple prostatectomy—patients with large-to-very-large glands are often treated with open, laparoscopic, or robotic-assisted prostatectomy
  • transurethral vaporisation of the prostate (TUVP)—this uses the same type of electro diathermy device as for TURP but can be used at lower temperatures, with subsequent reduced blood loss in comparison with TURP
  • the prostatic UroLift® system, which may be offered to patients who want to preserve erectile and ejaculatory function
  • water vapour thermal therapy (Rezum)—approved by NICE for treating LUTS secondary to BPH, this therapy uses water vapour to destroy excess prostate tissue, is carried out as a day case, and is cheaper than standard treatments such as TURP
  • transurethral incision of the prostate (TUIP)—offered to patients with a prostate size smaller than 30 g who are unwilling or unfit to have more invasive surgery. TUIP is associated with lower rates of retrograde ejaculation and need for blood transfusion compared with TURP but has a higher symptom recurrence rate.

New techniques, such as prostate artery embolisation, are still being assessed for efficacy and safety.

Summary 

BPH is a common condition affecting the male population that occurs with increasing age and can significantly impact patients’ everyday lives. It is essential that primary care practitioners are able to effectively diagnose and manage symptoms, while also considering the impact that BPH can have on quality of life.

Key Points

  • BPH is a condition in which the prostate and surrounding tissue enlarge and cause problems associated with the lower urinary tract
  • Symptom severity can be assessed using the IPSS, a self-administered questionnaire with eight questions (seven scoring symptom severity and one scoring quality of life)
  • Taking a detailed medical history is important to assess BPH, with a focus on voiding and storage symptoms
  • Physical examination should include a DRE to assess anal sphincter tone, prostate nodules, and rectal masses
  • Routine blood tests should assess full blood count, urea and electrolytes, creatinine, liver function, and PSA
  • Other investigations for BPH include dipstick urinalysis and an MSU to check for glycosuria, proteinuria, haematuria, and infection
  • Referral for suspected cancer should occur at an early stage
  • Offer an alpha-blocker as initial therapy for most patients, as they are generally better tolerated; 5-alpha-reductase inhibitors can be added to alpha-blocker therapy or offered alone
  • PDE-5 inhibitors may improve LUTS, erectile function, and quality of life; they can also be combined with an alpha-blocker
  • Anticholinergic therapy—alone or in combination with an alpha-blocker—may help to reduce symptoms in men with moderate-to-severe LUTS and bladder storage symptoms
  • Beta-3 adrenergic agonists, such as mirabegron, may also be offered in combination with an alpha-blocker to patients with moderate-to-severe LUTS with predominantly storage symptoms
  • In people with minimal symptoms (an IPSS score under 7), or unbothersome symptoms, ‘watchful waiting’, lifestyle modifications, and regular monitoring may be the optimal treatment options, provided that prostate cancer and other possible serious causes of symptoms have been excluded
  • Patients should be referred to a urologist for surgery for LUTS/BPH if they have BPH complications or have refractory responses to medication, do not wish to take medication, or experience unacceptable drug side effects.

BPH=benign prostatic hyperplasia; IPSS=International Prostate Symptom Score; DRE=digital rectal examination; PSA=prostate-specific antigen; MSU=midstream specimen of urine; PDE-5=phosphodiesterase-5; LUTS=lower urinary tract symptoms

Note: At the time of publication (June 2024), some of the treatments discussed in this article did not have UK marketing authorisation for the indications discussed. Prescribers should refer to the individual summaries of product characteristics for further information and recommendations regarding the use of pharmacological therapies. For off-licence use of medicines, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.