© The Canadian Journal of Urology™; 19(Supplement 1); October 2012
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Benign prostatic hyperplasia (BPH) management in the primary care setting
incidence and clinical manifestations of BPH, and
discuss how to diagnose and treat patients with BPH.
Background
Incidence and epidemiology
BPH is relatively common in men and symptoms can
start as early as age 30. By the age of 50, up to 50% of
men exhibit histologic evidence of BPH symptoms and
these symptoms tend to increase with age.
2
Clinical manifestations
BPH symptoms are generally referred to as “lower
urinary tract symptoms” or LUTS, and these can
be subdivided into voiding symptoms and storage
symptoms, as shown in Figure 1. Voiding symptoms
include hesitancy, intermittency, straining, dribbling,
and the decreased caliber of the urine stream. Storage
symptoms include frequency, urgency, and nocturia.
The severity of BPH can be measured by using
the International Prostate Symptom Score (IPSS)
questionnaire,
3
which includes seven questions about
urinary symptoms and an eighth, quality-of-life (QOL)
question that asks how much the patient is bothered
by these symptoms. Although most symptoms can
be attributed directly to the prostatic hyperplasia that
constricts the flow of urine, about 30% of men have
concurrent bladder detrusor overactivity, or overactive
bladder (OAB). These men will therefore require
therapy for OAB in addition to treatment for BPH.
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Cause
Outflow obstruction from BPH is caused by increased
prostate growth and large size, as well as by increased
smooth muscle tone of the prostate.
The main mediator of prostatic growth is
dihydrotestosterone (DHT), ametabolite of testosterone
that is formed in the prostate cell by the breakdown of
testosterone. The enzyme 5-alpha reductase converts
testosterone to DHT. This enzyme is the target of drug
therapy—the 5-alpha reductase inhibitors (5-ARIs),
such as finasteride and dutasteride—that aim to reduce
the size of the prostate.
Diagnosis
The diagnosis of BPH is derived from the patient’s
medical history—including the IPSS questionnaire—
and a physical examination of the prostate—that
is, a digital rectal examination (DRE). Taking the
patient’s medical history should include taking a
detailed analysis of voiding symptoms, Figure 1.
The IPSS questionnaire quantifies each of seven
Figure 1.
Symptoms of benign prostatic hyperplasia.
