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Benign Prostatic
Hyperplasia

Description/Etiology
Benign prostatic hyperplasia (BPH) is a nonmalignant condition in which excessive smooth muscle and
epithelial cell proliferation results in an enlarged prostate gland that constricts or deforms the lower urinary tract
and causes difficulty with urination. BPH occurs primarily in older men, affecting 50% of men over the age of
60 and 80% of men over the age of 70. BPH is rare in men under the age of 40.
Although the etiology of BPH is not fully understood, animal studies suggest age-related sex hormone
imbalances involving testosterone, estrogen, and dihydrotestosterone (DHT) may cause enlargement of prostatic
tissues, causing the gland to compress the urethra and even protrude into the bladder neck, resulting in urinary
outlet irritation, obstruction, and urinary retention. Hypothesized etiologies suggest prostate cell growth due to
reactivation of genes in the prostate cells and a role of impaired catechol-o-methyl transferase gene activity.
Complications of BPH include bladder stones, prostatitis, hematuria, urinary retention, and renal failure. BPH is
diagnosed based on patient history and a variety of tests, including digital rectal examination (DRE), prostatespecific antigen (PSA) blood test, ultrasound, and prostate biopsy. BPH must be differentiated from prostate
cancer (CaP), urinary tract infection (UTI), prostatitis, urethral stricture, overactive bladder, neurogenic bladder,
bladder cancer, poorly controlled diabetes, and neurologic conditions that produce neurogenic bladder and bladder
symptoms (e.g., Parkinsons disease, diabetic autonomic neuropathy, multiple sclerosis, spinal cord injury).
Treatment options for BPH include surgery and use of pharmacologic agents such as non-selective or selective
alpha-adrenergic blockers, to help relax the smooth muscle tissue of the prostate and bladder neck, improving
urinary flow; 5-alpha reductase inhibitors to reduce prostate size; stool softeners for constipation; analgesics for
pain; muscle relaxants to reduce pelvic muscle spasms; and antibiotics for infection. Surgical procedures include
transurethral resection of the prostate (TURP) and suprapubic or retropubic prostatectomy. Minimally invasive
surgical procedures include holmium laser ablation of the prostate, transurethral vaporization of the prostate,
interstitial laser coagulopathy, high-frequency focused ultrasound, transurethral needle ablation, transurethral
microwave thermoplasty, transurethral balloon dilatation therapy, transurethral ethanol ablation, and water-induced
thermoplasty. (For more information, see Quick Lesson AboutProstatectomy, Benign Prostatic Hypertrophy.)
The overall prognosis is fairly good, as treatment stabilizes symptoms in 7080% of cases.

ICD-9
600.90

Authors
Gilberto Cabrera, MD
Tanja Schub, BS

Facts and Figures

BPH is the most common cause of urinary tract obstruction in older men, affecting ~ 14 million men in the
United States and 30 million men worldwide. Evidence for racial predisposition is not supported. In the U.S.
in 2000, BPH accounted for $1.1 billion in health care costs, 4.4 million physician visits, 117,000 emergency
department visits, and 105,000 hospitalizations. Up to 33% of men with BPH have CaP, and 83% of CaP cases
develop in men who also have BPH.

Reviewers
Sara Grose, MSN, RN, PHN, CNL, CLE
Medical Writer
Cinahl Information Systems
Glendale, California
Eliza Schub, BSN, RN
Cinahl Information Systems
Glendale, California
Nursing Practice Council
Glendale Adventist Medical Center
Glendale, California

Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems

Risk Factors
Risk factors include advanced age, intact testes, and family history of BPH. Abdominal obesity is a possible
risk factor. The risk for complications increases proportionally with the amount of enlargement.

Signs and Symptoms/Clinical Presentation

Obstructive symptoms include urinary hesitancy or retention, decreased force and caliber of the urine stream,
sensation of incomplete bladder emptying, straining to urinate, and post-void dribbling. Irritating symptoms
include urinary urgency, frequency, and nocturia.

Assessment

44 Patient History
Ask the patient about history of urinary dysfunction and family history of BPH

44 Physical Findings of Particular Interest

DRE may reveal smooth, firm, elastic enlargement of the prostate

Physical examination may reveal bladder distention and neurological dysfunction (e.g., sensory
September 10, 2010

and/or motor)

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general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

44 Laboratory Tests That May Be Ordered

PSA levels may be elevated in BPH and CaP

Serum chemistry studies may reveal serum blood urea nitrogen (BUN) and creatinine levels
UA and urine culture to evaluate for UTI, prostatitis, hematuria, and pyuria
Histopathologic testing of biopsied prostate tissue is negative for malignancy in BPH

Pressure flow studies and flow rate test to assess for urinary flow abnormalities
Transrectal ultrasound to assess prostate size; abdominal ultrasound to assess for hydronephrosis or increased post-void residual
Cystoscopy to assess for renal obstruction
Chest X-ray and EKG to evaluate pre- and postoperative pulmonary and cardiac status

44 Other Diagnostic Tests

Treatment Goals

44 Provide Supportive Care During Treatment and Monitor for Complications

Assess all physiologic systems and review laboratory/diagnostic study results for abnormalities; assess for pain, voiding dysfunction, infection,
and constipation
Administer antibiotics for infection, nonselective alpha-adrenergic blockers (e.g., doxazosin, terazosin), selective alpha-adrenergic blockers
(e.g., terazosin, tamsulosin) to help relax the bladder, 5-alpha reductase inhibitors (e.g., finasteride, dutasteride) to reduce size of enlarged
prostate, stool softeners and laxatives for constipation and to reduce straining, muscle relaxants to reduce pelvic muscle spasms, and
analgesics (e.g., ibuprofen, aspirin) for pain
Insert an indwelling urinary catheter if ordered for urinary retention/obstruction and ensure meticulous hygiene; monitor catheter patency and
urine collection, and avoid rapid bladder decompression
Follow facility pre- and postsurgical protocols if patient becomes a surgical candidate; reinforce pre- and postsurgical education and ensure
completion of facility informed consent documents
Monitor closely for complications following surgical intervention (e.g., septic shock, renal failure, heart failure)
Monitor vital signs, intake and output, nutritional and respiratory status, response to treatment, and for medication side effects; ensure bed rest
and adherence to a fluid restrictive diet, and provide sitz baths for comfort, as ordered

44 Educate and Provide Emotional Support

Assess patients anxiety level and coping ability; express empathy, and educate about BPH, potential complications, and treatment risks and benefits

Food for Thought

44 Although sexual function is initially affected in some cases after surgery for BPH, it generally returns fully with time. Retrograde ejaculation (i.e.,
semen entering the bladder instead of exiting through the urethra during ejaculation), which can cause sterility, occurs rarely
44 Some men with BPH use alternative treatments (e.g., herbs such as saw palmetto, African plum tree, rye), although their effectiveness has not
been proven
44 Botulinum A toxin injections effectively reduce BPH symptoms and may be considered for patients who are poor surgical candidates or who
experience continued symptoms in spite of the conventional pharmacologic regimen
44 Improvement in medical management of BPH has resulted in an average 1015-year delay in the need for surgery, but has not eliminated it entirely

Red Flags
44 Avoid checking for fecal impaction, as a rectal examination may precipitate bleeding
44 Some alpha-adrenergic blockers (e.g., alfuzosin, doxazosin, terazosin) produce a vasodilatory effect that has been associated with increased risk for
developing vascular adverse events (e.g., presyncope, syncope)

What Do I Need to Tell the Patient/Patients Family?

44 Advise the patient to increase water intake to flush the bladder, avoid straining during bowel movements, eat a nutritious diet but avoid spicy foods,
avoid alcoholic or caffeinated drinks, avoid heavy lifting, and avoid driving or operating heavy machinery
44 Emphasize the importance of continued medical surveillance, including PSA screening
44 Educate to seek immediate medical attention for new or recurrent urinary symptoms, surgical complications, or medication side effects
44 Recommend finding additional information from the National Kidney and Urologic Diseases Clearinghouse (NKUDIC) at www.kidney.niddk.nih.gov

References

Auffenberg, G. B., Helfand, B. T., & McVary, K. T. (2009). Established medical therapy for benign prostatic hyperplasia. Urologic Clinics of North America, 36(4), 443-459.
Bushman, W. (2009). Etiology, epidemiology, and natural history of benign prostatic hyperplasia. Urologic Clinics of North America, 36(4), 403-415.
Longstroth, D., & Cyr, P. R. (2010). Prostatic hyperplasia, benign (BPH). In F. J. Domino (Ed.), The 5-minute clinical consult 2011 (19th ed., pp. 1068-1069). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Rosenberg, M. T., Miner, M. M., Riley, P. A., & Staskin, D. R. (2010). STEP: Simplified Treatment of the Enlarged Prostate. International Journal of Clinical Practice, 64(4), 488-496.
Thorner, D. A., & Weiss, J. P. (2009). Benign prostatic hyperplasia: Symptoms, symptom scores, and outcome measures. Urologic Clinics of North America, 36(4), 417-429.