Applied Evidence

What’s best for your patient with BPH?

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Let symptom scores and patient preferences guide your level of work-up and your treatment approach.



Practice recommendations
  • Watchful waiting is recommended for patients with benign prostatic hyperplasia (BPH) whose clinical symptoms do not affect their quality of life (B).
  • Use a validated patient questionnaire, such as the American Urological Association’s Symptom Index, to establish the severity of BPH symptoms and follow their progression (B).
  • α-Adrenergic blockers (either selective or nonselective) or 5-α reductase inhibitors are appropriate first-line therapies for patients bothered by BPH symptoms (A).
  • Consider surgery for patients with severe obstructive symptoms who have not benefited from medical therapy or who prefer surgery as first-line treatment (A).

Strength of recommendation (SOR)

  1. Good-quality patient-oriented evidence
  2. Inconsistent or limited-quality patient-oriented evidence
  3. Consensus, usual practice, opinion, disease-oriented evidence, case series

By age 60, more than half of men have histopathologic benign prostatic hyperplasia (BPH).1 And, given the publicity BPH is receiving today, it’s quite possible that those who are experiencing symptoms will be less reticent to discuss it than before.

So what does the evidence tell us about how to best manage these patients? Specifically, do you know what the minimal assessment is for those who are experiencing symptoms? When might advanced testing methods be helpful?

Furthermore, among men who are now 50 years old, the expected lifetime incidence for any type of surgical intervention for BPH is approximately 35%.2 What are the first-line treatments available to these patients? Who might be a candidate for combination drug therapy? Are herbal preparations worth considering? When might surgery be a first choice?

These questions underscore the importance of a proper primary care framework for evaluating and treating BPH, which we can develop based on a consensus guideline released by the American Urological Association (AUA)1 and on more recent research.

Assessing symptoms: 2 tools can help

Symptoms of BPH can include urinary frequency, nocturia, urgency, hesitancy, weak or intermittent urine stream, straining to void, and a sensation of incomplete voiding.1 Each patient experiences a unique constellation of these symptoms. Using a urinary symptom scoring system can help define the severity of BPH and be useful in monitoring the success of subsequent therapy. Available instruments for this purpose include the AUA’s 7-question Symptom Index for BPH ( and the International Prostate Symptom Score, which adds an eighth question to the AUA list to gauge the extent to which symptoms bother a patient ( If the patient is unclear about the pattern of his symptoms, consider asking him to keep a voiding diary.

Ruling out other causes of BPH-like symptoms

TABLE 1 lists the differential diagnoses of obstructive urinary symptoms, otherwise known as lower urinary tract symptoms (LUTS).

Look for clues in the history. Ask the patient whether he uses medications known to cause obstructive urinary symptoms—tricyclic antidepressants, first-generation antihistamines, anticholinergic agents, diuretics, narcotics, and decongestants. Does he have any first-degree relatives with prostate cancer? If the answer is yes, how young was he when the cancer was diagnosed?

Focus your examination. Perform a digital rectal examination (DRE) to check prostate size and to detect palpable nodules, induration, or irregularities associated with malignancy or infection. An enlarged prostate is commonly found on rectal examination; however, the degree of hypertrophy does not necessarily correlate with the degree of obstruction or the severity of symptoms. Any irregularity suggestive of cancer requires that you talk to your patient about his preferences for further investigation.6

Conduct a neurologic exam to check mental status, gait, lower extremity strength, and anal sphincter tone to assess for conditions that could cause a neurogenic bladder.

Lower urinary tract symptoms are also seen with these disorders31

Bladder calculiHematuria, ultrasonography finding
Bladder neck dyssynergiaLUTS in younger patients with normal prostate size,
diagnosed by cystoscopy or VCUG
Overactive bladderUrgency with possible urge incontinence
Prostate cancerFinding in DRE, elevated serum PSA
ProstatitisTender prostate gland
Stricture of the bladder neckPrior invasive treatment
Urinary bladder cancerHematuria, abnormal cytological finding
Urethral strictureBox-shaped flow curve on urinary flow-rate measurement
DRE, digital rectal examination; LUTS, lower urinary tract symptoms; PSA, prostate-specific antigen; VCUG, voiding cystourethrogram.

Consider these tests. Urinary tract infection (UTI) or bladder cancer may produce symptoms similar to those of BPH. For any patient who has LUTS, perform a urinalysis to screen for infection or hematuria. If a UTI is found, treat it and re-evaluate the patient. If you detect microscopic hematuria, do a further work-up to rule out bladder cancer. If DRE findings are suggestive of prostate cancer, you’ll need an ultrasound-guided biopsy and histological examination to make the diagnosis.

Optional tests in the work-up of LUTS include urinary flow rate measurements, post-void residual urine measurements, and pressure flow studies. These tests may be informative if the diagnosis is unclear based on the history and physical exam or when patients do not respond to initial therapy. Ultrasonography, intravenous pyelography, filling cystometrography, and cystoscopy are not routinely recommended for the evaluation of suspected BPH. However, they may be helpful if a patient has a complex medical history (eg, neurologic disorder or other disease known to affect bladder function, or prior failure of BPH therapy), or if he wants to pursue invasive therapy.1


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