Benign prostate hyperplasia(BPH)

Reporter: FM R1 余明謙

Supervisor: VS 張德宇
• Introduction

• Clinical presentation

• Evaluation

• Management

• Summary
Introduction
• Benign prostatic hyperplasia (BPH) is a histologic diagnosis
that refers to the proliferation of glandular epithelial tissue,
smooth muscle, and connective tissue within the prostatic
transition zone
• worldwide autopsy-proven histological prevalence starting at
age 40 to 45 years, reaching 60 percent at age 60, and 80
percent at age 80 

• 但由於 BPH 在臨床上並無一個標準化的定義，加上研究方式

及工具的不同，因此 BPH 的盛行率有很大差異。

• 攝護腺體積大小與臨床症狀並無絕對相關，但它的臨床症狀與
病人的生活品質息息相關。 65 歲以上的男性，有將近 30 ％
的人被下泌尿道症狀所困擾
• Introduction

• Clinical presentation

• Evaluation

• Management

• Summary
Clinical presentation
• Benign prostatic hyperplasia (BPH) can be asymptomatic

• When symptomatic, BPH presents with lower urinary tract

symptoms (LUTS)

Storage (irritative) Voiding symptoms

symptoms
• 尿柱變細或尿流無力
• 頻尿 (Urinary (weakstream)
frequency) • 尿遲滯 (hesitancy)

• 尿急感 (Urgency) • 排尿斷績 (intermlttency)

• 夜尿次數增多 (nocturia) • 尿解不乾淨 (incompleteempty)

• 尿失禁 (incontinence) • 用力解尿 (strainig)

Symptom questionnaires - AUA Symptom Index 
International Prostate Symptom Score (IPSS)
• The IPSS additionally includes disease-specific quality of life question
• Introduction

• Clinical presentation

• Evaluation

• Management

• Summary
Evaluation

• Detailed medical history 

• Focused physical examination

• Differential diagnosis

• Laboratory tests

• Additional tests for selected patients

History 
• Evaluation of LUTS: storage symptoms and voiding symptoms

• Excluding etiologies other than BPH

 history of fever, dysuria, pain suggestive of stones
 Gross hematuria or pain in the bladder region, which may
be suggestive of a bladder calculi or cancer
 History of urethral trauma, urethritis, or urethral
instrumentation that could lead to urethral stricture
 Underlying neurologic disease(neurogenic bladder)

 Cigarette smoking(a risk factor for bladder cancer)

 personal or family history of prostate or bladder cancer
• Symptoms of hematuria, incontinence, or urinary retention
should prompt urology referral
History 
• Identification of medication use
• Comorbidities (EX: CHF, Diabetes….)  
Physical examination
• 重點式的神經學檢查
整體精神狀態（ mental status ）、活動狀態（ ambulatory
status ）、下肢肌肉神經功能及肛門括約肌張力

• 肛門指診（ digital rectal examination, DRE ）

 To estimate prostate size, a normal prostate is approximately
the size of a walnut (between 7 to 16 grams) and firm and
nontender
 Identify other abnormalities
 An exquisitely tender prostate gland may reflect the presence
of prostatitis
 Asymmetry or nodules raises suspicion for malignancy
 Decreased sphincter tone or absence of perineal sensation
may suggest a neurologic etiology
DIFFERENTIAL DIAGNOSIS
• Urologic causes of obstruction – Urethral stricture, bladder neck
contracture, and prostate cancer
• Other urologic conditions – Urinary infections and bladder cancer
• Non-urologic conditions 
 Cardiovascular disease – Heart failure, peripheral vascular
disease, or cardiac dysfunction may worsen LUTS due to diuresis
 Neurologic disease – Patients with Parkinson disease or a history of
stroke frequently develop voiding dysfunction.
 Endocrine disease – Longstanding, poorly controlled diabetes mellitus
leads to decreased bladder sensation, decreased detrusor contractility,
and incomplete bladder emptying.
 Polydipsia –Information about the fluid type and timing of intake relative
to symptom onset, the use of a voiding diary, and the lack of obstructive
symptoms are helpful in uncovering this relationship.
Laboratory tests
• Obtain urinalysis in all patients being evaluated for BPH/LUTS. The
purpose is to identify pyuria, glucosuria, proteinuria, ketonuria, or
bacteruria, which may be signs of alternative diagnoses and thus
warrant further evaluation. 
 Although mild hematuria may occur with BPH, the finding of
hematuria requires further evaluation
 A urine culture is not needed unless there is other evidence
to suggest a urinary tract infection 

• Serum creatinine is not needed unless there is evidence to

suggest renal impairment (ie, high post-void residual [PVR])

• The routine use of urine cytology in the setting of LUTS and a

normal urinalysis should be avoided
Laboratory tests- PSA
• 臺灣國家衛生研究院前列腺癌研究委員會及美國癌症協會
(American Cancer Society) 建議男性 50 歲以上，有攝護腺癌
家族史者 45 歲 以上應接受 PSA 檢查
• The AUA recommends a serum PSA measurement in men with
lower urinary tract symptoms and a life expectancy greater
than 10 years(Update on AUA guideline on the management
of benign prostatic hyperplasia. J Urol. 2011)
• shared decision-making for men age 55 to 69 years that are
considering PSA screening(USPSTF)

• PSA should be measured prior to initiation of 5ARI

 such treatment may lower PSA levels
 only useful in men whose prostates are above 35 grams,
which correlates with a PSA >1.5 ng/dL
Additional tests for selected patients
• Post-void residual volume measurement 
 While evidence is limited, multiple organizations and their
guidelines include PVR measurement as part of the basic
evaluation of LUTS
 should be performed if history and physical examination suggest
urinary retention(AAFP)

 A rising PVR (normal residual urine is less than 100 mL) can
indicate medication failure and the need for surgical
intervention, or further workup may be warranted
Additional tests for selected patients
• Prostate imaging
 Transrectal ultrasound/CT/MRI is not needed for diagnosis
 Size of the prostate gland does not correlate with the
severity of LUTS
 It is indicated when the treatment choice of LUTS/BPH is
dependent on total prostate volume, as in the use of 5ARIs, or
in the choice of certain surgical techniques
• Cystoscopy 
 It should be considered in men with a history suggestive
of a urethral stricture or bladder neck contracture 
 urologists also routinely perform cystoscopy to assist in
planning surgical treatment of men with BPH.
Additional tests for selected patients
• Uroflowmetry
 office-based procedure

 consider uroflowmetry prior to intervention for LUTS/BPH

 help support the diagnosis of BPH by documenting
obstruction (flow rates of <10 mL/s)

• pressure flow studies (PFS)

 Invasive procedure
 consider pressure flow studies prior to intervention for LUTS/BPH
when diagnostic uncertainty exists. (eg, peak urinary flow [Qmax]
>10 mL/sec)
 help differentiate urinary retention related to detrusor
underactivity, detrusor sphincter dyssynergia, or obstruction
due to prostatic enlargement
• Introduction

• Clinical presentation

• Evaluation

• Management

• Summary
Management- General considerations
• Lifestyle modifications and behavioral interventions are first-
line treatments for all patients
• Watchful waiting(monitored annually) is recommended in
men who have mild symptoms (AUA Symptom Index score
<=7) or who do not perceive their symptoms to be particularly
bothersome

• Men presenting with bothersome, moderate to severe BPH

symptoms may be treated with lifestyle modifications,
medications, or surgery

• Regardless of symptoms, complicated lower urinary tract

symptoms (suspicious DRE findings, hematuria, abnormal PSA
findings, recurrent infection, distended bladder, or neurologic
disease) should prompt a referral to urology
Management- Medical therapy
• Men with LUTS/BPH can be treated with one or more classes of
medications and, in general, should try medical treatment prior
to considering surgical interventions
• For most patients, we initiate monotherapy with an alpha-1
adrenergic antagonist
• In men who have concomitant erectile dysfunction, PDE5
inhibitors are a reasonable alternative
• In men with low post-void residual urine volumes and
irritative symptoms, anticholinergics or beta-3 agonists are
a reasonable alternative
• In men with demonstrated benign prostatic enlargement
(BPE), treatment with 5-alpha reductase inhibitors (5ARIs) to
prevent disease progression is a reasonable option
Alpha-adrenergic receptor blockers
作用機轉

• 甲型腎上腺素受體分為 lA﹑lB 及 lD 三種亞型，攝護腺和膀胱

頸平滑肌主要是 lA 亞型，而 lB 亞型常見於血管平滑肌上。

• 此類藥物的作用機轉是抑制攝
護腺和膀胱頸平滑肌收縮，減
低膀胱出口阻塞，進而改善下
泌尿道症狀和尿流速度。
Alpha-adrenergic receptor blockers
臨床效益

• 研究顯示服用藥物後 48 小時病患就可感受到症狀改善，如
果超過一個月仍未改善就應重新評估

• 改善整體症狀約 30-40% ，尿流速度進步約 16-25%

• Equal efficacy across all alpha blockers, with no particular subset

of patients more or less suited for such treatment( AUA 2021)
Alpha-adrenergic receptor blockers
Side effects
• 非選擇性的甲型腎上腺素阻斷劑如 doxazosin 、
terazosin ，應注意姿勢性低血壓、頭暈、疲倦等副作用，睡
前低劑量開始給藥可減少副作用的發生

• The agents with greater prostate selectivity (eg, tamsulosin, silodosin

) have fewer systemic adverse effects but are associated with a
higher frequency of retrograde or anejaculation (8 to 28 percent)

• Patients prescribed alpha-1 adrenergic blockers should be

counseled about the possibility of intraoperative floppy iris
syndrome (IFIS)
Alpha-adrenergic receptor blockers
5-alpha reductase inhibitors
作用機轉
• 5ARIs block the conversion of testosterone (T) to
dihydrotestosterone (DHT)
5-alpha reductase inhibitors
臨床效益

• 相較於 Alpha-adrenergic receptor blockers ， 5ARIs 在改

善症狀的效果較緩慢且較不顯著，但可以減少 BPH 患者發生
急性尿滯留或需要接受攝護腺手術的可能性

• 使攝護腺體積 縮小 20-30% ，症狀改善約 15% ，尿流速度進

步約 1.3-1.6 毫升 / 秒

• Results from the Medical Therapy of Prostatic Symptoms (MTOPS)

study support the utility of 5ARIs in prostates larger than 35 g.
The larger the prostate, the bigger the impact of this class of
agents

• The reduction in prostatic volume by 5ARIs may take many

months, with the maximum effect in symptom relief seen typically
after 6 to 12 months
5-alpha reductase inhibitors
Side effects

• 根據 PLESS 研究，常見的副作用有性慾減低（ 6.4% ），

勃起功能障礙 （ 8.1% ），射精量減少（ 3.7% ），不到
1% 的患者有皮膚疹、乳房腫脹、疼痛

• 可逆性，且在第一年後就較少發生

• The use of 5ARIs suppresses serum PSA levels by about 50

percent. For this reason, baseline serum PSA should checked
prior to using any 5ARIs. 

• Most experts recommend multiplying PSA value by two in

patients receiving long-term (>3 months of continuous treatment)
5ARI therapy.
5-alpha reductase inhibitors
5-alpha reductase inhibitors
健保規定
Phosphodiesterase type 5 inhibitors
• For patients with LUTS/BPH irrespective of comorbid erectile
dysfunction (ED), 5mg daily tadalafil should be discussed as a
treatment option. (AUA, Moderate Recommendation; Evidence
Level: Grade B)

• Beneficial in improving symptom scores in patients with

LUTS/BPH, although no significant changes in urine flow rates

• commonly reported effects consisting of headache, flushing,

dyspepsia, nasal congestion, back pain, myalgias, and sinusitis.

• There is an increased risk of hypotension in patients also using

certain alpha-adrenergic blockers(terazosin and doxazosin)
Anticholinergic agents
• Anticholinergic agents, alone or in combination with an alpha
blocker, may be offered as a treatment option to patients with
moderate to severe predominant storage LUTS (AUA, Conditional
Recommendation; Evidence Level: Grade C)

• Due to the concern that these drugs may increase the risk of acute
urinary retention, a post-void residual should be measured prior to
initiating treatment with an anticholinergic agent

• There is an increased risk of urinary retention with a post-void

residual urine measurement greater than 250 mL
Anticholinergic agents
Beta-3-agonists
• Beta-3-agonists in combination with an alpha blocker may be
offered as a treatment option to patients with moderate to
severe predominate storage LUTS(AUA, Conditional
Recommendation; Evidence Level: Grade C)
• Beta-3 adrenergic agonists stimulate detrusor beta-3
adrenergic receptors to promote relaxation
• mirabegron and vibegron are available treatments
• may be preferred over anticholinergic agents as they do not
cause dryness of the mouth
• Mirabegron was not associated with an increased
incidence of urinary retention.
• However, blood pressure should be monitored because these
drugs can raise blood pressure 
Combination Therapy
• 5-ARI in combination with an alpha blocker should be offered as a
treatment option only to patients with LUTS associated with
demonstrable prostatic enlargement
 prostate volume of > 30cc on imaging,
 PSA >1.5ng/dL
 palpable prostate enlargement on DRE
(Strong Recommendation; Evidence Level: Grade A)
• Anticholinergic agents/Beta-3-agonists, in combination with an
alpha blocker, may be offered as a treatment option to patients
with moderate to severe predominant storage LUTS. (Conditional
Recommendation; Evidence Level: Grade C)

• Clinicians should not offer the combination of low-dose daily 5mg

tadalafil with alpha blockers for the treatment of LUTS/BPH as it
offers no advantages in symptom improvement over either agent
alone. (Moderate Recommendation; Evidence Level: Grade C)
Management- Surgical Therapy
• Surgery is recommended for (AUA,Clinical Principle)
 renal insufficiency secondary to BPH
 refractory urinary retention secondary to BPH
 recurrent urinary tract infections (UTIs)
 recurrent bladder stones
 gross hematuria due to BPH
 LUTS/BPH refractory to or unwilling to use other therapies

• 當良性攝護腺肥大引起以下嚴重併發症時，一般而言會
建議手術治療：
1. 頑固性尿滯留 (refractory retention)
2. 良性攝護腺肥大合併膀胱結石
3. 反覆性泌尿道感染
4. 反覆性明顯血尿
5. 良性攝護腺肥大引起阻塞性腎病變
6. 病人拒絕服藥 7. 藥物治療無效
Surgical Therapy
• 經尿道攝護腺切除術（ transurethral resection of prostate ， TURP﹚ :
 目前 TURP 仍被視為 BPH 的指標性手術，因為到目前為止其他新的手術
其結果比較均無法優於 TURP 。
 但它有較高比例﹙ 53﹣75 ％）會導致逆行性射精
 約 2 ％的比率會發生經尿道攝護腺切除症候群 ﹙ TURP Syndrome ）
 其他併發症包括 : 性功能障礙、尿道狹窄、尿路感染和術後出 血形成血塊
引起尿滯留等。

• 經尿道攝護腺切開術（ Transurethral incision of the prostate,TUIP﹚ :

適合使用在攝護腺體積小於 30 亳升的病人，發生逆行性射精的風險較
TURP 小，且病人症狀之改善是與 TURP 相當，但卻有較高的機率需要
二次治療。

• 經尿道攝護腺電燒汽化術（ transurethral elcctrovaporization of the

prostate ） :
將 TURP 的電燒 環換成特殊的金屬滾輪，通上高能量電流於攝護腺上來
回滾動使組織逐漸汽化，短時間其症狀改善效果與 TURP 依樣好，但術
後發生刺激性排尿症狀、排尿困難及尿滯留需導尿的比例卻較高。
Surgical Therapy
• 開放式攝護腺切除術﹙ openprostatectomy ）
指經由恥骨上﹑恥骨後或會陰部切除攝護腺，因具高度侵襲性，建
議使用於病患攝護腺體積非常大（＞ 80mL ）或同時合併有較大膀
胱結石或需同時切除膀胱憩室時。

• 雷射手術
對於中重度下泌尿道症狀，目前認為症狀的改善與傳統的 TURP 相
當，但出血量及輸血比例則有減少，適合於病患服用抗凝血劑或有
高心血管風險。
Indications for urologic referral

• Severe symptoms or pain

• Men < 45 years old
• Abnormality on digital rectal examination
• Hematuria
• Elevated prostate-specific antigen (PSA)
• Dysuria as a possible symptom of bladder cancer
• Incontinence
• Neurologic disease known to impact lower urinary tract
symptoms (LUTS)
• Urinary retention (post-void residual [PVR] urine volume >250 mL,
or a palpable bladder)
• Suspicion of other urological disease
Summary
• Clinical manifestations
LUTS, assessment and monitoring by AUA/IPSS score
• Evaluation: to rule out other potential causes
 History and physical examination
 LAB: urinalysis, PSA(if life expectancy >10 years or use 5ARI), +/-Cr
 Additional tests for selected patients: PVR, imaging, Urodynamic
testing, cystoscopy
• Determining need for treatment
 Watchful waiting(monitored annually) for mild symptoms (AUA
Symptom Index score <=7)
 bothersome, moderate to severe BPH: lifestyle modifications
+ medications or surgery
• Indications for urologic referral
Summary
Reference

• 家庭醫師臨床手冊 - 54 章 ( 良性攝護腺肥大
benign prostatic hyperplasia ， BPH)

• 2020 台灣泌尿科治療指引

• Management of Benign Prostatic Hyperplasia/ Lower

Urinary Tract Symptoms: AUA Guideline 2021

• Uptodate