Benign Prostatic Hyperplasia — BPH

That older male patient getting up five times a night to urinate may not have a UTI — the real culprit is a growing prostate slowly strangling the urethra from the outside in.

Benign prostatic hyperplasia is nonmalignant enlargement of the prostate gland that compresses the prostatic urethra, creating progressive bladder outlet obstruction. It affects roughly 50% of men by age 60 and up to 90% by age 85. The hallmark presentation is lower urinary tract symptoms (LUTS): hesitancy, weak stream, intermittency, incomplete emptying, post-void dribbling, frequency, urgency, and nocturia. These are divided into obstructive (voiding) symptoms — hesitancy, weak stream, straining — and irritative (storage) symptoms — frequency, urgency, nocturia. A key assessment finding is an elevated post-void residual (PVR) volume; greater than 100-200 mL signals significant retention. Digital rectal exam reveals a smooth, firm, symmetrically enlarged, nontender prostate — distinguishing BPH from prostate cancer, which feels hard, nodular, and irregular. PSA may be mildly elevated but is not diagnostic of BPH alone. First-line pharmacologic management includes alpha-1 adrenergic blockers (tamsulosin, doxazosin) that relax prostatic smooth muscle for rapid symptom relief, and 5-alpha reductase inhibitors (finasteride, dutasteride) that shrink the gland over 3-6 months. Teach orthostatic hypotension precautions with alpha-blockers (rise slowly, dangle legs) and warn that pregnant women must not handle crushed or broken finasteride tablets (teratogenic). Surgical intervention — typically TURP — is indicated when medical therapy fails or complications arise such as recurrent UTIs, hematuria, bladder stones, or renal insufficiency.

Key Distinctions

Don't confuse BPH's smooth, rubbery, symmetric enlargement on DRE with prostate cancer's hard, irregular nodules — the exam finding changes the clinical trajectory entirely. Students mix up alpha-blockers (fast-acting, relax muscle) with 5-alpha reductase inhibitors (slow-acting, shrink gland); tamsulosin works in days, finasteride takes months. Obstructive symptoms (hesitancy, weak stream) reflect mechanical compression, while irritative symptoms (frequency, nocturia) reflect detrusor muscle irritability from chronic obstruction.

Clinical Pearl

Think of BPH as a garden hose with someone slowly stepping on it — the water still flows, but the stream weakens before it stops completely.