Benign prostatic hypertrophy and prostate cancer: Clinical sciences

Benign prostatic hyperplasia, or BPH, refers to non-malignant enlargement of the prostate gland

caused by prostatic cell proliferation.

BPH is the leading cause of lower urinary tract symptoms in biologically male adults, especially after the age of 30.

On the other hand, prostate cancer is a common malignancy that usually affects biologically male patients between 64 and 75 years of age. While BPH and prostate cancer both present with urinary symptoms and are differentiated based on clinical and imaging findings, BPH does not increase the risk of prostate cancer.

When a patient presents with a chief concern suggesting BPH or prostate cancer, first perform a focused history and physical examination.

When it comes to BPH, affected individuals typically report difficulty urinating, a weak urine stream, and occasionally, nocturia or urinary incontinence. Digital rectal examination, or DRE, often reveals a firm, symmetrically enlarged prostate. With these findings, you should suspect BPH.

Here’s your first clinical pearl! Keep in mind that DRE can only detect prostatic hypertrophy once the prostate volume reaches 50 milliliters or more.

Whenever a patient presents with lower urinary tract symptoms, remember to perform a neurologic examination by assessing motor and sensory function of the pelvic region and lower extremities, to rule out other causes.

Now, once you suspect BPH, order a urinalysis to rule out other urinary tract pathology such as infection, and consider ordering a prostate-specific antigen, or PSA, level.

Here’s a clinical pearl! While PSA testing has a limited ability to accurately predict urinary retention or prostate size in patients with BPH, results might be useful when determining treatment. Using shared decision-making, be sure to discuss the risks and benefits of PSA testing with your patient.

Okay, in addition to lab testing, consider ordering a post-void residual, or PVR, scan. This test measures the amount of urine remaining in the bladder after voiding, to look for evidence of urinary retention. Additionally, order a transrectal ultrasound, which can assess prostate size more accurately than a DRE.

If your patient has no coexisting urinary tract pathology, the urinalysis will be negative for bacteria, protein, blood, white blood cells, and glucose. However, PSA levels might be elevated, and PVR may indicate mild to moderate urinary retention. Transrectal ultrasound typically reveals an enlarged prostate, which confirms BPH.

Next, to determine an appropriate treatment plan, you’ll need to assess your patient's symptom severity. To do this, have your patient use the International Prostate Symptom Score, or IPSS, a self-administered, validated metric that predicts the severity of urinary retention. This metric was previously called the American Urological Association Symptom Index. The IPSS questionnaire assesses the frequency of seven specific BPH symptoms, including incomplete bladder emptying; urinary frequency, hesitancy, and urgency; weakness of the urinary stream, straining with urination, and nocturia. IPSS also assesses a patient’s quality of life to determine symptom severity. The score ranges from 0 to 35, with higher scores predicting a greater severity of urinary retention.

Now, if the IPSS score is less than 8, diagnose mild BPH. Here, treatment primarily consists of behavioral and lifestyle modifications to alleviate symptoms. For example, your patient can reduce urinary frequency and nocturia by limiting fluid intake before bedtime or travel, and by reducing consumption of caffeine and alcohol, since both have a diuretic effect. Finally, be sure to recommend regular physical activity, pelvic floor muscle training, and weight loss, if indicated.

On the other hand, if the IPSS score is between 8 and 19, your patient has moderate BPH. In this case, treatment includes behavioral and lifestyle modifications, combined with pharmacologic therapy for symptom reduction. First-line medications for BPH include alpha-blockers, like tamsulosin; and phosphodiesterase-5, or PDE5 inhibitors, like tadalafil. Both medications relax the bladder and prostate muscles, which improves urine flow. Now, if these medications do not improve symptoms, consider starting a 5-alpha reductase inhibitor, like finasteride; or an anticholinergic, like solifenacin. Alternatively, you could start combination therapy, which could consist of an alpha-blocker with any of the other medications, or a PDE5 inhibitor combined with a 5-alpha reductase inhibitor.

Keep in mind that 5-alpha reductase inhibitors are most effective for patients with moderate to severe symptoms and an enlarged prostate. For this reason, you should only combine an alpha-blocker with a 5-alpha reductase inhibitor if your patient is symptomatic and has a prostate volume greater than 30 milliliters on a transrectal ultrasound, a palpably enlarged prostate on digital rectal exam, or a PSA of 1.5 nanograms per milliliter or more.