ABSTRACT
Microscopic BPH develops in most men in the West as they age. Due to a complex interplay of, genetic and hormonal influences many such men will also develop measurable enlargement of the prostate that obstructs bladder emptying. Urinary symptoms associated with prostatic enlargement affects 25% of the male population, increasing to 43% of men over 60. Dietary, hormonal, cardiac, renal and habitual factors will also contribute to urinary symptoms in both sexes, especially as they age. A focused history and examination and simple tests (prostatic specific antigen, creatinine) help make the diagnosis. Assessment of voiding function (flow rate, ultrasound) add useful information. Many can be stratified according to the severity of their symptoms by scoring systems. Lifestyle advice can improve mild symptoms. Medical therapy (with either alpha blockers, 5-alpha reductase inhibitors or both) is most appropriate for mild or moderate symptoms and may help severe symptoms. Phosphodiesterase inhibitors (PDEis) improve both lower urinary tract symptoms and erectile dysfunction. Antimuscarinic drug therapy can help urinary urgency and frequency. Severely symptomatic or obstructed men do best with telescopic removal (TURP or holmium laser enucleation HoLEP) or laser vaporisation of the obstruction. Electrical or laser incision (BNI/TUIP) may suffice for prostates under 30cc volume and an open prostatectomy or HoLEP may be necessary for prostate volumes over 100cc. Pressure–flow studies can improve the accuracy of diagnosis and the selection of appropriate candidates for surgery, but most symptomatic men respond well to treatment. Outcomes for obstructed and moderate to severely symptomatic men are good following surgery. Impotence and significant incontinence are no more common with surgery than with conservative management. 5-alpha reductase inhibitors offer the opportunity to prevent the development of further BPH either instead of or following surgical treatment. All treatments have side effects. No single treatment suits all men so a range of options are necessary.
