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Benign Prostatic Hyperplasia (BPH): Signs and Symptoms

• Benign prostatic hyperplasia (1/6): definitions, epidemiology and etiology
• Benign prostatic hyperplasia (2/6): signs and symptoms
• Benign prostatic hyperplasia (3/6): diagnosis
• Benign prostatic hyperplasia (4/6): treatment algorithm
• Benign prostatic hyperplasia (5/6): medical treatment
• Benign prostatic hyperplasia (6/6): surgical treatment

Review literature: (Burnett und Wein, 2006) (DGU-Guideline: diagnostic workup, 2009) (DGU-Guideline: treatment, 2009) (EAU-Guideline: Oelke et al., 2010)

Lower Urinary Tract Symptoms of BPH

Storage symptoms:

Occur during the storage phase, previously termed as irritative symptoms: frequency, pollakiuria, nocturia, urgency, incontinence (urge, mixed or continous, see below).

Causes of Storage Symptoms:

• Postvoid residual volume reduces the functional capacity of the bladder
• Hypertrophy of the detrusor muscle causes an increased excitability resulting in bladder contractions
• Age-related changes in bladder and central nervous system: e.g., reduced cortical inhibition of the bladder sphincter and afferent bladder innervation
• Higher probability of urinary tract infections

Voiding symptoms:

Occur during voiding phase, previously termed as obstructive symptoms: weak urinary stream, hesitancy, straining, dysuria, interrupted urine stream, terminal dribbling, feeling of residual urine, urinary retention.

• Weak or spraying urinary stream
• Hesitancy: delayed begin of micturition
• Straining to urinate
• Intermittency: interrupted urine stream
• Terminal dribbling/li>
• Urinary retention

Causes of obstructive micturition symptoms:

Prostatic hyperplasia leads to the compression and narrowing of the prostatic urethra and to obstructive micturition symptoms.

Overflow Urinary Incontinence:

BPH may cause different types of urinary incontinence: overflow urinary incontinence due to chronic urinary retention or urge incontinence due to detrusor instability. The surgical treatment of BPH includes the risk of developing stress urinary incontinence, if the urinary sphincter is damaged.

Erectile Dysfunction:

Erectile dysfunction may be caused by BPH itself or by different kind of treatments (e.g., open prostatectomy, 5alpha-reductase inhibitors). The treatment of BPH, however, may also improve sexual function, particularly alpha blocker such as doxazosin are advantageous.

Complications of Benign Prostatic Hyperplasia

Urinary retention:

Risk factors for the development of urinary retention are prostatitis, bladder overdistension, high fluid intake, alcohol, sexual activity, debility, drugs (e.g., sympathomimetics, anticholinergics), bed rest, surgery and general anesthesia. The prognosis for the recovery of spontaneous voiding after urinary retention is better, if above mentioned risk factors are present and the patient does not suffer from obstructive symptoms. In indolent patients, urinary retention may present as a lower abdominal tumor [fig. abdominal tumor due to urinary retention].

fig. urinary retention in benign prostatic hyperplasia (BPH): the massively distended bladder appears as an abdominal tumor. The patient suffered from overflow urinary incontinence but reported no abdominal pain. With kind permission, Dr. R. Gumpinger, Kempten.

Postrenal kidney failure:

BPH may lead to vesicoureteral reflux, hydronephrosis and postrenal kidney failure, symptoms of uremia may be lethargy, decreased mental acuity, coma, nausea, vomiting, bone pain, itch, shortness of breath and seizures.

Further complications of Benign Prostatic Hyperplasia (BPH):

• Bladder diverticula
• Bladder stones
• Hematuria
• Increased intra-abdominal pressure may cause hernias, hemorrhoids or, rarely, micturition syncope.
• Urinary tract infections like prostatitis, pyelonephritis or urosepsis.

Quantification of LUTS with the International Prostate Symptoms Score (IPSS)

The validated International Prostate Symptoms Score (IPSS) consists of 8 questions and should be used for the quantification of the BPH symptoms. This enables the monitoring of treatment success. The IPSS, however, has no diagnostic value, since other diseases like infections, neurogenic lower urinary tract dysfunction or tumors may also cause high IPSS scores.

Evaluation of the IPSS:

Seven questions deal with symptoms like incomplete bladder emptying, frequency, intermittency, urgency, weak stream, straining and nocturia. The score of each question (from 1 to 5) sums up for maximum of 35 points. The severity of BPH symptoms may be classified into mild (0 to 7 points), moderate (8 to 19 points) and severe (20 to 35 points). The 8th question deals with the quality of life (score from 1 to 6).

Residual urine:

Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?

• Not at all = 0 points
• Less than 1 time in 5 = 1 point
• Less than half of the time = 2 points
• About half of the time = 3 points
• More than half of the time = 4 points
• Almost always = 5 points

Frequency:

Over the past month, how often have you had to urinate again less than two hours after you finished urinating? (0–5 points, see classification residual urine)

Intermittency:

Over the past month, how often have you found you stopped and started again several times when you urinated? (0–5 points, see classification residual urine).

Urgency:

Over the last month, how difficult have you found it to postpone urination? (0–5 points, see classification residual urine)

Weak stream:

Over the past month, how often have you had a weak urinary stream? (0–5 points, see classification residual urine)

Straining during urination:

Over the past month, how often have you had to push or strain to begin urination? (0–5 points, see classification residual urine)

Nocturia:

Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? (0–5 points depending on the times of nocturia)

Quality of life:

If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? [1–5 points: from delighted (0), pleased (1), mostly satisfied (2), mixed – about equally satisfied and dissatisfied (3), unhappy (4) and terrible (5)]

References

  Deutsche Version: Symptome der benignen Prostatahyperplasie