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Benign Prostatic Hyperplasia: Signs and Symptoms

• Benign prostatic hyperplasia: definitions, epidemiology and etiology
• Benign prostatic hyperplasia: signs and symptoms
• Benign prostatic hyperplasia: diagnosis
• Benign prostatic hyperplasia: medical treatment
• Benign prostatic hyperplasia: surgical treatment

Lower Urinary Tract Symptoms of BPH

Storage Symptoms

Previously termed irritative symptoms. They occur during the storage phase and include frequency, nocturia, urgency, and urge, stress, or overflow urinary incontinence.

Causes

Postvoid residual urine causes the bladder to fill more rapidly and increases the risk of urinary tract infections. Detrusor hypertrophy increases bladder excitability. Cortical inhibition of bladder afferents and sphincter tone are less pronounced at night.

Voiding Symptoms

Previously termed obstructive symptoms. They occur during the voiding phase and include a weak or split urinary stream, hesitancy, straining to void, dysuria, intermittency, and urinary retention.

Causes

Static and dynamic obstruction of the prostatic urethra caused by BPH and increased smooth muscle tone.

Post-micturition Symptoms

Post-micturition symptoms occur after voiding and include a sensation of incomplete bladder emptying and post-micturition dribble.

Urinary Incontinence

Urinary incontinence is caused either by chronic urinary retention with overflow incontinence or by urge incontinence. Surgical treatment of benign prostatic syndrome may cause temporary or, rarely, persistent stress urinary incontinence.

Sexual Function

Severe LUTS impair sexual function, which may improve with effective treatment. 5-alpha reductase inhibitors can cause loss of libido and erectile dysfunction. Alpha-blockers and surgical treatment frequently cause retrograde ejaculation; erectile function is usually preserved.

Complications of Benign Prostatic Hyperplasia

Urinary Retention

Risk factors for developing urinary retention are prostatitis, bladder overdistension, high fluid intake, alcohol, sexual activity, medication such as sympathomimetics and anticholinergics, bed rest, surgery, and general anesthesia. The prognosis after predictable urinary retention in the presence of risk factors is better than after spontaneous urinary retention in a patient with preexisting voiding symptoms and no identifiable trigger.

In indolent patients, urinary retention may present as a lower abdominal mass.

Urinary retention caused by BPS: massively distended urinary bladder presenting as a lower abdominal mass and associated with overflow incontinence. With kind permission, Dr. R. Gumpinger, Kempten.

Postrenal Kidney Failure

Hydronephrosis and postrenal kidney failure are often asymptomatic. Symptoms of uremia may occur in advanced kidney failure.

Further Complications

• Bladder diverticulum
• Gross hematuria
• Increased intra-abdominal pressure during voiding may cause hernias, hemorrhoids, or, rarely, micturition syncope.
• Pyelonephritis and sepsis.
• Bladder stones

Quantification of LUTS with the International Prostate Symptom Score

The International Prostate Symptom Score (IPSS) is essential for quantifying BPS symptoms and documenting treatment response. However, it has no specific diagnostic value because other conditions can also cause high IPSS values.

Evaluation of the IPSS

Add the scores for questions 1–7; the maximum total score is 35 points. Scores of 0–7 indicate mild symptoms, 8–19 moderate symptoms, and 20–35 severe symptoms. Question 8 evaluates quality of life and is reported separately from the total score.

1. Incomplete Emptying

How often have you had a sensation of not emptying your bladder completely after you finished urinating?

2. Frequency

How often have you had to urinate again less than two hours after you finished urinating?

3. Intermittency

How often have you found that you stopped and started again several times when you urinated?

4. Urgency

How often have you found it difficult to postpone urination?

5. Weak Stream

How often have you had a weak urinary stream?

6. Straining

How often have you had to push or strain to begin urination?

7. Nocturia

How many times did you most typically get up to urinate from the time you went to bed until you got up in the morning?

8. Quality of Life

How would you feel if you had to spend the rest of your life with your urinary condition the way it is now? The choices are delighted (0), pleased (1), mostly satisfied (2), mixed (3), mostly dissatisfied (4), unhappy (5), and terrible (6).

References

Andriole u.a. 2004 ANDRIOLE, G. L. ; ROEHRBORN, C. ; SCHULMAN, C. ; SLAWIN, K. M. ; SOMERVILLE, M. ; RITTMASTER, R. S.: Effect of dutasteride on the detection of prostate cancer in men with benign prostatic hyperplasia.
In: Urology
64 (2004), Nr. 3, S. 537–41; discussion 542–3

Burnett und Wein 2006 BURNETT, A. L. ; WEIN, A. J.: Benign prostatic hyperplasia in primary care: what you need to know.
In: J Urol
175 (2006), Nr. 3 Pt 2, S. S19–24

Chapple 2004 CHAPPLE, C. R.: Pharmacological therapy of benign prostatic hyperplasia/lower urinary tract symptoms: an overview for the practising clinician.
In: BJU Int
94 (2004), Nr. 5, S. 738–44

DGU Guideline, “S2e Leitlinie Diagnostik und Therapie des Benignen Prostatasyndroms (BPS).,” 2023. [Online]. Available: https://register.awmf.org/assets/guidelines/043-034l_S2e_Diagnostik_Therapie_benignes_Prostatasyndrom_2023-04.pdf

Donovan u.a. 2000 DONOVAN, J. L. ; PETERS, T. J. ; NEAL, D. E. ; BROOKES, S. T. ; GUJRAL, S. ; CHACKO, K. N. ; WRIGHT, M. ; KENNEDY, L. G. ; ABRAMS, P.: A randomized trial comparing transurethral resection of the prostate, laser therapy and conservative treatment of men with symptoms associated with benign prostatic enlargement: The CLasP study.
In: J Urol
164 (2000), Nr. 1, S. 65–70

“EAU Guideline: Non-neurogenic Male LUTS,” Available: https://uroweb.org/guidelines/treatment-of-non-neurogenic-male-luts/.

Kopp, R. P.; Freedland, S. J. & Parsons, J. K. Associations of benign prostatic hyperplasia with prostate cancer: the debate continues.
Eur Urol, 2011, 60, 699-700; discussion 701-2.

Ørsted, D. D.; Bojesen, S. E.; Nielsen, S. F. & Nordestgaard, B. G. Association of clinical benign prostate hyperplasia with prostate cancer incidence and mortality revisited: a nationwide cohort study of 3,009,258 men.
Eur Urol, 2011, 60, 691-698.

Parsons, J. Kellogg; Messer, Karen; White, Martha; Barrett-Connor, Elizabeth; Bauer, Douglas C; Marshall, Lynn M; in Men (MrOS) Research Group, Osteoporotic Fractures & the Urologic Diseases in America Project Obesity increases and physical activity decreases lower urinary tract symptom risk in older men: the Osteoporotic Fractures in Men study.
Eur Urol, 2011, 60, 1173-1180.

Reich u.a. 2006 REICH, O. ; GRATZKE, C. ; STIEF, C. G.: Techniques and long-term results of surgical procedures for BPH.
In: Eur Urol
49 (2006), Nr. 6, S. 970–8; discussion 978

Uygur u.a. 1998 UYGUR, M. C. ; GUR, E. ; ARIK, A. I. ; ALTUG, U. ; EROL, D.: Erectile dysfunction following treatments of benign prostatic hyperplasia: a prospective study.
In: Andrologia
30 (1998), Nr. 1, S. 5–10

  Deutsche Version: Symptome der benignen Prostatahyperplasie

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