AKT · Renal & urology/Urological cancer & LUTS

Benign prostatic hyperplasia

Age-related stromal/glandular hyperplasia of the prostate transitional zone → bladder outflow obstruction

Overview

Non-malignant enlargement of the prostate causing lower urinary tract symptoms (LUTS) from bladder outflow obstruction in older men. Symptoms are voiding (hesitancy, weak stream, terminal dribbling, incomplete emptying) and storage (frequency, urgency, nocturia). Treatment escalates from conservative to an alpha-blocker, then a 5-alpha-reductase inhibitor for large glands, then surgery (TURP).

Recognise

Voiding (obstructive) symptoms: hesitancy, weak/intermittent stream, straining, terminal dribbling, incomplete emptying; storage: frequency, urgency, nocturia
Smoothly enlarged, non-tender prostate on DRE (no hard nodule/irregularity); raised PSA may occur (interpret with caution)
Complications: acute/chronic urinary retention, recurrent UTI, stones, haematuria, obstructive uropathy/CKD

Red flags

Acute urinary retention (painful, palpable bladder) → catheterise; high-pressure chronic retention with AKI → catheter + monitor post-obstructive diuresis
Hard/irregular/nodular prostate, very high PSA, weight loss/bone pain → suspect prostate cancer, not BPH

Differentials & how to tell them apart

Prostate cancerhard/irregular/nodular prostate, markedly raised PSA, bone pain — needs the cancer pathway

Overactive bladderstorage symptoms predominate without obstruction

UTI / bladder stone / neurological causeinfection, stone, or neurogenic bladder

Investigations

Symptom assessment (IPSS), DRE (size/consistency), urine dip (exclude infection/haematuria), PSA (after counselling), U&Es (obstructive nephropathy), bladder scan/post-void residual; flow studies/imaging as needed.

Management

Alpha-blocker (tamsulosin) first-line; add 5-ARI (finasteride) for large glands; TURP for refractory/complications

1Assess LUTS (IPSS), do a DRE and check PSA/urine/renal function. Conservative measures for mild symptoms; an alpha-blocker (tamsulosin) for bothersome symptoms (rapid relief).Gate: A hard/irregular/nodular prostate or markedly raised PSA → prostate-cancer pathway, not BPH treatment; acute retention → catheterise.
2Add a 5-alpha-reductase inhibitor (finasteride) for a significantly enlarged prostate (shrinks it over months, halves PSA); TURP for refractory symptoms, retention or complications.

Conservative: lifestyle (fluid timing, caffeine/alcohol reduction, bladder training) — for mild symptoms

Alpha-blocker (tamsulosin) — first-line drug — relaxes prostatic smooth muscle, rapid symptom relief; caution postural hypotension and intra-operative floppy iris syndrome (warn cataract surgeons)

5-alpha-reductase inhibitor (finasteride) — for a significantly enlarged prostate — shrinks it over months, reduces retention/surgery risk; lowers PSA (~halves it), sexual side-effects

Surgery — transurethral resection of the prostate (TURP) — for refractory symptoms, retention or complications; risks retrograde ejaculation, TUR syndrome, bleeding

Key points

Older man + voiding/storage LUTS + smoothly enlarged prostate = BPH → alpha-blocker (tamsulosin) first (fast relief; warn re floppy-iris at cataract surgery), add finasteride for a big gland (shrinks it, halves PSA, slow), TURP for refractory/retention. A HARD nodular prostate = cancer pathway.

Monitor & prognosis

IPSS/symptoms, PSA, renal function, retention/complications.

Good symptom control; progression to retention/surgery in a minority.

Source: NICE CG97 (LUTS in men)