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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Extremely common: affects ~50% of men by age 50, ~80% by age 80. Arises from transitional zone of prostate
- LUTS: storage (frequency, urgency, nocturia) and voiding (hesitancy, poor stream, terminal dribbling, incomplete emptying)
- First-line medical: alpha-blocker (tamsulosin 400 µg OD) for moderate LUTS. Add 5-alpha-reductase inhibitor (finasteride) if prostate >30 g
- Surgical: TURP (transurethral resection of prostate) — gold standard for refractory symptoms. Alternatives: HoLEP, UroLift, Rezūm
- Always measure PSA and perform DRE to exclude prostate cancer — then refer urgently if suspicion
Overview
Benign prostatic hyperplasia is a histological diagnosis of non-malignant proliferation of prostatic stromal and epithelial cells within the transitional zone of the prostate gland. It is testosterone/DHT-dependent and increasingly common with age. The enlarged prostate compresses the prostatic urethra, causing bladder outflow obstruction and lower urinary tract symptoms. The clinical condition is better termed "benign prostatic enlargement" (BPE) with "bladder outflow obstruction" (BOO). BPH does NOT directly increase the risk of prostate cancer (which arises from the peripheral zone), though both commonly coexist.
Epidemiology
BPH is present histologically in approximately 50% of men at age 50, rising to >80% at age 80. Approximately 30% of men develop moderate-to-severe LUTS requiring treatment. BPH is the commonest cause of LUTS in older men and the commonest reason for urology referral. Risk factors include age, family history, obesity, and metabolic syndrome. Approximately 25% of men with BPH will eventually require surgical intervention.
Clinical Features
Symptoms
Voiding (obstructive) symptoms: hesitancy, poor stream, intermittency, straining, terminal dribbling, incomplete emptying
Storage (irritative) symptoms: frequency, urgency, nocturia, urge incontinence
Post-micturition dribbling
Acute urinary retention (sudden painful inability to pass urine)
Recurrent UTIs (incomplete bladder emptying → residual urine → bacterial colonisation)
Haematuria (must exclude malignancy before attributing to BPH)
Signs
Smoothly enlarged, non-tender prostate on DRE (rubbery, symmetrical, preserved median sulcus)
Palpable distended bladder (chronic retention)
Hard, irregular, nodular prostate suggests MALIGNANCY, not BPH
Investigations
First-line
IPSS (International Prostate Symptom Score)Validated questionnaire quantifying LUTS severity (0–7 mild, 8–19 moderate, 20–35 severe). Guides treatment decisions
DREAssess prostate size, texture, and symmetry. Exclude malignancy (hard, nodular prostate)
PSATo exclude prostate cancer. Also correlates with prostate size (PSA >1.4 predicts prostate >30 g). Counsel about implications before testing (NICE NG131)
UrinalysisExclude UTI, haematuria
U&EsAssess renal function — chronic retention can cause obstructive nephropathy
Second-line
Flow rate (uroflowmetry) and post-void residual (PVR)Qmax <15 mL/s suggests obstruction. PVR >300 mL suggests significant retention
Renal USSIf raised creatinine, recurrent UTIs, or palpable bladder — assess hydronephrosis (chronic retention)
Frequency-volume chart (bladder diary)3-day diary of fluid intake, voiding times and volumes — helps distinguish BPH from overactive bladder
Specialist
Pressure-flow urodynamicsBefore surgery if diagnosis uncertain — distinguishes BOO from detrusor underactivity
1
Conservative
- Mild symptoms (IPSS <8): reassurance and lifestyle advice
- Fluid management: reduce evening fluid intake (improves nocturia), moderate caffeine and alcohol
- Bladder training techniques
- Watchful waiting with annual review
2
Medical — moderate symptoms
- Alpha-blockers (first-line): tamsulosin 400 µg OD or alfuzosin 10 mg OD. Relax prostatic smooth muscle → rapid symptom relief (days to weeks)
- Side effects: postural hypotension, dizziness, retrograde ejaculation, intraoperative floppy iris syndrome (inform ophthalmologist before cataract surgery)
- 5-alpha-reductase inhibitors: finasteride 5 mg OD or dutasteride 0.5 mg OD. Block testosterone → DHT conversion → prostate shrinks over 3–6 months. Best for large prostate >30 g
- Side effects: erectile dysfunction, reduced libido, reduced ejaculate volume, gynecomastia. Halves PSA — multiply measured PSA by 2 for true interpretation
- Combination therapy (alpha-blocker + 5ARI): most effective for large prostates with moderate-severe LUTS
3
Surgical
- TURP (transurethral resection of prostate): gold standard operation for BPH. Indications: refractory symptoms, recurrent retention, renal impairment from BOO, recurrent UTIs, bladder stones
- HoLEP (holmium laser enucleation): increasingly used — lower bleeding risk, effective for larger prostates
- Minimally invasive: UroLift (prostatic urethral lift), Rezūm (steam ablation) — preserve ejaculatory function
- Open prostatectomy: for very large prostates (>80–100 g) — rare now with laser availability
Complications
- Acute urinary retention: Sudden inability to pass urine — painful, requires catheterisation
- Chronic urinary retention: Painless, large residual volume — may present with renal impairment (obstructive uropathy) or overflow incontinence
- Recurrent UTIs: From residual urine promoting bacterial growth
- Bladder stones: From urinary stasis
- Post-TURP syndrome: Hyponatraemia from absorption of irrigating fluid (glycine) — confusion, seizures. Less common with bipolar TURP
- Obstructive nephropathy: Bilateral hydronephrosis and CKD from chronic high-pressure retention
UKMLA Exam Tips
- 1BPH = transitional zone. Prostate cancer = peripheral zone. This explains why BPH causes LUTS earlier than cancer
- 2Tamsulosin (alpha-blocker): rapid onset but causes retrograde ejaculation and floppy iris syndrome
- 3Finasteride (5ARI): takes 3–6 months to work. HALVES PSA — double the measured value when interpreting
- 4DRE in BPH: smooth, rubbery, symmetrical, preserved median sulcus. DRE in cancer: hard, irregular, nodular, lost sulcus
- 5High-pressure chronic retention → bilateral hydronephrosis → obstructive AKI. Must catheterise to decompress
- 6Post-TURP syndrome: dilutional hyponatraemia from glycine irrigation fluid absorption — presents with confusion, nausea, seizures
practicetest your knowledge on BPHApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — Renal and beyond.
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Benign Prostatic Hyperplasia: guidance by region
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