Benign prostatic hyperplasia

Disease Description (Causes and Symptoms)

• Definition summary: Benign prostatic hyperplasia (BPH) is a condition in which nodular and stromal proliferation of the prostate, located below the bladder, enlarges the prostate and compresses the urethra, causing difficulty urinating.
• Main causes and pathophysiology
  • Hormonal changes associated with aging and proliferation of prostate tissue (androgen dependence, increased DHT production due to 5α-reductase activity, etc.) are the main related factors.
  • Genetic predisposition, family history, and chronic inflammation may also have an influence.
  • Compression of the urethra and bladder neck → reduced urinary flow, increased post-void residual urine, bladder overactivity and wall thickening → reduced bladder emptying function; if prolonged, reflux and possible damage to the upper urinary tract (ureters and kidneys).
• Main symptoms
  • Delayed initiation of urination (hesitancy), weak urinary stream, feeling of residual urine after urination, residual urine (incomplete emptying)
  • Frequent urination, nocturia, urinary urgency
  • Recurrent urinary tract infections, hematuria, and acute urinary retention (inability to urinate) may occur

Treatment Methods

• Medication (first-line approach)
  • Alpha blockers (e.g., tamsulosin and alfuzosin): Improve urination by relaxing the smooth muscle of the prostate and bladder neck. Side effects: dizziness (orthostatic hypotension), fatigue, and changes in sexual function (ejaculatory dysfunction).
  • 5α-reductase inhibitors (e.g., finasteride and dutasteride): Reduce prostate size (a slight reduction in size, approximately 20%, has been reported after at least 3–6 months of use) and reduce symptoms and complications (urinary retention and the need for surgery). Side effects: decreased libido, erectile dysfunction, ejaculatory dysfunction, and decreased PSA levels (generally by about half), which requires caution when interpreting test results.
  • Others: PDE5 inhibitors (tadalafil) may help improve LUTS. If necessary, anticholinergics/β3 agonists may be considered in combination to control storage symptoms (urgency and frequent urination).
• Procedures and surgery
  • Transurethral resection of the prostate (TURP): A traditional standard surgery in which excess tissue is resected through the urethra. It has a significant effect on improving symptoms.
  • Holmium laser enucleation of the prostate (HoLEP): Causes less vascular damage and is effective even for large prostates. Recovery is rapid.
  • Minimally invasive treatments: UroLift (expansion of the urethra by inserting prostatic struts), Rezūm (steam therapy), prostatic artery embolization (PAE), etc. — Selection depends on the patient’s condition, prostate size, and medical environment.
  • Temporary or permanent stent placement and urethral catheterization: Used when surgery is not possible because of the patient’s general condition or when temporary relief is needed.
  • Common effects after surgery: Retrograde ejaculation (semen flows into the bladder) and possible temporary or persistent urinary incontinence.
• Lifestyle management (self-care)
  • Adjust the timing of fluid intake (avoid excessive intake in the evening), and limit caffeine, alcohol, and irritating foods
  • Maintain regular urination habits (timed voiding), control weight, and exercise regularly
  • Be cautious with medications that can cause urinary retention, such as cold medicines (antihistamines and sympathomimetics)
• Complications and prognosis
  • Without appropriate treatment, acute urinary retention, recurrent urinary tract infections, bladder stones, hydronephrosis, and decreased kidney function may occur.
  • Symptoms can generally be controlled with medication or procedures, but the choice of treatment varies depending on symptom severity, prostate size, patient preference, and general health.

Checkpoints Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items to bring (recommended)
  • A list of currently used medications (including prescription drugs, OTC medications, and supplements)
  • Copies of recent test results (PSA, urinalysis, ultrasound, uroflowmetry, etc.)
  • A voiding diary (number of urinations/nighttime urinations/amount per void during the most recent 24–72 hours) or a completed IPSS (International Prostate Symptom Score) is recommended
  • Past surgeries and medical history (especially urinary tract and cardiovascular diseases and whether anticoagulants are being taken)
• Information to show the doctor during the outpatient visit
  • When the symptoms began and how they have progressed (gradual/acute)
  • Changes in urinary flow, feeling of residual urine, and whether urinary blockage (acute urinary retention) has occurred
  • Changes in sexual function (erectile function, changes in ejaculation, etc.)
  • Symptoms of infection (fever, chills, flank pain)
• Possible tests during the outpatient visit
  • Digital rectal examination, urinalysis (infection and hematuria), serum PSA, transabdominal or transrectal ultrasound (prostate size and residual bladder urine), uroflowmetry, and, if necessary, urodynamic testing and cystoscopy

Examples of General Questions to Ask the Doctor

• What are the main side effects of this medication (alpha blocker/5α-reductase inhibitor), and what symptoms should I watch for?
• Is medication alone sufficient for my symptoms, or should I consider a procedure or surgery?
• If I undergo surgery, what changes might occur in sexual function (libido, erection, and ejaculation)?
• How much does my PSA test result suggest a risk of prostate cancer? (Including how to interpret PSA while taking a 5α-reductase inhibitor)
• Are there any common drug interactions I should be aware of while taking this medication (such as with antihypertensive drugs or anticoagulants)?

Examples of Disease-Specific Questions

• Do my prostate size (ultrasound findings), urinary flow (uroflowmetry), and residual urine volume meet the indications for surgery? When do you recommend surgery?
• Could the medications I am currently taking (e.g., antihypertensive drugs, antidepressants, or cold medicines) worsen my urinary symptoms or increase the risk of urinary retention? Do I need to stop or replace any of them?