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Benign prostatic hyperplasia

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Updated 2024 EAU guidelines for the diagnosis and management of benign prostatic hyperplasia.

Background

Overview

Definition
BPH is a nonmalignant enlargement of the prostate gland that affects aging men.
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Pathophysiology
The pathophysiology of BPH is complex and not fully understood. However, androgenic hormones, particularly dihydrotestosterone, play a significant role in the growth and maintenance of the prostate gland. Dihydrotestosterone is synthesized from testosterone by the action of 5-alpha reductase enzymes, and both normal and pathological growth of the prostate is dependent on dihydrotestosterone synthesis.
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Epidemiology
The incidence of BPH/LUTS in men is estimated at 15,000 per 1,000 person-years. The reported prevalence of BPH ranges from 8-14% in men aged 40-49 years to 21-43% in men aged 60-69 years.
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Risk factors
Risk factors for BPH include advancing age, familial predisposition, obesity, and the presence of comorbid conditions such as diabetes mellitus and CVD.
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Disease course
Clinically, BPH is primarily diagnosed based on a diverse array of progressive LUTS. These symptoms include increased urinary frequency, nocturia, urinary urgency, weak urinary stream, and a sensation of incomplete bladder emptying.
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Prognosis and risk of recurrence
The prognosis of BPH is variable. It is a progressive condition but is not necessarily life-threatening.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of benign prostatic hyperplasia are prepared by our editorial team based on guidelines from the American Urological Association (AUA 2024), the European Association of Urology (EAU 2024), and the Canadian Urological Association (CUA 2022).
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Diagnostic investigations

History and physical examination: as per EAU 2024 guidelines, elicit a complete medical history in patients with LUTS.
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  • Urinalysis

  • Renal function tests

  • PSA

  • Diagnostic imaging

  • Urodynamic testing

Diagnostic procedures

Urethrocystoscopy: as per AUA 2024 guidelines, consider assessing the prostate size and shape via cystoscopy, if available, before interventions for LUTS secondary/attributed to BPH.
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Medical management

Watchful waiting: as per EAU 2024 guidelines, offer watchful waiting in patients with mild/moderate symptoms, minimally bothered by their symptoms.
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  • Alpha-blockers

  • 5-ARIs

  • PDE5 inhibitors

  • Anticholinergic agents

  • Beta-3 agonists

  • Combination therapy

  • Management of nocturia (addressing underlying causes)

  • Management of nocturia (behavioral changes)

  • Management of nocturia (desmopressin)

  • Management of nocturia (anti-LUTS therapy)

  • Management of urinary incontinence (evaluation)

  • Management of urinary incontinence (conservative management)

  • Management of urinary incontinence (pharmacotherapy)

  • Management of urinary incontinence (surgical management)

  • Management of urinary incontinence (other therapeutic interventions)

Nonpharmacologic interventions

Phytotherapy: as per EAU 2024 guidelines, offer hexanic extract of Serenoa repens in patients with LUTS wishing to avoid any potential adverse events especially related to sexual function.
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inform patients that the magnitude of efficacy may be modest.
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Therapeutic procedures

Prostatic artery embolization: as per AUA 2024 guidelines, consider offering prostatic artery embolization, performed by clinicians trained in this interventional radiology procedure, for the treatment of patients with LUTS secondary/attributed to BPH following a discussion of the potential risks and benefits.
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  • Prostatic stenting

  • Temporary implantable nitinol device

  • Intraprostatic botulinum toxin injection

Surgical interventions

Indications for surgery
As per AUA 2024 guidelines:
Perform surgery in patients with any of the following:
renal insufficiency secondary to BPH
refractory urinary retention secondary to BPH
recurrent UTIs
recurrent bladder stones or gross hematuria due to BPH
LUTS secondary/attributed to BPH refractory to or unwilling to use other therapies
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Do not perform surgery solely for the presence of an asymptomatic bladder diverticulum. Consider evaluating for the presence of bladder outlet obstruction in these cases.
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  • Transurethral resection

  • Transurethral incision

  • Transurethral vaporization

  • Transurethral microwave therapy

  • Transurethral needle ablation

  • Anatomical endoscopic enucleation

  • Laser enucleation

  • Plasmakinetic enucleation

  • PVP

  • Prostatic urethral lift

  • Water vapor thermal therapy

  • Robotic waterjet ablation

  • Simple prostatectomy

Patient education

General counseling
As per AUA 2024 guidelines:
Counsel patients on options for intervention, including behavioral/lifestyle modifications, medical therapy, and/or referral for discussion of procedural options.
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Inform patients of the possibility of treatment failure and the need for additional or secondary treatments when considering surgical and minimally invasive treatments for LUTS secondary to BPH.
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Follow-up and surveillance

Follow-up
As per EAU 2024 guidelines:
Follow-up all patients receiving conservative, medical, or surgical management.
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Define follow-up intervals and examinations according to the specific treatment.
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