Clinical solutions - Benign prostatic hyperplasia

Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP.

Enlarged prostate
Enlarged prostate

The case
A 60-year-old man presents with a history of nocturia, urinary hesitancy and decreased strength of the urine stream. Per-rectal examination found a normally soft, symmetrical, non-tender, possibly enlarged prostate.

Confirm the diagnosis
Diagnosis relies on excluding other causes of lower urinary tract symptoms (LUTS) such as drugs that cause acute retention or polyuria, prostate or bladder cancer, a pelvic mass, a urethral stricture, an overactive bladder, a UTI or prostatitis.1

Which investigations?
Collect urine for dipstick urinalysis and an MSU. Measure U&Es if the man has presented in acute retention. Do not routinely measure PSA - it may be elevated in other situations and a normal PSA does not exclude BPH.2

When should I test PSA level?
The decision to measure PSA should be made on an individual basis. Early prostate cancer is usually asymptomatic and unlikely to be confused with symptomatic BPH;3 a raised PSA may be due to causes other than cancer. A negative PSA test may provide false reassurances when cancer is present. However, PSA level is sometimes used to guide the choice of drugs.

When should I refer someone with LUTS?
Refer to hospital immediately if there is acute renal failure. Refer urgently if prostate cancer is suspected, or there is a normal prostate but rising or elevated age-specific PSA, haematuria, or chronic urinary retention with overflow or night-time incontinence.4 Refer non-urgently men with treatment resistant symptoms, with chronic renal failure or persistent UTI.

How should I assess?
Assess symptoms using a scoring system (the IPSS) and consider advising a frequency-volume voiding diary for one to two weeks. Ask about aggravating factors and sexual problems. Examine the abdomen for an enlarged bladder. Examine the external genitalia and do a digital rectal examination to assess the size of the prostate. If uncertain about the size, consider PSA testing as a proxy for prostate size.5

How should I treat someone without bothersome symptoms?
For smaller prostates, advise watchful waiting and reassess annually. If the prostate is large, the options include watchful waiting or prescribing a 5 alpha-reductase inhibitor.

How should I treat someone with bothersome symptoms?
For smaller prostates prescribe an alpha-blocker. Follow-up after two weeks and titrate dose accordingly. If the prostate is large, start treatment with an alpha-blocker and a 5-alpha reductase inhibitor. Follow-up at two weeks, then at six months and annually thereafter.

Referral recommendations are based on the NICE guidelines for referral for suspected prostate cancer.4 Treatment recommendations are based on guidelines published by the British Association of Urological Surgeons,6 the European Association of Urology,7 and the American Urological Association.5



1. Madersbacher S, Alivizatos G, Nordling J et al. European Urology 2004; 46(5): 547-54.

2. Austoker J, Kirby M. Advising men about the PSA test for prostate cancer. NHS Cancer Screening Programmes. 2009.

3. Frydenberg M, Wijesinha S. Australian Family Physician 2007; 36(5): 345-7.

4. NICE. Referral guidelines for suspected cancer. 2005.

5. American Urological Association. Management of BPH. Updated 2006.

6. Speakman MJ, Kirby RS, Joyce A et al. BJU International 2004; 93(7): 985-90.

7. de la Rosette J, Madersbacher S, Alivizatos G. et al. Guidelines on benign prostatic hyperplasia. European Association of Urology. 2004.

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