Epidemiology

Etiology

• Dihydrotestosterone (DHT) is a potent prostatic growth factor.
• Androgen-estrogen imbalance: As men age, testosterone levels decline, but estrogen levels remain the same, which results in a higher estrogen/testosterone ratio.

Pathophysiology

Clinical features

Diagnostics

Serum PSA level

• Findings
  • Total PSA > 1.5 ng/mL: suggests an enlarged prostate (> 40 mL)
  • Total PSA > 4 ng/mL: increased likelihood of prostate cancer
• Free PSA levels and free PSA/total PSA ratio
  • ↑ Free PSA levels and ↑ free PSA/total PSA ratio: usually seen in BPH
  • ↓ Free PSA levels and ↓ free PSA/total PSA ratio: suggestive of prostate cancer

MRI and CT pelvis

Treatment

Pharmacological therapy

Uroselective alpha-1 blockers

• Tamsulosin, Doxazosin, Alfuzosin, Terazosin

5-alpha reductase inhibitors (5-ARIs)

• See Androgen and estrogen synthesis#Adrenal androgen synthesis
• Inhibition of 5-alpha reductase → ↓ conversion of testosterone to DHT → ↓ intraprostatic DHT levels → ↓ prostatic growth and ↑ prostatic apoptosis and involution → improvement of LUTS
• Adverse effects: sexual dysfunction (e.g., erectile dysfunction, decreased libido, ejaculatory dysfunction), gynecomastia
• Finasteride, Dutasteride

Phosphodiesterase type 5 inhibitors (PDE-5 inhibitors)

• Increase in intracellular cGMP → ↓ detrusor, prostate, and urethra muscle tone → improvement of LUTS
• Tadalafil

Complications

• Recurrent UTI
  • BPH → incomplete voiding → urinary stasis → predisposition to UTIs
• Urinary retention with bladder distension and bladder wall thickening (hypertrophy)
• Bladder calculi
• Hydronephrosis
• Chronic kidney disease