Asian Journal of Urology (2017) 4, 181e184

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Review

Benign prostatic hyperplasia and male lower

urinary symptoms: A guide for family
physicians
Farhad Fakhrudin Vasanwala a,*, Michael Yuet Chen Wong b,
Henry Sun Sien Ho c, Keong Tatt Foo c

a
Department of Family Medicine, Sengkang Hospital at Alexandra Hospital, SingHealth, Singapore
b
International Urology, Fertility and Gynaecology Centre, Mount Elizabeth Medical Centre, Singapore
c
Department of Urology, Singapore General Hospital, SingHealth, Singapore

Received 20 August 2016; received in revised form 4 January 2017; accepted 8 March 2017
Available online 14 June 2017

KEYWORDS Abstract Male patients with lower urinary tract symptoms (LUTS) and benign prostatic hyper-
Benign prostatic plasia (BPH) are increasingly seen by family physicians worldwide due to ageing demographics.
hyperplasia; A systematic way to stratify patients who can be managed in the community and those who
Male lower urinary need to be referred to the urologist is thus very useful. Good history taking, physical examina-
tract symptoms; tion, targeted blood or urine tests, and knowing the red flags for referral are the mainstay of
Guideline; stratifying these patients. Case selection is always key in clinical practice and in the setting of
Family physicians the family physician. The best patient to manage is one above 40 years of age, symptomatic
with nocturia, slower stream and sensation of incomplete voiding, has a normal prostate-
specific antigen level, no palpable bladder, and no haematuria or pyuria on the labstix. The
roles of a blockers, 5-a reductase inhibitors, and antibiotics in a primary care setting to
manage this condition are also discussed.
ª 2017 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V. This
is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction commonly seen by family physicians in the community due to

worldwide ageing demographics. This succinct guide serves
Male patients presenting with benign prostatic hyperplasia to assist the busy physician on the clinical examination, in-
(BPH) and lower urinary tract symptoms (LUTS) are vestigations and management in a primary care setting.

* Corresponding author. Sengkang Hospital at Alexandra Hospital, Singapore

E-mail address: [email protected] (F.F. Vasanwala).
Peer review under responsibility of Second Military Medical University.

http://dx.doi.org/10.1016/j.ajur.2017.05.003
2214-3882/ª 2017 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
182 F.F. Vasanwala et al.

2. Definition of clinical BPH suspicious for significant obstruction, which would

need more aggressive treatment and referral to the
Clinical BPH is prostate adenoma/adenomata (PA) causing a urologist.
varying degree of bladder outlet obstruction with or iv) Digital rectal examination (DRE): This is important in
without symptoms. PA comprises an important cause of differentiating PA (which feels firm and smooth) from
male LUTS [1]. PA is a widespread problem that increases malignancy (which feels hard and irregular). The
with age. Almost one in four men with prostate problems latter of course requires urgent referral to the urol-
aged 40e49 years receives treatment, and this increases to ogist. A useful guide for note is that when the pros-
three in every four men aged 70 years and older [2]. tate is flat, it is likely to be small, and when the
prostate feels globular, large. Another way to look at
this is that a finger’s breadth represents about
3. Definition of male LUTS
15e20 g and so a gland that is three fingers in breadth
across is 45e60 g [3].
Male LUTS can be classified as follows: v) Fasting serum glucose, serum urea and electrolytes
plus a urine dipstick: These tests are needed to rule
i) Voiding symptoms (obstructive) usually caused by pros- out diabetes, significant renal impairment (e.g., due
tate or bladder neck stenosis/urethral/meatal stricture; to hydronephrosis secondary to bladder outlet
symptoms include: hesitancy, weak stream, post obstruction), haematuria and urinary tract infection.
micturition dribble, urinary retention, straining and Those with significant renal impairment due to
incomplete emptying. obstruction and those with haematuria especially
ii) Storage symptoms (irritative) that may be caused by an isomorphic red blood cells on phase contrasts need to
overactive bladder or a bladder tumor/stone; symptoms be referred to the urologist. Patients with dysmorphic
include: urgency, urge incontinence, frequency, noctu- red blood cells should be referred to the renal phy-
ria, dysuria and suprapubic pain [2]. sicians to investigate for causes such as glomerulo-
nephritis or nephritis.
In general, the symptoms seen in early BPH are nocturia vi) Serum prostate specific antigen (PSA): PSA testing is
and slower urinary stream with sensation of incomplete recommended for patients with LUTS and prostate
voiding. When male patients present with urinary urgency cancer can be reasonably excluded if DRE is normal
and urge incontinence, the concern is that we are dealing and PSA is within the normal range of below 4 mg/L. A
with advanced BPH as they may have developed bladder serum PSA below 1.5 mg/L indicates minimal or no
dysfunctions. BPH if the flow is good and the patient’s symptoms
can be due to other causes such as OAB or ageing
4. Diagnosis of clinical BPH (PA) bladder. In general raised PSA can be due to cancer
and non-cancer reasons, and it is best to refer this to
Family physicians are usually the first medical professionals the urologist to differentiate between the two.
patients consult for symptoms and signs suggestive of PA.
The guidelines proposed here are suggestions on how family The following suggested optional tests can be performed
physicians can best diagnose and treat patients with PA. in the family practice setting, pending logistics:

i) Age: PA usually occurs after the age of 40 years. In i) Observation of the voiding process: The voided urine
the younger age group, urethral stricture should be can be collected in a urinal and the time required to
considered as a possible differential diagnosis, and in void is recorded. This would give an estimate of the
the older age group, “ageing bladder” and nocturnal average flow rate and severity of obstruction. As a
polyuria. point of reference, the average flow rate for males
ii) International Prostate Symptoms Score (IPSS) and aged 14e45 years is 21 mL/s, 12 mL/s for those aged
Quality of Life (QoL) Index: These scores give an idea 46e65 years and 9 mL/s for those aged 66e80 years
of the severity of LUTS and the most bothersome [4,5].
symptoms. On follow-up, these scores can give ac- ii) Voiding diary: Instruct the patient to note the volume
curate documentation of patients’ progression and of void, fluid intake and time of each event over the
deterioration. The deterioration of symptoms espe- course of 3 days. This is non-invasive and useful in
cially frequency and urgency may indicate develop- differentiating patients with OAB, inappropriate fluid
ment of an overactive bladder (OAB). It is encouraged intake, and nocturnal polyuria. Normally the amount
that the IPSS/QoL questionnaire be given in the of urine passed in 24 h should be between 1.5 L and
waiting area if the presenting complaint told to the 2.0 L, two thirds of which should be during waking
attending nurse in charge of the clinic is suggestive of hours and one third at night. In nocturnal polyuria,
BPH/LUTS in order to reduce the consultation time. seen in geriatric patients, this may be the reverse.
iii) Palpate and percuss for a distended bladder: A clini- iii) Radiological investigations: Ultrasonography is useful
cally detectable bladder immediately after urination for helping to determine bladder wall thickness,
indicates significant residual urine. The bladder prostate size and shape, degree of hydronephrosis and
needs to be at least 200 mL to be palpable. This is post-void urine. However, most family physicians do
Benign Prostatic Hyperplasia and Male Lower Urinary Symptoms 183

Figure 1 Benign prostatic hyperplasia/male lower urinary tract symptoms flowchart for the family physician. DRE, digital rectal
examination; IPSS, International Prostate Syndrome Score; PSA, prostate specific antigen; QoL, Quality of Life Index; 5-ARIs, 5-a
reductase inhibitors.

not have an ultrasound machine and generally it is not ii) a Blockers: Those patients who are bothered and
recommended for initial investigations of patients with without a palpable bladder and not better with phy-
uncomplicated LUTS in a family medicine practice. totherapy can be started on a trial of a blockers after
counselling on the side effects especially postural
hypotension. The usual advice is not to change the
5. Treatment of patients with PA/male LUTS position of the head too quickly when getting up from
bed and to be careful on bending down to fetch items
Case selection is always key in clinical practice and in the in the lower shelves in the super market. Patients also
setting of the family physician. The best patient to manage need to be careful when bending to play tennis or
is one above 40 years of age, symptomatic with nocturia, golf. It is encouraged to use selective a blockers to
slower stream and sensation of incomplete voiding, has a eliminate the need for titration. Most studies show
normal PSA level, no palpable bladder and no haematuria or that the effect of a blockers are seen after 2 weeks
pyuria on the labstix. and it is important not to give up too early and wait
for results of this trial of medication. In general a trial
i) Phytotherapy: Hexanic extract of Serenoa (HESr), can of 4e6 weeks is reasonable as some patients may
be used as initial treatment for patients with mild develop spells of urinary urgency in the first 3e4
LUTS. Double blind studies have shown that it has weeks; irritable bladder symptoms are largely
anti-inflammatory activity in men with BPH-related resolved by 4e6 weeks while the obstructive symp-
LUTS. Plus, it is well known as a safe product indi- toms are resolved much earlier at 2e4 weeks. If the
cated in the management of symptomatic BPH pa- family physician does not see any improvement after
tients [6]. 4e6 weeks of medication, the consideration is to
184 F.F. Vasanwala et al.

refer to the urologist to investigate. If the medication 6. Conclusion

is effective after 4e6 weeks, patients can be given
further courses of the a blocker and monitored at This serves as a concise guide for the family physician and a
intervals of 3e4 months, with PSA tested on a yearly flowchart of the management of BPH/male LUTS patients is
basis if there are no concerns. Patients should be shown in Fig. 1. We believe that by following this guideline,
advised that a blockers relieve symptoms only but do a significant proportion of such patients with BPH and LUTS
not prevent progression of the disease. This is can be managed in the community, thus ensuring a proper
because a blockers do not reduce the size of the balance in the need for referrals to the urologist and cost
prostate [7]. Patients’ symptoms may wax and wane effectiveness.
and therefore it may be reasonable for patients to
trial off the a blockers, or take them only on an as-
needed basis. Conflicts of interest
iii) Antibiotics: Prostatitis may be present at the time of
presentation. This may present more like irritable The authors declare no conflicts of interest.
bladder symptoms with intermittent dysuria and
elevated PSA. It is reasonable to give a course of
prostate-targeted antibiotics at the start of a Acknowledgements
blockers to improve the response to prostate medi-
cation. If the PSA remains elevated at 2e3 months The authors thank Ms Mei Ying Ng for her assistance in
follow-up after a course of antibiotics, then referral editing the manuscript.
to the urologist should be made.
iv) 5-a Reductase inhibitors (5-ARIs): 5-ARIs may be
added to those with larger prostate volumes on DRE References
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