Urology & Family Medicine & Internal Medicine
Benign prostatic hyperplasia (BPH)
Benign prostatic hyperplasia (BPH) is a non-malignant proliferation of stromal and epithelial cells in the transition zone of the prostate, leading to a progressive increase in glandular volume and lower urinary tract symptoms (LUTS) in men. It is one of the most common conditions in aging men: histologically present in 50 % of men aged 50 and 90 % of those aged 85 (Berry 1984 - Journal of Urology). The normal prostate weighs 20-25 grams; symptomatic BPH typically reaches 30-80 grams, sometimes more. The pathophysiology is based on an age-related hormonal imbalance - relative increase in estrogens versus testosterone and accumulation of dihydrotestosterone (DHT) in prostate tissue - combined with hypersensitivity of androgen receptors in the transition zone. The resulting cervical-urethral obstruction produces two types of symptoms: obstructive BPAH (weak stream, hesitation, incomplete voiding) and irritative BPAH (urinary urgency, pollakiuria, nocturia), quantified by the International Prostate Symptom Score (IPSS). BPH must be distinguished from prostate cancer, which can coexist and requires specific screening with PSA and digital rectal examination. Treatment options range from active surveillance for mild forms to well-established drug therapies (alpha-blockers, 5-alpha-reductase inhibitors, antimuscarinics, PDE5 inhibitors) to minimally invasive surgery or transurethral resection of the prostate (TURP) for severe or complicated forms.
Pathophysiology, risk factors and clinical assessment
- Pathophysiology of BPH - role of DHT, estrogens and stroma : prostate transition zone (McNeal 1984 - American Journal of Surgical Pathology): exclusive site of BPH → represents 5 % of prostate volume in young adults → can reach 90 % of volume in severe BPH → peripheral zone: site of prostate cancer (70 % of cancers) → central zone: rarely affected by BPH or cancer; role of androgens: testosterone → converted to DHT by type 2 5-alpha-reductase (in stromal cells) → DHT: intratissular androgen 5× more potent than testosterone → affinity to androgen receptor ×5 → accumulation of DHT in transition zone with age → stimulates cell proliferation + inhibits apoptosis → castrated before puberty: never develop BPH → confirmation of central role of DHT + aging: relative increase in estrogens (decrease in free testosterone) → estrogens increase stromal sensitivity to DHT + up-regulate androgen receptors → synergistic effect on proliferation; obstructive component - mechanical vs. dynamic: mechanical obstruction: direct compression of prostatic urethra by glandular volume → surgically reversible → dynamic component: urethral and bladder neck smooth muscle tone (alpha-adrenergic innervation - alpha-1A receptors predominant in prostate 70 % + alpha-1D in bladder) → explanation for rapid efficacy of alpha-blockers on SBAU → detrusor hypertrophy: in response to chronic obstruction → thick bladder walls → trabeculations → diverticula → bladder instability → voiding emergencies → long-term: bladder decompensation → large post-micturition residue (PMR) → chronic retention → risk of obstructive renal failure; BPH risk factors (Parsons 2007 - Journal of Urology - meta-analysis): age (main factor) + obesity and metabolic syndrome (insulin resistance → IGF-1 ↑ → prostatic proliferation) + hyperlipidic diet + reduced physical activity + genetic predisposition (risk × 4 if brother or father affected before age 60) + type 2 diabetes + hypertension + ischemic heart disease (association with metabolic syndrome) → protective factors: physical activity + Mediterranean diet (rich in lycopene + polyunsaturated fatty acids) + statins (modest effect on prostate volume) + moderate alcohol (paradoxical effect - possible via estrogens); IPSS score (International Prostate Symptom Score) - central assessment tool: 7 questions on SBAU over the past 4 weeks (score 0-5 per question) → total score 0-35 → mild SBAU: 0-7 + moderate SBAU: 8-19 + severe SBAU: 20-35 → + 1 quality-of-life (QoL) question out of 6 → internationally validated IPSS (Barry 1992 - Journal of Urology) → used for follow-up under treatment (improvement ≥3 points = clinically significant) → correlates modestly with prostate volume and urine output → important : severe SBAU can coexist with moderate prostatic volume (predominantly dynamic component) and vice versa → maximum urinary flow rate (Qmax) on uroflowmetry: normal >15 mL/s → obstructive BPH: <10-12 mL/s → plateau or staccato curve → micturition volume ≥150 mL required for interpretation
- Diagnostic workup - initial evaluation and additional tests : recommended basic assessment (EAU Guidelines 2023 + AUA 2021 + Urology Canada guides): complete history: obstructive BPH (weak stream + hesitancy during micturition + chopped stream + sensation of incomplete emptying + two-stage micturition) + irritative BPH (micturition urgency + diurnal and nocturnal pollakiuria + nocturia - document the number of nocturnal lifts) + IPSS score + QoL + duration of evolution + history (prostate cancer + urethral stricture + pelvic surgery + neurological) + pro- BPH medications (anticholinergics + opioids + antihistamines + psychotropics).BPH (anticholinergics + opioids + antihistamines + psychotropics + alpha-adrenergic decongestants - worsen retention) + anti-BPH drugs (diuretics → nocturia → worsens IPSS score without worsening BPH itself) ; digital rectal examination (DRE): assessment of approximate prostate volume (correlates imperfectly - ±30 % vs ultrasound) + consistency (firm and elastic in BPH vs hard and irregular in cancer) + symmetry + sensitivity + median sulcus + assessment of external sphincter → TR mandatory before any treatment to rule out clinically detectable cancer → PSA (prostate-specific antigen): recommended if life expectancy >10 years and if result may modify management → normal total PSA: <4 ngml (seuil traditionnel) → mais les seuils adaptés à l'âge sont plus pertinents : <2,5 si<60 ans + psa utilisé pour évaluer le volume prostatique (corrèle avec — 1 ≈ 30 de glandulaire)>1.5 ng/mL → predictive of BPH progression → guides indication for 5-alpha-reductase inhibitors + PSA unexpectedly elevated → prostate cancer to be ruled out (biopsy if indication); serum creatinine + eGFR: search for chronic obstructive renal failure (underlying chronic retention) → formal indication if complicated BPH + urinalysis (dipstick + ECBU if leukocytes): rule out urinary tract infection + microscopic haematuria → if haematuria → cystoscopy + urinary cytology → bladder tumour assessment; further tests as indicated: renal and bladder ultrasound + measurement of RPM (post-micturition residue): RPM normal <50 ml → rpm>300 mL → risk of complete retention + kidney damage → reinforced surgical indication → suprapubic prostate ultrasound: prostate volume (ellipsoid formula: 0.52 × L × H × W) → guides therapeutic decision (5-ARI inhibitors if volume >30-40 mL) → TRUS (transrectal ultrasound): more precise + guided biopsy if cancer suspected + uroflowmetry: Qmax + flow curve + micturition volume → RPM by ultrasound immediately after + micturition diary (micturition diary - 3 days): frequencies + volumes + nocturia + emergencies → distinguish nocturia of urological origin from nocturnal polyuria (nocturnal polyuria if nocturnal volume >33 % of 24h urinary volume) + cystoscopy: if hematuria + suspicion of urethral stricture + atypical symptoms + pelvic surgical history + urodynamic assessment (pressure-flow): if doubt between obstruction and bladder hypocontractility (organic obstacle vs neurological decompensation)
- Differential diagnosis - distinguish BPH from other causes of SBAU : prostate cancer: may coexist with BPH → PSA + TR + biopsy if indication → presence of cancer does not always alter management of BPH + chronic prostatitis: predominant irritative SBAU + pelvic + perineal pain + history of acute prostatitis → NIH-CPSI (Chronic Prostatitis Symptom Index) + ECBU + sperm culture + urethral stricture: history of trauma + STI (gonorrhea) + catheterization + surgery → uroflowmetry: low plateau curve → urethrocystoscopy or retrograde urethrography + neurogenic bladder dysfunction: stroke + Parkinson's disease + MS + diabetes + spinal cord injury → mixed SBAU + neurological involvement → urodynamic assessment + idiopathic bladder instability (overactive bladder - OAB): pure irritative SBAU (urgency + pollakiuria) without obstruction → normal Qmax + low RPM → treatment : antimuscarinics or mirabegron + nocturnal polyuria: nocturnal diuresis >33 % of total 24h diuresis → origin: heart failure + sleep apnea + diabetes insipidus + diuretic intake in the evening → treatment: nocturnal desmopressin (Noctiva) if isolated nocturnal polyuria confirmed → do not treat as BPH.
Medical and surgical treatments
| Treatment | Mechanism, dosage and efficacy | Side effects and follow-up |
|---|---|---|
| Active monitoring and dietary hygiene measures IPSS ≤7 - behavioral advice - nocturnal water restriction - annual follow-up |
Active surveillance (watchful waiting) - indications and rationale: IPSS ≤7 (mild SBAU) + absence of complications (retention + renal failure + recurrent hematuria + recurrent infection + bladder stone) → BPH progression is variable and unpredictable: 1/3 of men improve spontaneously + 1/3 remain stable + 1/3 progress (Watchful Waiting Study Group - Wasson 1995 - NEJM: surveillance vs RTUP in moderate IPSS → at 3 years, 36 % in the surveillance group chose surgery + spontaneous improvement in 16 %) → behavioral and hygienic-dietary measures: water restriction in the evening (after 6pm) → reduces nocturia + avoid caffeine and alcohol (diuretics) → especially in the evening + double micturition (wait 30 seconds after the first micturition to empty the residue) + bladder training (gradually lengthen the intervals between micturitions to increase functional capacity) + reduction of aggravating drugs: revision of nasal decongestants (pseudoephedrine → alpha-adrenergic → contraction of bladder neck + worsening of retention) + anticholinergics (tricyclic antidepressants + antihistamines + antipsychotics) + opioids → physical activity: reduction of symptomatic BPH (Parsons 2007 - Journal of Urology) + weight management: obesity → metabolic syndrome → DHT ↑ + IGF-1 ↑ → BPH + diet: lycopene (tomatoes) + zinc + omega-3 fatty acids → less robust data; phytotherapy - limited evidence: Serenoa repens (saw palmetto): widely used in self-medication → presumed mechanism: partial inhibition of 5-alpha-reductase + anti-inflammatory → clinical trials: Bent 2006 - NEJM: randomized controlled trial → Serenoa repens 320 mg/d × 1 year → no significant difference vs placebo on IPSS + Qmax + prostate volume → CAMUS (Barry 2011 - JAMA): increasing doses of Serenoa repens → no superior effect to placebo whatever the dose → consensus: not recommended in EAU/AUA guideline → can be discussed if requested by patient with information on lack of solid evidence + Pygeum africanum + Urtica dioica (nettle): insufficient data → not recommended in 1st line | Actively monitored follow-up: IPSS + Qmax + RPM + TR + PSA → annually → if symptoms worsen (IPSS ≥8) or complication → initiate medical treatment + educate patient about warning signs requiring urgent consultation: total inability to urinate (acute retention) + persistent macroscopic hematuria + fever + back pain (obstructive pyelonephritis) + rapid progression of symptoms; risk factors for BPH progression - MTOPS study (McConnell 2003 - NEJM): PSA >1.5 ng/mL + prostate volume >30-40 mL + IPSS ≥8 + Qmax <10.6 mL/s → high risk of progression to retention or surgery → these patients benefit from combination therapy (alpha-blocker + 5-ARI inhibitor) rather than monitoring alone + CombAT study (Roehrborn 2008 - European Urology): dutasteride + tamsulosin vs monotherapy at 4 years → combination superior for clinical progression (retention + surgery) in high-risk men (volume ≥30 mL + PSA ≥1.5 ng/mL) |
| Alpha-blockers (alpha-1-antagonists) Tamsulosin - alfuzosin - silodosin - rapid onset of action - hypotension - retrograde ejaculation |
Mechanism of action and pharmacological rationale: alpha-1A receptors : predominant in prostate (70 % of prostatic alpha-1 receptors) + bladder neck + prostatic urethra → contraction of smooth muscle → blockade → relaxation of bladder neck + decrease in urethral tone → improvement in urine flow → dynamic component of obstruction → rapid effect (48-72h) → no effect on prostatic volume (do not alter the natural history of BPH); available molecules and selectivity: tamsulosin (Flomax): 0.4 mg/d → uroselective (alpha-1A) → most prescribed in Canada → taken after a meal to reduce hypotensive effects → sustained release → alfuzosin (Xatral): 10 mg/d LP → less selective + less effect on ejaculation → doxazosin (Cardura): 1-8 mg/d → non-selective (alpha-1A + vascular alpha-1B) → antihypertensive effect useful if concomitant hypertension → more marked orthostatic hypotension → terazosin (Hytrin): similar to doxazosin + silodosin (Rapaflo): 8 mg/d → highly selective alpha-1A → better efficacy on flow + retrograde ejaculation ++ (28 % of patients); clinical efficacy of alpha-blockers - evidence: meta-analysis Chapple 2004 - European Urology: alpha-blockers → IPSS improvement of 35-40 % + Qmax improvement of 20-30 % vs placebo → onset of action: 48h-2 weeks → maximum efficacy at 4-6 weeks → OMNIC Oncology Study (Nickel 2008 - BJU International): tamsulosin 0.4 mg/d × 2 years → IPSS reduction -4.9 points + Qmax +1.6 mL/s → efficacy maintained long-term → no reduction in risk of acute retention (Roehrborn 2005 - Urology) → do not alter the natural history of BPH → no volume reduction → no long-term prevention of surgery; target IPSS score under alpha-blocker: improvement ≥3 points = therapeutic success → if no improvement at 4-6 weeks → check compliance + reassess diagnosis → switch to combination or surgical treatment | Important side effects and drug interactions: orthostatic hypotension: risk with non-selective molecules (doxazosin + terazosin) → less with tamsulosin and alfuzosin → increased risk if diuretics + antihypertensives + nitrates + PDE5 inhibitors → introduce at low dose + gradual titration → retrograde ejaculation or anejaculation: tamsulosin: 5-10 % + silodosin: 28 % → mechanism: relaxation of the bladder neck → ejaculate in the bladder → benign but may affect fertility → inform the patient → intraoperative floppy iris syndrome (IFIS): risk during cataract surgery on alpha-blockers → iris loses tone → intraoperative complications → inform ophthalmologist and ophthalmic surgeon before any cataract → stopping tamsulosin does not always prevent IFIS (persistent effect on iris muscle receptors) → reporting in medical record essential + asthenia + rhinitis + headache (vasodilation) → major interactions: PDE5 inhibitors (sildenafil + tadalafil + vardenafil) + alpha-blockers → risk of severe hypotension → if combination necessary → prefer tadalafil 5 mg/d (approved indication BPH) + respect a 4-6h interval between doses if non-selective alpha-blocker |
| 5-alpha-reductase inhibitors (5-ARI) Finasteride - dutasteride - volume ≥30 mL - PSA - gynecomastia - prostate cancer |
Mechanism and rationale for use: finasteride (Proscar 5 mg/d): selectively inhibits type 2 5-alpha-reductase → reduces intratissular DHT by 70-90 % → prostate volume reduction by 20-30 % over 6-12 months → dutasteride (Avodart 0.5 mg/d): inhibits both isoforms (type 1 + type 2) → DHT reduction of 90-95 % → slightly more effective than finasteride on volume reduction (Roehrborn 2010 - Journal of Urology: dutasteride vs finasteride → slightly greater volume reduction with dutasteride) → indications for 5-ARIs (Endocrine Society + EAU 2023 + AUA 2021): prostate volume ≥30-40 mL (primary endpoint) + PSA ≥1.5 ng/mL → high-risk markers for progression → 5-ARIs modify the natural history of BPH → reduce the risk of acute retention and long-term surgery → PLESS trial (McConnell 1998 - NEJM): finasteride 5 mg × 4 years → reduced risk of acute retention by 57 % + reduced risk of surgery by 55 % + reduced prostate volume by 18 % → COMBAT trial (Roehrborn 2010): dutasteride alone + tamsulosin alone + combination → combination superior to monotherapies for clinical progression at 4 years (voluminous prostates); onset of action: 3-6 months → inform patient → assessment of efficacy at 6 months (IPSS + Qmax + echo volume + PSA); impact on PSA - 50 % rule: 5-ARIs reduce PSA by 50 % after 6 months of treatment → Glenski's rule (AUA): multiply PSA measured under 5-ARI × 2 to estimate equivalent value without treatment → if PSA has not decreased by 50 % after 6 months under 5-ARI → insufficient compliance OR abnormal increase → prostate cancer to be eliminated → biopsy if indication → prostate cancer under 5-ARI : PCPT (Thompson 2003 - NEJM): finasteride → 25 % reduction in prostate cancer prevalence → but relative increase in high-grade cancers (Gleason ≥7) → interpretation debated → detection effects (atrophy of healthy tissue + facilitated detection of aggressive foci) + REDUCE (Andriole 2010 - NEJM): dutasteride → 23 % reduction in low-grade cancer prevalence → non-significant increase in high-grade cancers | Side effects of 5-ARIs and impact on sexuality: erectile dysfunction: 5-8 % under finasteride + 9 % under dutasteride → reversible on discontinuation → mechanism: reduction of DHT → precursor of estradiol synthesis and local erectile function → decreased libido: 3-6 % → partial loss of libido → reversible in the majority of cases + retrograde ejaculation: less frequent than with alpha-blockers + gynecomastia: 1-2 % → glandular + painful → mechanism: DHT/estrogen imbalance → Post-finasteride syndrome (PFS): controversial → persistent symptoms (sexual dysfunction + depression + cognitive decline) after discontinuation of finasteride → FDA 2011 + Health Canada statements → mention in monograph → true incidence difficult to establish → recommend informing patient before prescribing + duration of treatment: 5-ARIs should be taken for life (or until surgery) → discontinuation leads to prostate volume regain in 6-12 months → PSA monitoring: every 6 months the 1st year → annually thereafter → with ×2 rule for interpretation; combination alpha-blocker + 5-ARI - MTOPS (McConnell 2003 - NEJM): doxazosin + finasteride vs monotherapies → at 4.5 years → combination → reduction in clinical progression of 67 % vs 39 % (doxazosin) and 34 % (finasteride) → CombAT (Roehrborn 2008 - European Urology): tamsulosin + dutasteride (Duodart) → superior to monotherapies on IPSS + Qmax + acute retention + surgery at 4 years → in prostates ≥30 mL + PSA ≥1.5 ng/mL → combination recommended upfront by EAU/AUA in these patients |
| Other drug treatments - antimuscarinics, mirabegron, PDE5 inhibitors Component OAB - tadalafil 5 mg - mirabegron - Residual irritant SBAUs |
Antimuscarinics and mirabegron - treatment of the OAB (overactive bladder) component in BPH: rationale: 50-75 % of men with BPH have an OAB component (urgency + pollakiuria) linked to bladder instability induced by chronic obstruction → antimuscarinics: oxybutynin + solifenacin (Vesicare 5-10 mg/d) + tolterodine (Detrol LA 4 mg/d) → block bladder M2 + M3 muscarinic receptors → reduce urgencies + pollakiuria → classic fear: urinary retention (inhibited detrusor contraction) → studies: Kaplan 2006 - BJU International: tolterodine + tamsulosin vs monotherapies → combination → significant improvement in irritative UBW without increase in RPM if RPM 200-250 mL + angle-closure glaucoma + severe xerostomia + severe constipation + cognitive impairment (long-term dementia risk with non-selective molecules - anticholinergics and Alzheimer risk) + mirabegron (Myrbetriq 25-50 mg/d): beta-3-adrenergic agonist → detrusor relaxation during filling → reduces urgency + pollakiuria → no risk of retention → no neurological contraindication → preferred to antimuscarinics in the elderly → side effects: HTA (monitor BP) + mild retention (rare) → combination mirabegron + solifenacin (SYMPHONY trial - Chapple 2017 - European Urology): superior to monotherapies on urgency and quality of life + vibegron (Vibegron): 2nd-generation beta-3 agonist → fewer drug interactions; PDE5 inhibitors - tadalafil 5 mg/d : mechanism: smooth muscle relaxation via the cGMP pathway + PDE5 inhibition in prostate + urethra + bladder → double benefit: UABS + erectile dysfunction (ED - very common in BPH patients) → FDA 2011 + Health Canada approval: tadalafil 5 mg/d for BPH ± ED → key TRIAL: McVary 2011 - Journal of Urology + Porst 2011 - European Urology: tadalafil 5 mg/d → IPSS improvement of 22-37 % + IIEF (erectile function) + comparable efficacy to alpha-blockers on SBAU → do not combine with non-selective alpha-blockers (hypotension) → tamsulosin + tadalafil: association possible with precautions (respect 4-6h delay) → preferred indication: BPH + concomitant ED + contraindications to or ineffectiveness of alpha-blockers | Desmopressin (DDAVP) for isolated nocturia: specific indication: nocturnal polyuria documented by voiding diary (nocturnal volume >33 % of total 24h diuresis) → without significant obstruction → Noctiva (nasal desmopressin) or Nocdurna (sublingual lyophilisate) → reduction of nocturnal diuresis → reduces nocturnal rising → contraindications: hyponatremia + heart failure + renal failure (eGFR 150-200 mL + suspicion of prostate cancer (abnormal TR + elevated PSA) + macroscopic hematuria + obstructive renal failure + acute urine retention (after removal of retention) + bladder calculus on BPH + consider surgery |
| Surgical treatment - TURP and minimally invasive alternatives RTUP - HoLEP laser - UroLift - REZUM - laser vaporization - absolute indications |
Transurethral resection of the prostate (TURP) - historical surgical reference: TURP has remained the reference procedure for surgical BPH for decades → technique: transurethral endoscopic resectoscope → electrical resection of obstructive prostatic lobes → specimen sent to anatomopathology (eliminate occult cancer - 10 % of RTUPs reveal cancer) → duration: 60-90 min → general anesthesia or spinal anesthesia → hospital stay: 2-3 days → bladder catheterization 2-3 days → formal indications for surgery (EAU 2023 - AUA 2021): recurrent acute or chronic retention refractory to medical treatment + BPH-related obstructive renal failure + bladder lithiasis on BPH + recurrent macroscopic hematuria refractory to 5-ARI + recurrent urinary tract infections on post-micturition residual + IPSS ≥20 refractory to optimal medical treatment → optimal prostate size for TURP: 30-80 mL → beyond 80-100 mL → open adenomectomy or HoLEP; RTUP efficacy: IPSS reduction of 70-80 % + Qmax improvement of 100-200 % → AUA 2021: interventional gold standard for prostates 30-80 mL + classic complication: irrigation fluid reabsorption syndrome (TURS - TUR Syndrome) → hyperhydration + dilution hyponatremia → agitation + convulsions → prevented by use of saline (bipolar resection) or by limited duration of monopolar resection (80 mL → but feasible for all sizes → enucleation of adenomatous lobes with holmium laser + intravesical morcellation → advantages: reduced bleeding + no TURS (saline) + applicable under anticoagulants + histology available → equivalent or superior long-term efficacy to RTUP (Ahyai 2010 - European Urology: meta-analysis) + longer learning curve; GreenLight laser (photoselective vaporization - PVP): 532 nm KTP laser → vaporization of prostate tissue → simultaneous hemostasis → effective under anticoagulants → no histology → long-term efficacy slightly inferior to HoLEP | Minimally invasive techniques - modern options for prostates 80 mL + REZUM (steam thermal vaporization): injection of steam into the prostatic stroma → coagulative necrosis → volume reduction by absorption → under local anesthesia → office-based → FDA 2015 + water heated to 103°C + Dixon 2019 - Journal of Urology : IPSS -53 % + Qmax +50 % at 4 years + preservation of ejaculatory function in 88 % of cases + prostatic high-intensity focused ultrasound (HIFU) ablation: under evaluation + prostatic artery embolization (PAE): interventional radiology → selective embolization of prostatic arteries → volume reduction by ischemia → encouraging data for large volumes + high surgical risk → Pisco 2016 - Journal of Vascular and Interventional Radiology + open or laparoscopic/robotic transvesical adenomectomy: reserved for very large volumes (>100-150 mL) → or if associated pathology requiring an open approach → Millin (retropubic) or Freyer (transvesical) incision + general complications of prostate surgery: retrograde ejaculation: 65-90 % after TURP → almost constant → to be distinguished from erectile dysfunction (preserved in 80 % of TURPs) + transient urinary incontinence: 10-30 % short-term → definitive <1-2 % + urethral stenosis: 3-5 % + transient post-operative dysuria + infection + bleeding |
ℹ️
The IPSS score guides all therapeutic decisions in BPH: IPSS 0-7 → active surveillance + behavioral measures - IPSS 8-19 → medical treatment (alpha-blocker ± 5-ARI depending on prostate volume and PSA) - IPSS ≥20 or complications → consider surgery. Improvement of ≥3 points in IPSS after 4-6 weeks of treatment is the validated threshold for therapeutic success. Persistent irritative SBAU despite an alpha-blocker should prompt a search for an OAB component (bladder instability) that may respond to mirabegron or an antimuscarinic.
Situations requiring urgent medical assessment
Acute complete retention of urine (ACRU): total inability to urinate + painful bladder globe palpable above the pubis → urological emergency → immediate bladder catheterization (transurethral bladder catheter or suprapubic catheter if transurethral route impossible) → relief of retention → etiological workup (trigger: anticholinergic + decongestant + constipation + retention on advanced BPH) → alpha-blocker initiated before catheter removal (OMNIC + Roehrborn 2005 - Urology: alpha-blocker 3 days before catheter removal → increases spontaneous micturition rate) → if two attempts at catheter removal fail → urology for discussion RTUP or HoLEP.
Total macroscopic hematuria (blood in all the urine from the start of micturition to the end) + urinary clots + inability to empty the bladder → bladder tamponade on clots → urological emergency → continuous bladder irrigation with large-caliber catheter (3 ways) → evacuation of clots + if known BPH: 5-ARI to reduce prostatic vascularization → if bleeding persists or recurs despite 5-ARI → RTUP or endoscopic coagulation → prostate or bladder cancer to be ruled out (cystoscopy + biopsy if indication).
Fever ≥38.5°C + intense perineal pain + abruptly aggravated micturition disorders + painful + fluctuating TR in a patient known to have BPH → prostatic abscess or severe acute prostatitis → emergency → ECBU + blood cultures + injected pelvic CT if abscess suspected → IV antibiotic therapy + drainage if abscess formed → do not massage the prostate on RT if acute prostatitis (risk of bacteremia).
Progressive rise in creatinine + dilatation of bilateral renal cavities on ultrasound + very high RPM (>400-500 mL) in an asymptomatic or minimally symptomatic patient → chronic retention with renal damage (bilateral obstructive uropathy) → immediate bladder drainage + post-drainage diuresis monitoring (obstruction lifting syndrome - massive diuresis → hypokalemia + dehydration) → full renal workup + urgent urological referral.
Consult at Clinique Omicron
Clinique Omicron's physicians evaluate male urinary disorders using IPSS scores, digital rectal exams, PSA assays and appropriate complementary tests, prescribe drug treatments for BPH and coordinate urological referrals for cases requiring surgery or specialized evaluation. Consultations for male urinary disorders are available at several points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The contents of this page are provided for information purposes only and do not replace the advice of a physician or urologist. Any new or rapidly progressive urinary disorder in a man should be the subject of medical consultation, particularly to rule out prostate cancer.
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