Benign Prostatic Hyperplasia (BPH) – A PLAB 2 Guide

Ann Augustin
Jul 24
3 min read

Updated: Aug 29

Benign Prostatic Hyperplasia (BPH) is a common and high-yield condition in PLAB 2, especially in male patients presenting with lower urinary tract symptoms (LUTS) or complications like urinary retention or UTI. This blog will guide you through history-taking, examination, investigations, management, and patient-friendly explanations.

🧠 What Is BPH?

BPH is a non-cancerous enlargement of the prostate gland, often seen in men over 50. As the prostate enlarges, it compresses the urethra, leading to difficulty in urination and complications like incomplete bladder emptying.

🗣️ Layman Explanation:

“Your prostate is a small gland that sits below the bladder and helps make semen. As men get older, it can grow bigger and press against the tube that carries urine out. This can make it harder to pass urine and sometimes causes infections.”

⚠️ Risk Factors for BPH

Increasing age (most important)
Hormonal changes (e.g. increased DHT)
Family history of BPH
Obesity and metabolic syndrome
Type 2 diabetes
Sedentary lifestyle
Hypertension
Erectile Dysfunction (ED) – both share vascular and hormonal links
High-fat diet and low intake of fruits and vegetables

🚨 Symptoms: Lower Urinary Tract Symptoms (LUTS)

LUTS are classified into:

🔹 Storage (Irritative):

Frequency
Urgency
Nocturia
Urge incontinence

🔹 Voiding (Obstructive):

Hesitancy
Weak stream
Straining
Intermittency
Incomplete emptying
Terminal dribbling

🔹 Post-micturition:

Dribbling after urination
Persistent feeling of a full bladder

🩺 Examination & Bedside Investigations

🔎 Examination:

Abdominal exam → Palpate for bladder distension
Digital Rectal Exam (DRE) → Smooth, firm, enlarged prostate with a central sulcus suggests BPH⚠️ Hard or nodular prostate suggests malignancy

🧪 Bedside Investigations:

Urine dipstick → Check for signs of UTI
Bladder scan → Check post-void residual volume (>100–150 mL = incomplete emptying)
Urine culture → If infection suspected
PSA → Baseline before starting finasteride
U&Es → Rule out renal impairment

💊 Management

✅ Mild symptoms:

Watchful waiting + lifestyle changes (limit caffeine, alcohol, double voiding)

✅ Moderate to Severe symptoms:

Tamsulosin (α-blocker) – Relieves symptoms quickly
Finasteride (5α-reductase inhibitor) – Shrinks prostate; takes 3–6 months to work
Combination therapy if prostate is significantly enlarged or PSA >1.5 ng/mL

📍 Both tamsulosin and finasteride can be started by a GP after basic workup.

❗ Erectile Dysfunction and BPH – A Dual Concern

Erectile Dysfunction (ED) is both:

A risk factor for developing BPH
A complication that may arise from BPH or its treatments (e.g. finasteride)

✅ Treatment Strategy:

Tadalafil 5 mg once daily – effective for both ED and LUTS
May combine cautiously with α-blockers (monitor BP)
Consider ED impact before starting finasteride

⚠️ Complications & When to Admit

Complication	Action
Acute retention	Immediate catheterization + admit
Recurrent UTIs	Consider retention or incomplete voiding
Renal dysfunction	Admit if U&Es deranged
Sepsis from UTI	Blood + urine cultures, IV antibiotics, admit
Gross bladder distension (>500–600 mL)	Urgent decompression, monitor for post-obstructive diuresis
Erectile Dysfunction	Address both BPH and sexual health needs holistically

🛏️ Trial Without Catheter (TWOC)

After acute retention, start α-blocker and arrange TWOC in 3–5 days. If unsuccessful, refer to urology.

🧠 PLAB 2 Tips

✅ Use SOCRATES for symptom analysis

✅ Screen for red flags: hematuria, weight loss, bone pain

✅ Use lay language for explanation

✅ Offer safety-netting and follow-up

✅ Always check and explain post-void residual findings

✅ If UTI present with penicillin allergy, consider nitrofurantoin, trimethoprim, or fosfomycin (avoid cephalosporins if severe allergy)

🧾 Sample Patient-Friendly Explanation (UTI + BPH):

“It looks like you have a urine infection, likely because your prostate has become enlarged and isn’t letting your bladder empty fully. The leftover urine can allow germs to grow and cause infections. We’ll start treatment and monitor your bladder function.”

📌 Takeaway

BPH is a common station that tests your clinical reasoning, communication, and safety-netting. Focus on structured symptom assessment, relevant examination, and offering a clear management plan. Don’t forget to ask about and address sexual health, especially if ED is already present or if considering medications that may worsen it.

📚 References: