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As men age. the normal golf ball-sized prostate increases in size due to hyperplasia of the prostatic epithelium. A subsequent increase in the fibromuscular stroma causes the prostate gland to encroach on the urethra. Why the prostate usually enlarges with age is unknown, though the action of androgens at a cellular level seems to have a major influence. The bladder compensates for the increased resistance by thickening its wall with hypertrophic muscle bundles that, when visualized cytoscopically. appear as trabeculation. Irritation may accompany obstructive symptoms because the thickened bladder wall is noncorn-pliant and spontaneous bladder contractions occur with distention.
TABLE 64-3 lists the American Urological Association’s scoring system for benign prostatic hyperplasia. A man with a score of ^ 8 is considered to have moderate symptoms; a score > 20 indicates severe symptoms. However, neither symptoms, flow rale, nor excessive post-voiding bladder volumes per se indicate the need for medical or surgical treatment. These symptoms and signs of benign prostatic hyperplasia are highly variable. The degree to which the problem bothers the patient is usually the best indication of his need for treatment.
Evaluation
A man with moderate symptoms (eight or more) should have at least a serum creatinine measurement and a urinalysis. Poslvoiding residual is besl measured by catheterization. More than 5 KBCs per high-power field in uninfected urine requires cystoscopy to rule out bladder cancer. Abnormal renal function should prompt ultrasound evaluation of the ureters and of the bladder after voiding for signs of obstruction. Hydronephrosis or a large postvoiding residual (> 350 mL) usually requires surgical intervention. Recurrent, severe urinary tract infection wilh a large postvoiding residual, or jargc bladder calculi in a patient with trabeculation and visible prostatic obstruction, also call lor prostate surgery.
Treatment
The treatment of benign prostatic hyperplasia can be divided into three categories: surgery, medical therapy, and watchful waiting. For most men with advanced symptoms, surgery is the besl and most effective option.

Surgery: The choice of surgical procedures includes open prostatectomy, transurethral incisions, and transurethral resection of the prostate (TURP). Surgery is recommended when creatinine levels are increasing, when hematuria or outflow obstruction recurs because of an enlarged prostate, or when other therapies fail. Surgery is also the most effective treatment for men with moderate to severe symptoms and significant distress from benign prostatic hyperplasia. Open prostatectomy is most appropriate for removal of exceedingly large prostate glands. Its advantage is that subsequent surgery is needed less often for recurrence of symptoms. However, it is associated with more short-term complications. TURP is usually performed under spinal anesthesia in an inpatient setting. Transurethral incision is most useful in men who have significant symptoms but a small prostate gland. Transurethral incision can be done under spinal or iocal anesthesia. Regardless of which procedure is used, frail older men may need longer inpatient stays. Since the length of surgery adds significantly to the risk, very ill older patients may do best with incisions or removal of small amounts of tissue by TURP.
A recent Veterans Administration Cooperative Trial compared TURP to close monitoring without surgical intervention in men with moderate symptoms of benign prostatic hyperplasia. It showed no mortality from TURP, although other studies suggest a mortality rate of about 1%. The most common postoperative complications were retention requiring recatheterization (4%) and hemorrhage requiring a transfusion (1%). Although uncontrolled studies have suggested that TURP causes incontinence in as many as 22% of patients and impotence in 2% to 12% of patients, these problems were not statistically associated with surgery in this controlled trial. About 10% of TURP patients developed bladder neck contracture or needed urethral dilatation or another TURP procedure within 3 yr.
Other invasive treatments are available for benign prostatic hyperplasia. Urethral stents may be placed in a frail man with severe obstruction and a limited life expectancy to avoid any need for general anesthesia. Laser prostatectomy may be as effective as TURP, but it is much more expensive, requires a long period of catheterization after treatment, and will probably have a similar profile of complications

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