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Upon completion of the chapter, the reader will be able to:

  1. Explain the pathophysiology of benign prostatic hypertrophy (BPH).

  2. Recognize the symptoms and signs of BPH.

  3. List the desired treatment outcomes for BPH.

  4. Identify factors that guide selection of a particular α1-adrenergic antagonist for an individual patient.

  5. Compare and contrast α1-adrenergic antagonists, 5α-reductase inhibitors, anticholinergic agents, tadalafil, and mirabegron in terms of mechanism of action, treatment outcomes, adverse effects, and interactions.

  6. Describe the indications, advantages, and disadvantages of a combination drug regimen that includes an α1-adrenergic antagonist and 5α-reductase inhibitor.

  7. Describe the indications for surgical intervention.

  8. Apply the patient care process to develop an individualized treatment plan.


The prostate is an organ, which is the shape and size of a horse chestnut. It encircles the portion of the proximal posterior urethra that is located at the base of the urinary bladder. The prostate produces secretions, which are part of the ejaculate.

Benign prostatic hypertrophy (BPH) is the most common benign neoplasm in men who are at least 40 years of age. BPH can produce lower urinary tract symptoms (LUTS), a collection of obstructive and irritative voiding symptoms that are consistent with impaired emptying of urine from and defective storage of urine in the bladder, respectively. Medications are first-line treatment to reduce symptoms and/or delay complications of BPH.1


BPH first presents as benign prostatic hyperplasia, a histologic disease in many elderly men which increases in prevalence with advancing patient age. Benign prostatic hyperplasia may progress to BPH, which is clinically evident, and then to benign prostatic obstruction, which produces LUTS. Of patients with histologic disease, only about 50% of patients develop an enlarged prostate on digital palpation and 25% of patients exhibit clinical voiding symptoms.2,3 It is estimated that 8% of men 40 years of age, increasing to 35% of men 60 to 69 years of age, have voiding symptoms consistent with BPH, and 20% to 30% of all male patients who live to the age of 80 years will require a prostatectomy for severe voiding symptoms of BPH.3

Two chief etiologic factors for BPH include advanced patient age and the stimulatory effect of androgens.

  • Prior to 40 years of age, the prostate in men is approximately 15 g (0.5 oz) to 20 g (0.7 oz). However, in men who have reached 40 years of age, the prostate undergoes a growth spurt, which continues as men advance in age. BPH can result in clinically symptomatic LUTS.3,4

  • The testes and adrenal glands produce 90% and 10%, respectively, of circulating testosterone. Testosterone enters prostate cells, where predominantly Type II 5α-reductase converts testosterone to dihydrotestosterone, which combines with a cytoplasmic receptor. The complex enters the nucleus and induces changes ...

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