Prostate disease includes benign prostatic hyperplasia (BPH) and prostatitis.
GPs are typically the first point of contact for men with these conditions. This article provides information on managing BPH and prostatitis, including clinical assessment, treatment, referral and follow-up.
Benign prostatic hyperplasia
BPH is the non-cancerous enlargement of the prostate gland1. While not normally life-threatening, BPH can have a considerable impact on quality of life2.
Diagnosing benign prostatic hyperplasia
To diagnose BPH, review medical history for lower urinary tract symptoms (LUTS) and conduct a physical examination. You may also need to undertake additional tests.
BPH has several urinary symptoms. However, some men with BPH may not present with many or any symptoms of the disease.
It is recommended that GPs use the International Prostate Symptom Score (IPSS)3 questionnaire to evaluate symptoms. This will assist in treatment allocation and response monitoring.
Urinary symptoms of BPH
- Weak stream
- Post micturition dribble
- Sensation of incomplete bladder emptying
- Urgency (if there is severe incontinence)
- Nocturnal incontinence
- Urinary retention
Conduct a thorough assessment that includes:
- Digital rectal examination to estimate prostate size and identify other prostate pathologies
- Basic neurological examination
- Perianal sensation and sphincter tone
- Bladder palpation
- Calibre of the urethral meatus
Order a urinalysis or midstream urine.
If you suspect urinary retention or large post-void residual volume:
- Order an ultrasound of the kidneys and bladder
- Check creatinine levels to assess renal function
Prostate-specific antigen (PSA) levels
Conduct a PSA test:
- If prostate cancer is suspected e.g. following a prostate examination
- As part of screening for prostate cancer, after discussing pros and cons with the patient
Routine PSA screening is not necessary for patients with BPH. Patients with LUTS are not at increased risk of having prostate cancer.
PSA levels for different age groups of Western men:4
- 40-49 years: 0.7 ng/mL (serum PSA median); 2.5 ng/mL (serum PSA upper limit of normal)
- 50-59 years: 1.0 ng/mL (median); 3.5 ng/mL (upper limit)
- 60-69 years: 1.4 ng/mL (median); 4.5 ng/mL (upper limit)
- 70-79 years: 2.0 ng/mL (median); 6.5 ng/mL (upper limit)
Other PSA tests
Other PSA tests include creatinine levels, post-void residual urine (ultrasound) and PSA velocity (or doubling time).
Assessing PSA velocity:
- If the PSA level doubles in 12 months, it may indicate prostate cancer or prostatitis
- An elevated PSA and a stable velocity suggests BPH
- A high free-to-total PSA ratio (greater than 25%) suggests BPH; a low ratio (less than 10%) suggests prostate cancer
The Prostate Health Index (PHI) is not covered by the MBS. PHI is thought to be more specific for diagnosing prostate cancer than PSA level alone. But quality evidence is lacking, and it’s not recommended in Australian prostate cancer testing guidelines.
Investigations by a urologist
This can include:
- Tests outlined in the section on GP investigations above
- Uroflowmetry and post-void residual assessment
- Voiding diary
- Urodynamic assessment
Managing benign prostatic hyperplasia
Managing BPH depends on the type and severity of symptoms.
Observation and review
- This course of action is appropriate for mild or low-impact symptoms
- Optimise through reassurance, education, periodic monitoring and lifestyle modifications
- Consider adjusting medication e.g. timing of diuretic
- Once daily alpha-blockers are used to manage moderate to severe symptoms
- Tamsulosin, silodosin or alfuzosin are generally the first options to try
- Side-effect profiles may favour tamsulosin.
These include dutasteride and finasteride. 5ARIs are rarely used as monotherapy.
Combining dutasteride and tamsulosin is better for patients with large prostates (greater than 30 ml). However, 5ARI can affect sexual function so consider it carefully in sexually active men.
5ARI may be associated with prostate cancer risk so PSA surveillance is recommended. If PSA increases while the patient is on 5ARI, refer them to a urologist to exclude prostate cancer.
Bladder-directed medications are most commonly used for overactive bladder symptoms.
- Mirabegron, a beta-3 adrenergic agonist, which requires blood pressure monitoring within the first week
- Anticholinergics like oxybutynin, solifenacin, and darifenacin
Refer the patient to a urologist if there are any of the following indicators:
- Urinary retention history
- Urinary tract infection
- Failed medical therapy
- Incontinence (of any type)
- Post-void residual greater than 100 ml
- Severe symptoms (especially if poorly responsive to medications)
- Renal impairment
- Bladder stones
- Suspected prostate or bladder cancer
- An associated neurological condition e.g. Parkinson’s disease, multiple sclerosis
Indications for surgery are similar to the indications for referral to a urologist. Surgery can be considered when medications are no longer suitable. Stopping medication therapy usually results in the recurrence of symptoms.
The gold standard operation is transurethral resection of the prostate (TURP). However, there are many operations available, each with its pros and cons. These include:
- Transurethral Incision of the Prostate (TUIP)
- Green light laser resection of the prostate
- Minimally invasive insertion of small retractors into prostate
- Plasma Vaporisation
- Water vapour therapy
- Holmium Laser Enucleation of the Prostate (HoLEP)
When determining a suitable operation for the patient, consider the following factors:
- Prostate size and configuration
- Anti-coagulation status
- Side effects e.g. preference to preserve antegrade ejaculation
- Day stay versus overnight stay in hospital
- Catheter duration
- Durability of operation
Long-term catheterisation is a last resort for patients unfit or unwilling for surgery but with complications e.g. urinary retention. In these cases, a supra-pubic catheter is preferred to an indwelling urethral catheter. GPs should also consider intermittent self-catheterisation.
It is appropriate for a GP to monitor and follow up with a patient, regardless of their treatment modality. However, if the patient is not responding to medical treatment, refer them to a urologist.
Recommended follow-up timeline after BPH treatment:
- Observation and review: follow up at six months and annually thereafter
- 5α-reductase inhibitors: follow up at 12 weeks, 6 months and annually thereafter
- α-blockers: follow up at six weeks, six months and annually thereafter
- Surgery or minimally invasive treatment: follow up at six weeks, 12 weeks, six months and annually thereafter. Men who have had TURP remain at risk for prostate cancer and still need routine prostate cancer checks.
Prostatitis is an inflammation of the prostate gland from bacterial or non-bacterial infection. Acute bacterial prostatitis is the least common form but can be serious if the infection is left untreated.
Like BPH, prostatitis is rarely life-threatening, but quality of life can be severely affected.
Look for urinary symptoms and pain.
Symptoms of prostatitis:
- Dysuria (painful urination)
- Urgent need to urinate
- Frequent urination
- Painful ejaculation
- Lower back pain
- Perineal pain
- Chills and/or fever
- Muscular pain
- General lack of energy
Digital rectal examination:
- This should not be performed if you suspect acute severe prostatitis because it can be very painful
- Some tenderness and swelling may accompany sub-acute prostatitis
- May be dramatically high
- If the PSA level doubles in 12 months, it may indicate prostate cancer or prostatitis
- First pass urine: chlamydia urine PCR test
- Midstream urine: MC&S
- Urine PCR for STIs if chlamydia or another STI is a likely cause
There are several therapeutic options for prostatitis. There is limited evidence for benefits of these treatments; however, they may be trialled with the patient.
Bacterial prostatitis (acute and chronic) can be treated using antibiotics. Once diagnosed, rapid treatment is essential to avoid further complications.
For chronic nonbacterial prostatitis (chronic prostate pain syndrome), treatment is difficult, and cure is often not possible. Treatment focuses on symptom management to improve
quality of life. Non-medical therapy is recommended as the initial treatment.
The type of treatment a urologist will use varies according to the patient, their condition and their stage of treatment. Most patients will have antibiotic therapy at some stage.
- These are suited to patients with moderate to severe LUTS
- They include tamsulosin, silodosin and alfuzosin
- Side-effect profiles may favour tamsulosin
- Not all antibiotics penetrate the prostate gland.
- Recommended antibiotics are norfloxacin, ciprofloxacin, trimethoprim, sulphamethoxazole/trimethoprim, erythromycin and gentamicin.
- Young men with confirmed chlamydia prostatitis should be given doxycycline
Other medication options are analgesics and non-steroidal anti-inflammatory drugs.
Surgery has a very limited role and requires an additional, specific indication e.g. prostate
obstruction, prostate calcification.
A transurethral incision of the bladder neck or a transurethral resection of the prostate are the options for surgery.
There are also treatments outside of medication and surgery. These include:
- Prostate massage
- Heat therapy
- Supportive therapy: biofeedback, relaxation exercises, acupuncture, massage therapy, chiropractic therapy and meditation
- Lifestyle changes, for example, avoiding activities involving vibration or trauma to the perineum (bike riding, tractor driving, long-distance driving), cutting out caffeine, spicy foods and alcohol, and minimising constipation
- Treatment by a specialised pelvic floor physiotherapist, which may include pelvic floor relaxation techniques and trigger point massage
Indicators for referral to a urologist:
- The GP is not confident managing prostatitis
- The GP is concerned there are other potential diagnoses, particularly prostate or bladder cancer
- The patient does not respond to first-line therapies such as antibiotics or α-blockers. More invasive investigations, such as cystoscopy and a transrectal prostate ultrasound scan, are commonly done for these patients
- The need for urologist follow-up depends on the patient’s progress
- Most urologists will refer back to the GP to monitor the progress of the patient
- The urologist will seek re-referral if the patient’s progress is not satisfactory
- A GP can re-refer if they do not feel comfortable managing a relapse
Free clinical resource
Download the clinical summary guide as a print-ready PDF:
- Ng & Baradhi. Benign Prostatic Hyperplasia. In: StatPearls. Available at www.ncbi.nlm.nih.gov/books/NBK558920/
- Hong, et al., 2005. The importance of patient perception in the clinical assessment of benign prostatic hyperplasia and its management. BJU International
- Barry et al., 2017. The American Urological Association Symptom Index for Benign Prostatic Hyperplasia. The Journal of Urology
- Oesterling, 1993. Serum Prostate-Specific Antigen in a Community-Based Population of Healthy Men. JAMA
- Davis & Silberman. Bacterial Acute Prostatitis. In: StatPearls. Available at www.ncbi.nlm.nih.gov/books/NBK459257/