Dr. R K Shimpi – Benign Prostatic Hyperplasia (BPH) & Over Active Bladder (OAB)

The prostate gland is a small but essential male organ that surrounds the urethra and contributes to the production of seminal fluid. In healthy men around the age of 40, it typically measures about 2–3 cm and weighs 10–15 grams. As men grow older, natural hormonal shifts, particularly a relative increase in estrogen compared with testosterone, stimulate gradual enlargement of the prostate. This enlargement, known as benign prostatic hyperplasia (BPH), is a common, age-related process, with obstruction predominating after the age of 60. While nearly half of men develop symptoms beyond this age, a small proportion remain relatively asymptomatic despite prostate enlargement. As the prostate enlarges, it narrows the urinary passage and interferes with normal urine flow, placing constant pressure on the bladder and leading to progressive changes in the bladder wall that affect urine storage and emptying.

BPH is extremely common with advancing age. More than 42% of men older than 60 years experience this condition, and prevalence rises to over 90% in men above 90 years of age. Alongside BPH, overactive bladder (OAB) is another frequently encountered problem. Although OAB is more common in women, the prevalence among men is about 11.6%-27.1%. In men with lower urinary tract symptoms (LUTS), up to half may exhibit features of both BPH and OAB. When these conditions coexist, patients often report a marked decline in quality of life. Despite the burden of symptoms, many men delay seeking medical attention due to embarrassment or lack of awareness.

The symptoms of BPH and OAB overlap but arise from different mechanisms. BPH primarily presents with voiding symptoms such as difficulty initiating urination, reduced force of the urinary stream, intermittent flow, terminal dribbling, and a persistent sensation of incomplete bladder emptying. OAB, in contrast, is dominated by storage symptoms, including sudden urgency, increased daytime frequency, nocturia, and urge urinary incontinence. Urgency is particularly distressing, as patients may need to rush to the toilet immediately to avoid leakage. Normally, individuals void once or twice at night; however, waking more than three to four times is considered nocturia and significantly disrupts sleep. Bladder overactivity may develop due to prolonged outlet obstruction or from neuronal changes affecting the detrusor muscle. These symptoms often lead patients to restrict fluid intake, plan daily activities around toilet access, and limit social participation.

Evaluation begins with detailed history-taking, focusing on daily fluid intake, frequency of urination, urgency, nocturnal symptoms, leakage episodes, urinary burning, and changes in flow over time. Physical examination includes a digital rectal examination to assess prostate size, consistency, tenderness, or nodularity. Investigations such as prostate-specific antigen (PSA) testing help screen for malignancy and monitor trends over time, while ultrasound provides information on prostate size, changes in the bladder wall, residual urine volume, and upper urinary tract involvement. Uroflowmetry objectively assesses urinary flow rates and helps determine the severity of obstruction. More advanced tests, such as cystoscopy or urodynamic studies, are reserved for selected cases.

Metabolic syndrome has emerged as a key link between BPH and OAB. Central obesity, diabetes, cardiovascular disease, and associated lifestyle factors contribute to worsening urinary symptoms through inflammatory, vascular, and neural mechanisms. Management, therefore, begins with lifestyle and behavioral measures such as evening fluid restriction, reducing caffeine and alcohol intake, weight reduction, smoking cessation, and optimal metabolic control. Pharmacological therapy includes alpha-blockers to improve urinary flow, 5α-reductase inhibitors to reduce prostate size, and agents targeting bladder overactivity when storage symptoms persist. Even after surgical intervention, bladder overactivity may continue due to long-standing bladder changes, and ongoing medical therapy may be required to achieve sustained symptom relief.