Enlargement of the prostate is nearly universal in aging men. Hyperplasia usually begins by age 45 years, occurs in the area of the prostate gland surrounding the urethra, and produces urinary outflow obstruction. Symptoms develop on average by age 65 in whites and 60 in blacks. Symptoms develop late because hypertrophy of the bladder detrusor compensates for ureteral compression. As obstruction progresses, urinary stream caliber and force diminish, hesitancy in stream initiation develops, and postvoid dribbling occurs. Dysuria and urgency are signs of bladder irritation (perhaps due to inflammation or tumor) and are usually not seen in prostate hyperplasia. As the postvoid residual increases, nocturia and overflow incontinence may develop. Common medications such as tranquilizing drugs and decongestants, infections, or alcohol may precipitate urinary retention. Because of the prevalence of hyperplasia, the relationship to neoplasia is unclear.
On digital rectal examination (DRE), a hyperplastic prostate is smooth, firm, and rubbery in consistency; the median groove may be lost. Prostate-specific antigen (PSA) levels may be elevated but are ≤10 ng/mL unless cancer is also present (see below). Cancer may also be present at lower levels of PSA.
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