Benign Prostatic Hyperplasia
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​Last updated on 5 Aug 2026

  • Benign Prostatic Hyperplasia Care Protocol will be implemented from January 2027 – HSG GPs may refer to updates from AIC for details on the implementation of these protocols.


Clinical Benign Prostatic Hyperplasia (BPH) can be defined as prostate adenoma (pleural: adenomata) resulting in varying degrees of bladder outlet obstruction (BOO)1. BPH is one of the most common diseases in ageing men and the most common cause of lower urinary tract symptoms (LUTS). The prevalence of BPH increases after the age of 40 years, with a prevalence of 8%–60% at age 90 years2.   ​​

​​
1. Assess lower urinary tract symptoms (Voiding Symptoms and Storage Symptoms)

​2. Assess for other red flags 

​3. Consider differentials 

4. Digital rectal examination (DRE) to evaluate prostate size, and exclude features suggestive of prostate cancer 

5. Evaluate bladder outlet obstruction by assessing for a palpable bladder 

6. Individualise treatment 


7. Consider International Prostate Symptom Score (IPSS) and Quality of Life Questionnaires (QoL)  for evaluation of symptom severity and impact on quality of life

8. Initial investigations to consider for patients with LUTS 

​a. Urinalysis, Urin​e culture if UFEME abnormal 

b. Baseline Prostate Specific Antigen (PSA)

c. Voiding diary (optional): Used when nocturia is the dominant symptom ​


​Male Lower Urinary Tract Symptoms (LUTS) Flowchart 
Watchful waiting and lifestyle changes

  1. ​Reduce caffeinated/alcoholic beverages 

  2. Avoid excessive fluids at night, empty bladder before bed.
     
  3. Avoid/ monitor usage of some drugs which may cause urinary symptoms (diuretics, antihistamines, antidepressants) 

  4.  Optimise diabetic control 

Medical Therapy 
  1. Al​pha-blockers (AB): 
     ​
    a. Indicated for patients with bothersome OR moderate (IPSS score 8-19) BPH symptoms and/or QoL ≥ 3 

    b. Takes 1-2 weeks to see effect, maximal effect seen within 2-4 weeks 
    ​
    ​​Dosing r​​ecommendations for AB may be found within                                                                   ​

  2. 5-Alpha-Reductase Inhibitor [5ARI]
    ​​
    a. Indicated for prostate volumes >30 g (PSA > 1.5    µg/L) and significant obstruction 

    b. Takes about 3-6 months to see clinical effect 

    c. Reduces the size of the prostate over time 

    d. Reduces PSA by 50% after 6 - 12 months 

    ​Dosing recommendations for 5ARI may be fou​nd within 

  3. ​Phosphodiesterase 5 inhibitors (e.g. Tadalafil*) 

    a. Can be considered as an adjunct to basic treatment** for patients who have concomitant erectile dysfunction (ED) 

    ​*Tadalafil is not under the Healthier SG Whitelist 

    **Dosing of PDE5i used for LUTS differs from dosing for ED, please refer to available references.

Follow-up treatment
​​​
  1. Review of LUTS using IPSS Score 

  2. For patients starting on 5ARI, PSA may be repeated within the next 6 to 12 months to establish a new baseline. Any further rise in PSA henceforth, especially rises > 0.5µg /L, should prompt further evaluation12,17,18  ​
Recommended Care Components

Table 1: Recommended Care Components 
​​ ​Recommended Care Components
 ​Minimum Frequency* 
​ ​​R​emarks  
​Review of Lower Urinary Tract Symptoms
 ​Annually
 ​Recommended tool for assessing the severity of LUTS is the International Prostate Symptom-Quality of Life (IPSS-QoL) Score​ 
​Clinical Examination – 
Abdominal and Digital Rectal Exam 

 ​Initial Assessment 
 ​Abdominal examination includes assessment for a palpable bladder. 
Rectal examination to assess size, consistency and regularity of prostate  
​Co-Morbidity Assessment 
(includes medication review) 
 ​Initial Assessment 
​
​Urinalysis# 
 ​Initial Assessment
 ​Screen for haematuria, pyuria and glycosuria ​

​*More frequently if clinically indicated 
​#This is also a non-reportable clinical indicator 

Consideration for Specialist Referral
  1. Presence of any red flags​   
    ​
  2. History / risk of urethral stricture 
    ​
  3. Neurological disease raising the likelihood of primary bladder disorder 

  4. Failure of medical treatment at primary care level ​

​

The following data fields should be documented in GPs’ case notes as part of good clinical practice for all patients enrolled to their practice. 

Submission of data fields marked with asterisks* is required for the Healthier SG payments. ​
​
Diagnosis 
  1. Diagnosis* 
  2. CDMP Condition(s)* 
  3. Diagnosis Year ​

International Prostate Symptom Score (IPSS) 

  1. ​International Prostate Symptom Score (IPSS) 

  2. Date of assessment 
Quality of Life Questionnaire (QoL)  
  1. Quality of Life Questionnaire (QoL) score 

  2. Date of assessment ​​

​CHAS/PG/MG cardholders who are Healthier SG enrollees can opt to use the Healthier SG Chronic Tier at their enrolled clinics, which provides percentage-based subsidies for selected chronic medications sold within the stipulated price caps.  ​

  1. Foo KT. What is a disease? What is the disease clinical benign prostatic hyperplasia (BPH)? World J Urol. 2019 Jul;37(7):1293-1296

  2. Lim KB. Epidemiology of clinical benign prostatic hyperplasia. Asian J Urol. 2017 Jul; 4(3): 148–151.
     
  3. Report of The Screening Test Review Committee. Academy of Medicine, Singapore. March 2019 

  4. Cancer screening. MOH Clinical Practice Guidelines 1/2010.

  5. Wei JT, Barocas D, Carlsson S, et al. Early detection of prostate cancer: AUA/SUO guideline part I: prostate cancer screening. J Urol. 2023;210(1):45-53 

  6. Ng Lay Guat, Lee Lui Shiong. An Approach to Common Urological Disorders (A Guide For Family Physicians). Department of Urology, Singapore General Hospital. August 2013. 

  7. Ehiremhen Ozah, Dele Eradebamwen Imasogie. The Diagnostic Accuracy of Prostate-Specific Antigen and Digital Rectal Examination in the Diagnosis of Prostate Cancer at the University of Benin Teaching Hospital. J West Afr Coll Surg. 2023 Jul-Sep; 13(3): 91–95. 

  8. Abdelkarim A Abdrabo , Adil I Fadlalla, Imad M Fadl-Elmula. Significance of serum total prostate specific antigen and digital rectal examination in the diagnosis of prostate cancer. Saudi Med J 2011; Vol. 32 (11): 1133-1136. 

  9. Singhealth Polyclinics Doctors’ Guidebook: Benign Prostatic Hyperplasia (BPH), Lower Urinary Tract Symptoms & Acute Retention of Urine in Primary Care. Updated as of June 2020 

  10. National Healthcare Group Polyclinics Clinical Practice Guidelines. Benign Prostatic Hyperplasia. Updated as of September 2020. 

  11. National University Polyclinics Clinical Practice Guidelines. Benign Prostatic Hyperplasia. Updated as of February 2024. 

  12. European Association of Urology. Management of Non-neurogenic Male LUTS.  Updated 2024. ​

  13. Levi A Deters. Benign Prostatic Hyperplasia (BPH) Differential Diagnoses (2024, December 24). Medscape. https://emedicine.medscape.com/article/437359-differential 

  14. Vasanwala FF, Wong MYC, Ho HSS, Foo KT. Benign prostatic hyperplasia and male lower urinary symptoms: A guide for family physicians. Asian J Urol. 2017 Jul; 4(3): 1810184 

  15. Singapore Urological Association Male Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia Guidelines Committee 2015. Singapore Med J. 2017 Aug;58(8):473-480.  

  16. Chronic Disease Management Program – Handbook for Healthcare Professionals. Ministry of Health Singapore 2024. 

  17. Agency for Care Effectiveness (ACE). Dutasteride, tamsulosin, alfuzosin and dutasteride/tamsulosin combination for treating benign prostatic hyperplasia- Technology Guidance from the Drug Advisory Committee, Ministry of Health, Singapore. April 2020  

  18. Andriole GL, Bostwick D, Brawley OW, et al. The effect of dutasteride on the usefulness of prostate specific antigen for the diagnosis of high grade and clinically relevant prostate cancer in men with a previous negative biopsy: results from the REDUCE study. J Urol 2011; 185:126. ​