1)      Benign enlargement of prostate – i) If AUA scores 0-7 watchful waiting monitoring AUA score changes ii) If prostate > 40 g finasteride reduce volume by 30% iii) IVS/OVS doxazosin and terazosin reduce smooth muscle tone and thus have immediate effects on urine flow and improve BPH symptoms.  Patients who do not respond to non-selective alpha-blockers may respond to selective alpha-blocker tamsulosin iv) OVS – alfuzosin, prazosin,  v) Prostate size – each finger breath equals 15-20 g of prostate, most symptomatic prostates are around 2-3 finger breaths, use index finger pad, when prostate size is large finasteride works best vi) BPH with acute urinary retention,  failed voiding trials, recurrent gross hematuria, UTI and renal failure require prostate surgery vii) If prostate > 75 g OR if bladder stones or diverticula present OR if patient cannot be positioned for transurethral surgery open prostatectomy indicated.  Rest either transurethral resection of the prostate or 1 of many minimally invasive prostate destruction procedures.  viii) BPH with LUTS medical therapy with receptor-specific alpha blockers first-line therapy, alpha 1a receptors are seen mainly in the prostate, bladder neck, and urethra, alpha 1a receptor blocker tamsulosin is the most uroselective. Prostate and hair follicle growth is androgen dependent and 5-alpha reductase inhibitors block this androgen.  It may not work in all men with symptoms, but if they work the effect is great and the initial response may take several months

2)      Malignant enlargement of prostate – hard, irregular prostate typical of Ca is felt on DRE then urgent referral is indicated.  PSA should also be measured and accompanied by the patient with a referral letter.