Benign Prostatic Hyperplasia B028

Current RMA Instruments:

Changes from previous Instruments:

ICD Coding:

• ICD-10-AM: N40

Brief description

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland, which is located at the base of the bladder (in men only). This condition is common in older men and results in urinary symptoms. 

Confirming the diagnosis

The diagnosis is made from clinical evaluation, with pathology and imaging tests generally helpful but not required for confirmation.

To establish this diagnosis, the assessment and/or management may involve consultation with a urologist. 

Additional diagnoses covered by SOP

• Benign prostatic hypertrophy
• Benign enlargement of the prostate
• Prostate enlargement
•  

Conditions not covered by SOP

• Malignant neoplasm of the prostate *
• Overactive bladder #
• Prostatitis #

* another SOP applies  - the SOP has the same name unless otherwise specified

^# non-SOP condition

Clinical onset

This condition involves lower urinary tract symptoms that are non-specific to benign prostatic hyperplasia. Symptoms typically appear slowly and progress gradually over a period of years. Once the diagnosis has been confirmed, clinical onset can be dated to the onset of the first clinical event or presentation that is judged by a treating doctor to be related to the condition.

Clinical worsening

The normal course of the condition is for gradual progression of the symptoms. Most men experience symptom relief with medical or surgical treatments.  Not being able to obtain appropriate clinical management can lead to worsening. However, establishing clinical worsening beyond the normal course of the condition will best be assessed by a urologist.