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The Stromal–Glandular Dichotomy in the Prostate: Pathophysiological Significance, Radiological Correlation, and Implications for the Management of Benign Prostatic Hyperplasia | ||
| Basrah Journal of Surgery | ||
| Article 9, Volume 32, Issue 1, 2026 | ||
| Document Type: Review Paper | ||
| DOI: 10.33762/basjsurg.2026.167815.1154 | ||
| Author | ||
| Syed Qasim Jaffry* | ||
| University Hospital Galway, Consultant Urologist and Minimally Invasive Surgery at University hospital Galway. MBBS, DHMS, DIP SFCD, MMEDSC (UROL), FRCS, FRCSI, FEBU, FACS.. Ireland | ||
| Abstract | ||
| Abstract Benign prostatic hyperplasia (BPH) is a common, heterogeneous condition involving non-malignant proliferation of stromal and epithelial elements within the prostate. The relative dominance of these components influences the development of lower urinary tract symptoms (LUTS), produces recognisable imaging characteristics, and determines responsiveness to medical therapy. This review outlines the stromal–glandular architecture of the normal and hyperplastic prostate, examines its correlation with magnetic resonance imaging (MRI), and evaluates its impact on therapeutic strategies for BPH. In the normal prostate, stroma constitutes approximately 40% of tissue volume, with glandular epithelium comprising about 60%. In BPH, stromal proliferation frequently predominates, with stromal-to-glandular ratios ranging from 2:1 to 5:1. This stromal excess contributes primarily to dynamic obstruction. On T2-weighted MRI, stromal-rich regions appear hypointense, whereas gland-dominant tissue produces a hyperintense appearance due to increased fluid-filled glandular spaces. These imaging features provide valuable non-invasive insight into underlying tissue composition. Therapeutically, alpha-adrenergic antagonists are most effective in stroma-dominant BPH, where smooth muscle tone drives obstruction. In contrast, 5-alpha reductase inhibitors (5-ARIs) provide greater benefit in gland-dominant prostate enlargement, particularly in larger glands. Combination therapy offers enhanced long-term outcomes in mixed phenotypes. Surgical and minimally invasive procedures achieve symptomatic improvement irrespective of tissue composition. Tissue phenotype is therefore a meaningful determinant of disease behaviour and therapeutic response. Incorporating stromal–glandular assessment, supported by MRI, may facilitate more personalised and mechanism-based management of BPH. | ||
| Keywords | ||
| Benign Prostatic Hyperplasia (BPH); Stromal-Glandular Architecture; Magnetic Resonance Imaging (MRI); Lower Urinary Tract Symptoms (LUTS); Therapeutic Strategies | ||
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