What is BPH (Benign Prostatic Hyperplasia) with LUTS (Lower Urinary Tract Symptoms)?

Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms (LUTS)

BPH with LUTS refers to a condition where prostate gland enlargement causes urinary symptoms in men, characterized by both obstructive and irritative voiding patterns that significantly impact quality of life, with prevalence increasing with age to nearly 50% by the eighth decade of life. 1

Definition and Pathophysiology

BPH is a histologic diagnosis referring to the proliferation of:

• Glandular epithelial tissue
• Smooth muscle
• Connective tissue within the prostatic transition zone 1

This proliferation can lead to:

• Benign prostatic enlargement (BPE)
• Benign prostatic obstruction (BPO) at the bladder neck
• Bladder outlet obstruction (BOO) 1

Epidemiology

• Nearly ubiquitous in aging males
• Prevalence increases from age 40-45 years
• Reaches 60% by age 60
• Reaches 80% by age 80 2
• 90% of men between 45-80 years suffer some type of LUTS 1

Lower Urinary Tract Symptoms (LUTS)

LUTS attributed to BPH can be categorized into:

Obstructive Symptoms

• Urinary hesitancy
• Weak stream
• Straining during urination
• Prolonged voiding
• Sensation of incomplete bladder emptying
• Interrupted urination 1, 3

Irritative Symptoms

• Increased urinary frequency
• Urgency
• Nocturia
• Urge incontinence
• Reduced voiding volumes 1, 3

Risk Factors

• Age (primary factor)
• Hormonal factors (testosterone and DHT)
• Family history/genetic factors
• Black race and Hispanic ethnicity
• Obesity
• Type 2 diabetes
• High alcohol consumption
• Physical inactivity 2, 4

Diagnosis

The American Urological Association recommends:

1. Medical history
2. AUA Symptom Index (AUA-SI) or International Prostate Symptom Score (IPSS)
3. Urinalysis
4. Post-void residual (PVR) in select patients 1

Impact on Quality of Life

Although BPH with LUTS is rarely life-threatening, it can significantly impact quality of life through:

• Sleep disruption from nocturia
• Social limitations due to frequent urination
• Anxiety about urinary urgency
• Sexual dysfunction (often coexisting with LUTS) 1

Disease Progression

Untreated BPH with LUTS may lead to serious complications:

• Acute urinary retention
• Recurrent urinary tract infections
• Bladder stones
• Gross hematuria
• Renal insufficiency
• Bladder wall hypertrophy/increased bladder mass 1, 5

Treatment Approaches

Treatment is based on symptom severity and impact on quality of life:

Mild Symptoms

• Watchful waiting/active surveillance 4

Moderate to Severe Symptoms

1. Pharmacotherapy:

   • Alpha-1 adrenergic blockers (first-line): Tamsulosin relaxes smooth muscles in bladder neck and prostate 6, 4
   • 5-alpha reductase inhibitors: Finasteride reduces prostate volume by 17.9% over 4 years 7
   • Combination therapy is more effective than monotherapy for symptom relief and prevention of progression 4, 8

2. Surgical Intervention (indicated for):

   • Renal insufficiency secondary to BPH
   • Refractory urinary retention
   • Recurrent UTIs
   • Recurrent bladder stones
   • Gross hematuria due to BPH
   • LUTS refractory to medical therapy 1

Important Considerations

• Sexual dysfunction is common in men with LUTS/BPH
• Surgical treatments can cause ejaculatory dysfunction and may worsen erectile dysfunction
• Patients should be counseled about sexual side effects of interventions 1
• Shared decision-making is essential, with patients receiving risk/benefit profiles for all treatment options 1

Monitoring

Regular follow-up is necessary to:

• Assess symptom progression
• Monitor treatment efficacy
• Evaluate for complications
• Consider treatment modifications as needed

BPH with LUTS is a progressive condition that requires ongoing assessment and management to maintain quality of life and prevent complications.