What is the definition of Benign Prostatic Hyperplasia (BPH) in an older male patient with lower urinary tract symptoms (LUTS) such as hesitancy, weak stream, or nocturia?

Definition of Benign Prostatic Hyperplasia (BPH)

BPH is a histologic diagnosis that refers to the proliferation of glandular epithelial tissue, smooth muscle, and connective tissue within the prostatic transition zone. 1

Key Conceptual Distinctions

The term "BPH" is frequently misused in clinical practice, and understanding the precise terminology is critical for accurate diagnosis and treatment:

• BPH itself is a microscopic pathological finding that describes cellular proliferation in the prostate and does not require treatment—it is not the target of interventions. 1

• BPH can lead to benign prostatic enlargement (BPE), which is the macroscopic enlargement of the prostate gland that may be palpable on digital rectal examination or visible on imaging. 1

• BPE may cause benign prostatic obstruction (BPO), which is obstruction at the level of the bladder neck due to the enlarged prostate. 1

• The clinical syndrome that patients experience is properly termed "lower urinary tract symptoms attributed to BPH" (LUTS/BPH), which encompasses symptoms like hesitancy, weak stream, and nocturia in men for whom an alternative cause is not apparent. 1

Pathophysiology of Symptoms

The urinary symptoms in older men with BPH arise from two distinct mechanisms:

• Static component: Direct bladder outlet obstruction from enlarged prostatic tissue physically compressing the urethra. 2, 3

• Dynamic component: Increased smooth muscle tone and resistance within the enlarged gland, mediated by alpha-1 adrenergic receptors (approximately 70% are alpha-1A subtype in the prostate). 2, 4, 3

Clinical Presentation

Symptoms are categorized into two groups:

• Voiding (obstructive) symptoms: Hesitancy, weak stream, straining, prolonged voiding, intermittency, and sensation of incomplete emptying. 5, 3, 6

• Storage (irritative) symptoms: Frequency, urgency, nocturia, urge incontinence, and reduced voiding volumes. 5, 3, 6

Epidemiology

• BPH is nearly ubiquitous in aging males, with prevalence reaching 60% by age 60 and 80% by age 80. 2

• Moderate-to-severe LUTS affects nearly 50% of men by the eighth decade of life, and approximately 90% of men between ages 45-80 experience some type of LUTS. 1, 2

• The condition is rarely life-threatening but significantly impacts quality of life, making symptom severity and patient bother the primary drivers of treatment decisions. 1, 2