Benign Prostatic Hyperplasia (BPH)

362

Practical Urology: EssEntial PrinciPlEs and PracticE

disease in population studies. Some degree of

MTOPS.9 Using a stricter parameter such as

association has been found between BPH and

increase of prostate volume of 26% or higher,

growth factors such as Insulin Growth Factor-1

22.6% of men progressed over a 4.2-year period

and its binding globulin (IGFBP-3). LUTS have

in the population-based Krimpen study.8 PSA

also been correlated with sexual dysfunction

concentration is known to be related to age and

and the relation holds true in different studies

prostate volume; in the Krimpen study, a 5%

also after data were adjusted for age although no

increase of serum PSA per year was seen. A

clear explanation has been found. A weak asso-

shorter PSA doubling time was observed in men

ciation between clinical manifestations of BPH

with BPH compared to those without it. Asian

and cardiovascular disease has been described.

populations were recently investigated to obtain

No relation between LUTS and lifestyle factors

epidemiological data on LUTS/BPH. Prevalence

(namely diet and exercise) has been observed.

of LUTS is comparable to that observed in

Since surgical treatment of BPH was devel-

Europe and USA with an 8% increase per decade

oped, the condition is no longer life-threatening

(from 41.7% in the fifth decade to 65.4% in men

but remains progressive. Studies on the natural

of 70 years or older). Although mean prostate

history of the disease tell us that an increase of

volume in Japan community-based studies is

about 0.2 points/year in the IPSS scale is

lower than in Caucasian-American and Africa-

expected; 50–80% of men will remain stable

American series, Japanese prostates are more

over a 1–5-year period with a 20–50% progres-

glandular. In Malaysia no difference in Qmax and

sion rate also depending on the definition of

prostate volume was found among Chinese,

progression and type of population. The risk of

Malay, and Indian populations.10

acute urinary retention (AUR) varies from 2 to

18 per 1,000 person-years with lower values

observed in community studies (2–6.8%) and

higher ones in the placebo arms of clinical trials.

Age, symptom severity, and maximum flow rate

(Qmax) were independent predictors of AUR. In

The term “prostatism,” suggesting a cohort of

the Olmstead County study, an age-related dete-

symptoms deriving from the enlarging prostate,

rioration of flow rate was observed with a 1.3%

has been replaced by the term “Lower Urinary

decrease per year in men in the 40s and 6.5%

Tract Symptoms.”11 LUTS terminology was rede-

decrease in men in their 70s.5 Longitudinal stud-

fined 8 years later and now includes filling/

ies of voiding dynamics are rare. Thomas et al.

storage,

emptying/voiding,

and postvoiding

reported no significant increase of bladder out-

symptoms (Table 27.1).3 Voiding symptoms are

flow obstruction over a 13.9-year period

known to be more prevalent than storage ones

although decrease of detrusor contractility was

althoughthesearemorebothersome.12 Frequency

found.6 The prostate gland tends to grow over

with reduced voided volume may be associated

time; population studies suggested a 1.6–2.0%

with detrusor overactivity, significant post-void

increase of prostate volume per year.7,8 A 4.5%

residual, bladder neoplasms, fear of urinary

increase was observed in the placebo arm of the

retention,

and psychogenic

causes. A small

Table 27.1. lUts

Filling/storage

Emptying/voiding

Postvoiding symptoms

Frequency

Hesitancy

Post-micturition dribbling

Urgency

straining to void

Feeling of incomplete emptying

nocturia

Poor stream

Urgency incontinence

intermittency

stress incontinence

dysuria

nocturnal incontinence

terminal dribbling

Bladder/urethral pain

absent or impaired sensation

bladder capacity may occur because of fibrosis,

examination; urinalysis; biochemical testing;

noninfectious inflammatory disorders, irradia-

post-void residual urine measurement, imaging,

tion, and previous bladder surgery. Frequency

and endoscopy of lower urinary tract (LUT)

with normal voided volume may depend upon

(Table 27.2, Figs. 27.1 and 27.2).13

polydipsia, osmotic diuresis, or diabetes insipi-

History and physical examination aims at

dus. Urgency (the sudden compelling desire to

diagnosing concomitant conditions of the blad-

void, which is difficult to defer), urgency inconti-

der, the central nervous system, or other organs

nence, and overactive bladder indicate neuro-

that may be responsible for LUTS beyond benign

genic origin (reduced suprapontine inhibition,

and malignant disorders of the prostate.

damaged axonal paths in the spinal cord,

Frequency–volume charts are instrumental to

increased afferent input to the lower urinary

analyze dayand night-time frequency, mean

tract, loss of peripheral inhibition, enhancement

voided volume, total urine output, nocturnal

of excitatory neurotransmission, in the micturi-

urine output, urgency and urgency incontinence

tion reflex pathway), myogenic (due to the effect

episodes. Threeto seven-day charts are used

of BOO on smooth muscle fibers) and structural

with voided volumes recorded at least for 1 day.

causes. Nocturia, defined as the need to wake up

The instrument is accurate and inexpensive and

at night to void, is a troublesome symptom that

its widespread use should be encouraged.

should always be distinguished from nocturnal

Symptom score have been developed to stan-

polyuria. Prevalence of nocturia increases with

dardize the assessment of symptom severity by

age and is sometimes considered part of the nor-

using questions that have been psychometrically

mal aging process.Voiding symptoms include all

validated although they can also be used to pre-

symptoms experienced during voiding. There is

dict the response to treatment and to assess

no pathophysiological correlation between these

treatment outcome. Different symptom scores

symptoms and urodynamic parameters of outlet

are available and have been validated in several

obstruction and this is why the term“obstructive

languages (IPSS, ICIQMLUTS, Dan PSS, OABq);

symptoms” has been dropped. The relation

they all contain one or more questions about

between LUTS and BPH is complex particularly

quality of life and symptom bother. Although

when epidemiological data suggested a similar

the IPSS is the most popular symptom score, it

prevalence in women.12

does not address urinary incontinence and may

therefore be suboptimal whenever continence is

impaired. Urinalysis is a recommended test also

Patient Assessment

at the primary level because it allows to diag-

nose concomitant conditions that may or may

not be associated with LUTS such as hematuria,

Patient assessment aims at establishing the

but it is also instrumental in suspecting urinary

tract infection, a common cause of LUTS.

pathophysiology of LUTS in the individual sub-

Although there is no association between BPE,

ject and include: history taking, frequency–

BPH/BPO, and chronic kidney disease, some

volume charts, and symptom scores; physical

national guidelines still recommend to measure