Comprehensive patient evaluation for benign prostatic hyperplasia.

It is time to consider new approaches to benign prostatic hyperplasia (BPH). Previously, obstruction, prostatism, and hyperplasia of the prostate were considered to be almost synonymous. Today, there is increasing awareness that some men have hyperplasia, some have symptoms, and others obstruction. Currently, BPH is discussed in terms of benign prostatic enlargement (BPE), bladder outlet obstruction (BOO), and lower urinary tract symptoms (LUTS). Symptom questionnaires, uroflowmetry, prostate volume determination, residual urine volume determination, and pressure-flow studies continue to be the instruments used for assessing BPH patients. Prostate enlargement, prostatic muscle tone, and bladder function all impact voiding function. A large part of BPH symptomatology may be explained by bladder dysfunction, which tends to be discounted in discussions about BPH. In the future, bladder dysfunction must receive more attention, and better measures should be developed to quantify it. Postvoid residual urine is a sign of abnormal bladder function rather than the result of BOO. However, variability limits the predictive value of residual urine volume. Uroflowmetry is also criticized for excessive variability, which is increased among men with LUTS secondary to BPH. Approximately 70% of men with uroflow < 15 mL/sec are obstructed, which means that at least 10 million men in the United States have BOO. Therefore, alleviation of obstruction would be a daunting and overwhelming task. It is still widely believed that prostatism is due to an enlarged prostate and can be cured by reducing the size of the prostate. Prostate volume can be used to select treatment, but it is not reasonable to decide whether to treat a patient with LUTS on the basis of prostate size. One of the problems with symptom-based treatment is that LUTS is not gender specific. Questions about LUTS in patients with BPH may elicit very inconsistent responses, and numeric improvement in symptom score is not proportional to how bothered the patient is. Bother, not symptom score or objective measures such as postvoid residual urine and uroflowmetry, is what drives the decision-making process in BPH management. The most recent international guidelines for BPH treatment emphasize that the degree to which the patient is bothered is more important than symptom score. More than a third of all elderly men (and women) have moderate or severe LUTS, and not all of them should receive treatment. In the future, measuring bother due to LUTS and impact on the patients' quality of life with the BPH impact should be imperative and central to treatment decisions.