Benign prostatic hyperplasia (BPH) refers to the nonmalignant growth of the prostate observed very commonly in aging men. Although on the surface this statement seems straightforward and simple, there are considerable definitional problems associated with the condition that subsequently lead to problems with epidemiologic definitions, calculations of incidence and prevalence rates, and, ultimately, difficulties with formalizing therapeutic algorithms.
BPH, the actual hyperplasia of the prostate gland, develops as a strictly age-related phenomenon in nearly all men, starting at approximately 40 years of age. In fact, the histologic prevalence of BPH, which has been examined in several autopsy studies around the world, is approximately 10% for men in their 30s, 20% for men in their 40s, reaches 50% to 60% for men in their 60s, and is 80% to 90% for men in their 70s and 80s. No doubt, when living long enough, most men will develop some histologic features consistent with BPH.1
Histologic BPH, although identified by the International Classification of Diseases (ICD) code 600, does not necessarily constitute a problem to the patient. In fact, many men with histologic BPH will never see a doctor for this condition, nor do they ever need any treatment for it. The condition becomes a clinical entity if and when it is associated with subjective symptoms, the most common manifestation being lower urinary tract symptoms (LUTS). It must be recognized, however, that not all men with histologic BPH will develop significant LUTS, although other men who do not have histologic BPH will develop LUTS. Such men might have other conditions of the prostate (prostatitis or prostate cancer), other causes for subvesical outlet obstruction (urethral stricture, bladder neck sclerosis), conditions of the bladder (carcinoma in situ, inflammation, stones), or other conditions leading to the rather nonspecific constellation of symptoms commonly labeled as “LUTS” (Figure 1). The LUTS symptom complex can be conveniently divided into obstructive and irritative symptoms. Among the obstructive symptoms are hesitancy, straining, weak flow, prolonged voiding, partial or complete urinary retention, and, ultimately, overflow incontinence. The often more bothersome irritative symptoms consist of frequency, urgency with urge incontinence, nocturia, and painful urination, as well as small voided volumes. The prevalence of LUTS increases steadily with increasing age. Observations to this effect have been obtained from many cross-sectional studies in various countries and racial groups.2 Not all men with obstructive or irritative voiding symptoms will be bothered by these symptoms, and so will not seek medical attention. Considerable efforts have been expended to understand the reasons men do or do not consult a health care provider when experiencing LUTS. In many cases, these symptoms are accepted as a natural occurrence with aging, and men learn to live with them. Also, the threshold for men to seek consultation with a health care provider for LUTS differs greatly within and between racial groups. Ultimately, however, when men are significantly bothered by these symptoms, they will usually consult a health care provider in hopes of remedying the situation.