Male Lower Urinary Tract Symptoms (LUTS) and Benign Prostatic Hyperplasia (BPH)

The guest editors of this special issue, both members of the European Association of Urology Guidelines Office dealing with male lower urinary tract symptoms and benign prostatic hyperplasia (BPH), have been asked by the editorial board of the World Journal of Urology to collect and publish a series of articles on BPH to document the latest developments of this disease. Next to this issue solely dealing with the treatment of BPH, another special issue on basic science, epidemiology, and assessment of BPH is already in preparation and anticipated to be published later in 2010. Both special issues contain a mixture of original scientific as well as review articles on BPH and summarize the latest knowledge of the BPH disease. We thank all authors who have followed our invitation and shared their professional inside information with us. As all articles have been peer-reviewed, we would also like to thank all reviewers for their valuable time, work, and suggestions. BPH is the term used only to describe benign growth of epithelial, muscular, and/or fibrotic cells in the prostate. Microscopic changes increase with ageing and approximately 40, 70, 80, and 90% of men are affected in their sixth, seventh, eighth, and ninth decade, respectively [1]. Based on the prevalence data, BPH appears to be a physiological ageing process. BPH becomes a disease when benign prostatic enlargement (BPE), benign prostatic obstruction (BPO), or lower urinary tract symptoms (LUTS) appear. No strict correlations between these components have been found so far and, therefore, each component of the BPH disease has to be assessed and treated separately. It is estimated that one-third to one-half of men with BPH develop BPE, approximately half of men with BPH–LUTS have BPO, and up to 40% of men in a community have LUTS. LUTS is the most frequent cause of annoyance and decreased life quality in patients with BPH and associated with health-seeking behavior [2]. Although in most cases not life-threatening, BPH–LUTS has a tremendous socio-economic impact. Data from the Integrated Health Care Information Solutions National Managed Care Benchmark Database which included more than 30 health care plans between July 1997 and January 2003 and covered 25 million men aged 50 years or older demonstrated that BPE–LUTS is the fifth most commonly treated disease in the US, following cataracts, hypertension, osteoarthritis, and bursitis [3]. It was calculated from this database that medical costs of BPE–LUTS are among the seven most costly diseases. The chance of developing a significant clinical event (defined as acute urinary retention or need for prostate surgery) within 12 months after initiating medical treatment was the second highest of all diseases. Inpatient treatment of BPE–LUTS was responsible for 40% of the total costs which were only higher for cataracts, coronary artery diseases, osteoarthritis, and arrhythmias. It was concluded that improvement of the understanding of BPE (BPO or LUTS) would have the potential to significantly decrease costs. However, it is expected that the number of patients will dramatically increase as the average life expectancy increases worldwide, and therefore, further improvements in assessment and treatment of BPE, BPO, and LUTS will help in decreasing the cost related to BPH-related conditions. Assessment and treatment of BPH, BPE, BPO, or male LUTS has been and will be the “bread and butter” of urologists not only because of the pure amount of patients, but also because of the special skills necessary to treat these patients. Urology would definitely not exist as a separate specialization without BPH and BPH-specific treatments. Amazingly, the importance of this disease is not reflected by the amount of publications in peer-reviewed journals or abstracts of major urology congresses. Of 536 published articles in European Urology in 2009, only 12 articles (2.2%) dealt with BPH or male LUTS. Therefore, the number one topic of urology is clearly underrepresented in the current literature. The guest editors of this issue of the World Journal of Urology are therefore grateful to have the opportunity to draw more attention to the most frequent urological disease. We wish our readers a joyful and interesting time reading the following articles on medical or surgical treatment of clinical BPH. Yours,

Society of Interventional Radiology Research Reporting Standards for Prostatic Artery Embolization

ABSTRACTIn this review, we focus on current trends in the management of male lower urinary tract symptoms (LUTS), defined here as LUTS, namely, storage, voiding, and post-micturition symptoms presumed secondary to benign prostatic hyperplasia (BPH), and discuss possible novel approaches toward better care.According to results of a PubMed database search covering the last 10 years and using keywords pertaining to male LUTS, this condition continues to be globally undiagnosed or diagnosed late, partly because of men’s hesitation to seek help for perceived embarrassing problems or problems considered a normal part of aging. In addition, the prevalence of male LUTS is continually increasing because of a constantly aging population. Male LUTS can be bothersome and affect the quality of life (QoL) and sexual function. Additional effective alternatives for managing this condition need to be identified and incorporated into the current care model.Considering that most male LUTS such as frequency, hesitancy, urgency, and intermittency are easy to self-identify, a self-management approach toward male LUTS is proposed. Limited evidence supports the efficacy of phytotherapies and herbals as self-management options for male LUTS. However, introducing over-the-counter (OTC) medication with proven efficacy, accompanied by lifestyle and behavioral modifications, may be a promising approach that will encourage more men to treat their symptoms in a timely manner. Formal guidelines, along with appropriate education programs for patients and support from the healthcare community, will be needed to ensure that the promise of this approach is fully materialized.

The guest editors of this topic issue on basic science, epidemiology and assessment of lower urinary tract symptoms (LUTS) in adult men with or without benign prostatic hyperplasia (BPH) have invited leading urologists to contribute articles to one of the above-mentioned topics. Additionally, several original scientific articles on the same topics have been added to this issue to sharpen the reader’s view and emphasize the complexity of this medical problem that is responsible for healthy seeking behaviour of an increasingly large number of men in ageing societies. Our urology teachers lived in an easily understandable world. When dealing with LUTS in adult men, it was postulated that LUTS always originated from bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE). It was assumed that there was a linear relationship between BPE, BOO, and LUTS. Hence, it was logical to wait with treatment when the patients had only mild symptoms or BPE because BOO could not be severe in these cases. In men with large prostates or severe or treatment resistant LUTS, surgical procedures, usually performed as open removal or later as transurethral resection of the prostatic adenoma, needed to be applied to get rid of BOO and secondary of LUTS. In 2011, this ancient vision on LUTS has proven to be untrue. Our understanding of LUTS and BPH has changed dramatically when it became clear that the linear relationship between BPE–BOO–LUTS is untrue for the majority of men. It also became obvious that histological BPH (or related conditions) is not the only origin of LUTS but is rather multifactorial as, for example, detrusor overactivity, detrusor underactivity, or nocturnal polyuria may also cause similar symptoms. Therefore, assessment and differentiation between the various causes of LUTS have become more challenging during the last decades. Various new drugs and surgical treatments contributed to this complexity. If urologists do not want to use the “trial and error” approach for their patients, they should understand and distinguish the various causes of LUTS and learn how to apply the appropriate tests to prove and treat either condition. Let us shortly reflect what we really know about BPH or male LUTS. Do we know the underlying cause(s) of BPH, detrusor overactivity, detrusor underactivity, or nocturnal polyuria in our patients? if community-dwelling men are similar to patients we see in our offices? what the exact reasons are why patients seek medical help? why some men develop serious medical problems (e.g. upper urinary tract dilatation and renal insufficiency) while most others do not? whom we should primarily treat with drugs and whom with surgery? what drugs or combinations thereof we should use in men with particular symptoms or conditions? what surgery we have to use for which patient? We should be honest enough to admit that much of our assessment and treatment strategy is gut feeling and “trial and error”. Despite learning a lot about the complexity of LUTS in the last three or four decades, this does not necessarily mean that we really understand the individual patient in our office. This special issue aims to add new mosaic stones to the general picture, but it would be precocious to assume that we solve the entire problem within the near future.

Long-Term Effects of Doxazosin, Finasteride and Combination Therapy on Quality of Life in Men with Benign Prostatic Hyperplasia

Phosphodiesterase Type 5 Inhibitors Improve Male Lower Urinary Tract Symptoms

Male Lower Urinary Tract Symptoms: A Riddle Waiting to Be Solved

Traditionally, male lower urinary tract symptoms (LUTS) have been considered a synonym for benign prostate hyperplasia (BPH) because most male LUTS develops in aging men. Medical treatment should be the first-line treatment for BPH and surgical intervention should be performed when there are complications or LUTS refractory to medical treatment. Recent investigations have revealed that bladder dysfunction and bladder outlet dysfunction contribute equally to male LUTS. In the diagnosis of LUTS suggestive of BPH (LUTS/BPH), the following questions should be considered: Is there an obstruction? Are the LUTS caused by an enlarged prostate? What are the appropriate tools to diagnose an obstructive BPH? Should patients with LUTS be treated before bladder outlet obstruction is confirmed? This article discusses the current consensus and controversies in the diagnosis of LUTS/BPH.

Lower urinary tract symptoms (LUTS) are prevalent and bothersome symptoms, both for males and females.1 Most attention is given to LUTS in older males because in this group the prevalence is high and doctor visits are more common.2 The possibilities for physicians — both GPs as well as urologists — to encounter LUTS in daily practice are limited. The 2010 guideline The Management of Lower Urinary Tract Symptoms in Men , by the National Institute for Health and Clinical Excellence (NICE), presents an authority-based algorithm for this patient group. Education about the natural history of LUTS and the reassurance that LUTS are not caused by prostate cancer are important specific anchors for GPs and their patients.3,4 Treatment options for GPs are restricted to physiotherapy, alpha-blocking agents, 5-alpha reductase inhibitors, anticholinergics, or combination therapy.3 Urologists may offer operative treatment in those with severe symptoms not responding to non-invasive treatment. The efficacy and effectiveness of treatments for LUTS in older males are limited.3 The probable explanation is that LUTS are multifactorial in their origin, whereas the therapeutic approach is simplistic, targeting specific organs. Prostatic pathophysiology — especially prostate enlargement and prostate obstruction — was long thought to be the explanation for (nearly all) LUTS in older males and most of the drugs approved for LUTS in males aim to influence prostate function. Evidence is growing that this is a misconception. It is now clear that prostate enlargement or benign prostate obstruction is not the common cause of male LUTS.5 Many men with LUTS do not have prostate enlargement nor prostatic obstruction, whereas many men with an enlarged …

Re: Burden of Male Lower Urinary Tract Symptoms (LUTS) Suggestive of Benign Prostatic Hyperplasia (BPH)—Focus on the UK

Modifiable Risk Factors for Benign Prostatic Hyperplasia and Lower Urinary Tract Symptoms: New Approaches to Old Problems

Combination Therapy for Non-neurogenic Male Lower Urinary Tract Symptoms: 1 + 1 Does Not Equal 2

The epidemiology of benign prostatic hyperplasia (BPH) and male lower urinary tract symptoms (LUTS) has evolved considerably during the past several years. The term LUTS describes a distinct phenotype and allows for a broad epidemiologic description of urinary symptoms at a population level. Although it is becoming the preferred term for studying urinary symptoms in populations, LUTS remains interconnected with BPH in the literature. The incidence and prevalence of BPH and LUTS are increasing rapidly as the US population ages. BPH and LUTS are associated with serious medical morbidities, an increased risk of falls, depression, diminished health-related quality of life, and billions of dollars in annual health care costs. Although age and genetics play important roles in the etiology of BPH and LUTS, recent insights at the population level have revealed that modifiable risk factors are likely key components as well. Serum dihydrotestosterone, obesity, elevated fasting glucose, diabetes, fat and red meat intake, and inflammation increase the risk; vegetables, regular alcohol consumption, exercise, and NSAIDs decrease the risk.

LUTS (R)evolution: Let's Jump on the Bandwagon

Tamsulosin, a superselective subtype alpha 1a and 1d blocker, is used for the treatment of male lower urinary tract symptoms (LUTS) commonly caused by benign prostatic hyperplasia (BPH). This prospective study evaluated the efficacy and safety of a new formulation, Tamsulosin OCAS® (Oral Controlled Absorption System), for LUTS associated with BPH in Thai patients. Fifty one patients over 40 years old with complaints of LUTS associated with BPH were recruited. Patients received an 8 week course of once daily 0.4 mg tamsulosin OCAS®, and were followed up at 2 (visit 3), 4 (visit 4) and 8 (visit 5) weeks post-treatment. At each visit, patients were assessed using the International Prostate Symptom Score (IPSS), Nocturia Quality of Life (N-QoL) Questionnaire, QoL Assessment Index (IPSS-QoL), and International Index of Erectile Function (IIEF). The primary outcome was efficacy of Tamsulosin. The secondary outcomes included change in the mean number of nocturia episodes, hours of undisturbed sleep (HUS) and uroflowmetry measurements. Total IPSS significantly decreased at week 8 from baseline (from 19.52 to 6.08; p < 0.001). Similarly, the voiding and storage subscores of IPSS also continued to improve significantly starting from the second and third visits, respectively (p < 0.001 versus baseline). The IPSS-QoL and N-QoL scores significantly improved at visit 3 through end of study. In addition, we observed significant nocturia and HUS improvement in their last clinic visit. Uroflowmetry parameters, Qmax and Qave, improved significantly at 3rd clinic visit. Three patients experienced mild dizziness. Tamsulosin OCAS® treatment led to significant improvements in LUTS, HUS and QoL in Thai patients with bladder outlet obstruction from BPH with few side effects.