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Lower urinary tract symptoms (LUTS) are common in older women and men and can have a significant impact on quality of life. The diagnostic evaluation and treatment plan of such conditions can be challenging for the primary care clinician, who must align the patients’ goals of care with the risks and benefits of the available testing and treatment options. This chapter discusses two common causes of LUTS that frequently occur in older adults: benign prostatic hyperplasia (BPH) in men and overactive bladder (OAB) in both men and women.



  • Symptoms of obstruction while voiding in men.

  • An elevated American Urologic Association Symptom Index score with bothersome obstructive symptoms; establish baseline symptoms to monitor symptom trajectory and treatment efficacy.

  • Absence of other diagnoses that might cause symptoms (eg, prostatitis or urinary tract infection [UTI]) as determined through a urinalysis.

General Principles

BPH remains a common condition in older men that can lead to diminished quality of life. Based on physician office visits, BPH affects 70% of men over age 60 and 80% of those over age 70. Although not all men with BPH will develop bothersome symptoms, many older men who are symptomatic underreport their symptoms to their clinicians and, therefore, are less likely to receive treatment for bothersome complaints.


BPH is a histologic diagnosis in which smooth muscle and epithelial cell proliferation in the prostatic transition zone can lead to LUTS via bladder outlet obstruction and increased smooth muscle tone and resistance.


Data from observational studies suggest that men who maintain a healthy weight and exercise regularly are less likely to develop BPH; however, no randomized studies have been conducted to confirm these associations.

Clinical Findings

A. Symptoms & Signs

When patients develop clinically significant BPH, they typically complain of LUTS such as increased urinary hesitancy, straining, a weak urinary stream, and incomplete bladder emptying. In addition to these symptoms, BPH often presents with concurrent symptoms of overactivity, such as urgency and nocturia. Dysuria and hematuria are not commonly associated with BPH and may be an indication that another disease process is present.

The American Urological Association Symptom Index (AUASI; referred to interchangeably as the International Prostate Symptom Score [IPSS]) is a seven-item tool that health care providers can use to screen for symptomatic BPH as well as to assess a patient’s LUTS severity. Individual item scores range from 0 for “not at all” to 5 for “almost always,” with a total maximum score of 35 (Table 62–1). Symptoms such as incomplete emptying, a weak urinary stream, and straining with urination are particularly specific for obstructive symptoms that could be due to BPH. Scores ...

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