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Learning Objectives

  • Understand the epidemiology and pathophysiology of benign prostate disease in older men.

  • Perform an evaluation of older men with lower urinary tract symptoms (LUTS) that incorporates an understanding of the role of etiologic factors beyond benign prostate disease.

  • Manage evidence-based stepped treatment of LUTS, including appropriate specialist referral.

Key Clinical Points

  1. Benign prostate hyperplasia (BPH), prostate hypertrophy, and bladder outlet obstruction are related but not always coincident common conditions in older men.

  2. The natural history of benign prostate disease and lower urinary symptoms is variable and includes symptom regression.

  3. Multimorbidity, medications, and functional and cognitive impairment may be the predominant cause of LUTS even in men with benign prostate disease.

  4. Many men with LUTS can be effectively managed with medical treatment.


Many terms are used to describe benign prostate disease, often interchangeably. Precision is important, however, because the conditions overlap only partially (Figure 38-1). Benign prostate hyperplasia (BPH) is a histologic condition characterized by benign proliferation of stromal and/or epithelial prostate tissue. Its prevalence increases with age and is nearly universally present in men by the ninth decade. Benign prostate enlargement (BPE) occurs in about half of men with BPH, and is quantified by milliliters of prostate tissue (eg, as measured by ultrasound). Bladder outlet obstruction (BOO) occurs in only a subset of men with BPE.

FIGURE 38-1.

Overlap between benign prostatic hyperplasia (BPH), benign prostatic enlargement (BPE), bladder outlet obstruction (BOO), and lower urinary tract symptoms (LUTS) in men.

Common voiding symptoms are urgency, frequency, nocturia, slow stream, hesitancy, incomplete emptying, postvoiding dribbling, and incontinence, which may be related to BPH, BPE, BOO, age-related physiologic changes in the lower urinary tract, and/or comorbid conditions and medications. However, women may experience these same symptoms. Therefore, voiding symptoms are best described by the nonspecific term lower urinary tract symptoms (LUTS).


Early autopsy and epidemiologic studies demonstrated a marked rise in prevalence of BPH and BPE with age, especially during the sixth and seventh decades, and a similar relationship between age and “clinical BPH” (LUTS and BPE on examination) (Figure 38-2). In a racially, ethnically, and socioeconomically diverse population in the United States, the overall prevalence of LUTS was 19% and increased with age (11% at age 30–39 to 26% at age 70–79) but did not differ by sex or race/ethnicity. Other studies suggest that 28% to 35% of older men without previous prostate surgery have moderate to severe LUTS. More recent data from longitudinal epidemiologic studies and placebo arms of treatment trials confirm that the incidence of benign prostate disease gradually and variably increases with age until the ninth decade (Figure 38-3). Only weak correlations exist between BPE, BOO, and LUTS, suggesting that ...

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