© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
13
Apractical primary care approach to lower urinary tract symptoms caused by benign prostatic hyperplasia (BPH-LUTS)
Definition of disease
The term BPH-LUTS inherently refers to symptoms
caused by obstruction which can include various
degrees of poor flow, hesitancy and intermittency.
There are many terms used in the literature to describe
prostate related LUTS such as benign prostatic
hypertrophy (BPH), benign prostatic enlargement
(BPE), bladder outlet obstruction (BOO), benign
prostatic obstruction (BPO) and enlarged prostate
(EP) to name a few.
1
The terminology can occasionally
be confusing as enlargement of the prostate does
not always mean the patient has symptoms, nor
does the presence of symptoms mean enlargement.
However, in order to keep this practical for the PCP
we will use the term BPH to define the patient having
obstructive symptoms secondary to either increased
smooth muscle tone within the prostate or the bulky
enlargement of the prostate.
There are also many terms used to define LUTS
when the bladder is involved. Overactive bladder
(OAB) is a syndrome or symptom complex defined
as: Urgency, with or without urgency incontinence,
usually with frequency and nocturia.
2
Urgency is
defined as a sudden, compelling need to void which is
difficult to defer. Frequency is defined as voidingmore
than 8 times per day. Nocturia is defined as voiding
more than once per night. Incontinence is defined as
the involuntary loss of urine. It is referred to as urge
incontinence when preceded by urgency and stress
incontinence when this loss occurs while coughing,
sneezing, laughing, or other physical activities.
Understanding symptoms
The initial challenge for the physician is to identify
the existence of LUTS and then to establish the cause.
In order to recognize the symptoms of lower urinary
tract abnormalities it is imperative to understand the
normal function of both the prostate and the bladder.
In fact, both may be functioning normally and the
cause could be from another medical issue.
The prostate is a gland that encircles the urethra and
produces and directs the fluid for seminal emission, in
concert with the bladder neck. In the unaffectedmale,
the urinary stream is functionally unobstructed during
voiding through the prostate. Experts have clinically
described this good flow as a smooth arc-shaped curve
with high amplitude andwithout interruption.
3
As the
male ages, there is proliferation and expansion of cells
within the gland. This normal occurrence makes BPH
themost commonbenignneoplasmamongstmen.
4
The
problems associated with prostatic growth occur via
two possible mechanisms. The first is direct physical
bladder outlet obstruction (BOO), which is defined
as the “static” component. The second mechanism is
related to an increase in smooth muscle tone creating
a resistance to dilation within the prostatic urethra,
which is called the “dynamic” component. Either of
these possible mechanisms, alone or in combination,
would cause an increased resistance to flow of urine
and, subsequently, a clinical finding of hesitancy, poor
flow, and/or incomplete emptying.
1
The bladder ’s function is to store urine and,
subsequently, empty the same volume. The bladder
normally holds 300 mL-500 mL of fluid. It should be
able to store this amount at a comfortable and low
pressure. When 300 mL-500 mL are reached, emptying
should occur with an adequate bladder contraction
leaving a minimal residual. Abnormal function of the
bladder is seen as voiding frequently of small amounts,
having an uncontrollable urge or incomplete emptying.
Therefore, knowing the voided volume associated
with the symptoms offers key insights into the bladder
function and assists in identifying its role in the patient’s
symptoms. The bladder should also provide adequate
outlet resistance. Abnormal resistance would be seen
as leakage or incontinence.
Prevalence
There is no denying the high prevalence of prostatic
hyperplasia in men. In the United States, there is a
prevalence of 40% among men at or above the age of
60 and 90% for men at or above the age of 80.
5
Due to
the aging population, these numbers will only increase.
Not all patients will be symptomatic however, left
untreated; men with these symptoms may progress.
The untreated symptomatic male has a 23% lifetime
risk of developing acute urinary retention.
6
If a man
has obstructive symptoms, and is over the age of 60,
he has a 39%probability of undergoing surgery related
to the prostate within 20 years.
7
Treatment gaps
Despite the large number of men affected by LUTS,
the number of those who seek medical attention is
extremely low. While 90% of men reported LUTS in
theMultinational Survey of theAgingMale (MSAM-7),
only 19% sought medical care and only 11% actually
received treatment.
8
Primary care approach
There are many ways for the PCP to approach the
