COMPREHENSIVE PATIENT-EVALUATION FOR BENIGN PROSTATIC HYPERPLASIA

It is time to consider new approaches to benign prostatic hyperplasia (BPH). Previously, obstruction, prostatism, and hyperplasia of the pro state were considered to be almost synonymous. Today, there is increas ing awareness that some men have hyperplasia, some have symptoms, and others obstruction. Currently, BPH is discussed in terms of benign pro static enlargement (BPE), bladder outlet obstruction (BOO), and lower urinary tract symptoms (LUTS). Symptom questionnaires, uroflowmetry, p rostate volume determination, residual urine volume determination, and pressure-flow studies continue to be the instruments used for assessi ng BPH patients. Prostate enlargement, prostatic muscle tone, and blad der function all impact voiding function. A large part of BPH symptoma tology may be explained by bladder dysfunction, which tends to be disc ounted in discussions about BPH. In the future, bladder dysfunction mu st receive more attention, and better measures should be developed to quantify it. Postvoid residual urine is a sign of abnormal bladder fun ction rather than the result of BOO. However, variability limits the p redictive value of residual urine volume. Uroflowmetry is also critici zed for excessive variability, which is increased among men with LUTS secondary to BPH. Approximately 70% of men with uroflow <15 mL/sec are obstructed, which means that at least 10 million men in the United St ates have BOO. Therefore, alleviation of obstruction would be a daunti ng and overwhelming task. It is still widely believed that prostatism is due to an enlarged prostate and can be cured by reducing the size o f the prostate. Prostate volume can be used to select treatment, but i t is not reasonable to decide whether to treat a patient with LUTS on the basis of prostate size. One of the problems with symptom-based tre atment is that LUTS is not gender specific. Questions about LUTS in pa tients with BPH may elicit very inconsistent responses, and numeric im provement in symptom score is not proportional to how bothered the pat ient is. Bother, not symptom score or objective measures such as postv oid residual urine and uroflowmetry, is what drives the decision-makin g process in BPH management. The most recent international guidelines for BPH treatment emphasize that the degree to which the patient is bo thered is more important than symptom score. More than a third of all elderly men land women) have moderate or severe LUTS, and not all of t hem should receive treatment. In the future, measuring bother due to L UTS and impact on the patients' quality of life with the BPH impact sh ould be imperative and central to treatment decisions. (C) 1998, Elsev ier Science inc. All rights reserved.