Appropriate Clinical Situation for BPH Treatment Initiation and Latest BPH Consensus Statements

Benign prostatic hyperplasia (BPH) is a prevalent health concern in males characterized by prostate enlargement.¹ In India, there has been an alarming 90.9% upsurge in BPH cases from 9.55 million in 2000 to 18.2 million in 2019.² With BPH, men often experience lower urinary tract symptoms (LUTS), including nocturia, frequent urination, urgency, weak urinary stream, etc.³ Nocturia, the need to wake up at night one or more times to void, affects 70%–90% of BPH patients and significantly impacts their quality of life.⁴ Its consequences are closely associated with the duration of undisturbed sleep before the first void or the ability to resume sleep after voiding.⁵ Additionally, peak flow rate, a critical predictor of urinary obstruction, indicates a 90% likelihood of obstruction when it falls below 10 mL/s.⁶

Regarding therapy, the prime question is which patient requires treatment. Traditionally, the primary treatment goal is to only alleviate bothersome LUTS.⁷ If LUTS is not significantly bothersome or if the patient does not wish to pursue treatment, no further evaluation or treatment of LUTS is recommended, and watchful waiting can be employed.^7,8

Recently, an Indian panel of urologists reviewed literature evidence as well as expert opinions and established consensus statements for various BPH aspects.²

• Mandatory assessments for diagnosis of BPH: Unanimously, 100% of urologists strongly agreed that medical history, physical examination, symptom score, and urinalysis are essential for the diagnosis of BPH.² This consensus was backed by the American Urological Association (AUA), European Association of Urology, and Canadian Urological Association guidelines.²
• Use of International Prostate Symptom Score (IPSS): While IPSS is commonly used to assess symptom severity in BPH, there was a lot of variation in the consensus as 11.1% of the urologists strongly agreed to the statement, 22.2% agreed, 44.4% neither agreed nor disagreed, 11.1% strongly disagreed, and 11.1% disagreed to the statement.² The consensus was supported by AUA guidelines, systematic review, and meta-analysis.²

Conclusion

Only BPH patients who have bothersome LUTS should be treated and not the ones who do not have bothersome LUTS or do not desire to be treated.^7,8 Further, BPH statements from the latest Indian BPH consensus have multiple levels of agreements and disagreements among the clinicians.²

CTA: Join the experts Dr. V Surya Prakash and Dr. N Mallikarjuna Reddy as they delve into BPH consensus statements and decision-making for BPH/LUTS treatment requirements.

1. Ye Z, Wang J, Xiao Y, et al. Global burden of benign prostatic hyperplasia in males aged 60–90 years from 1990 to 2019: Results from the global burden of disease study 2019. BMC Urol. 2024;24(1):193.
2. Reddy M, Sarkar K, Sabnis R, et al. Algorithmic approach to benign prostatic hyperplasia: An Indian perspective. J Assoc Physicians India. 2024;72(7):e1–e7.
3. Mobley D, Feibus A, Baum N. Benign prostatic hyperplasia and urinary symptoms: Evaluation and treatment. Postgrad Med. 2015;127(3):301–307.
4. Singam P, Hong GE, Ho C, et al. Nocturia in patients with benign prostatic hyperplasia: Evaluating the significance of ageing, co-morbid illnesses, lifestyle and medical therapy in treatment outcome in real life practice. Aging Male. 2015;18(2):112–117.
5. Everaert K, Anderson P, Wood R, et al. Nocturia is more bothersome than daytime LUTS: Results from an observational, real‐life practice database including 8659 European and American LUTS patients. Int J Clin Pract. 2018;72(6):e13091.
6. Trumbeckas D, Milonas D, Jievaltas M, et al. Importance of prostate volume and urinary flow rate in prediction of bladder outlet obstruction in men with symptomatic benign prostatic hyperplasia. Cent European J Urol. 2011;64(2):75–79.
7. Macey MR, Raynor MC. Medical and surgical treatment modalities for lower urinary tract symptoms in the male patient secondary to benign prostatic hyperplasia: A review. Semin Intervent Radiol. 2016;33(3):217–223.
8. Yunou WU, Davidian MH, Edward M, et al. Guidelines for the treatment of benign prostatic hyperplasia. US Pharm. 2016;41:36–40.

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