Prof. Giacomo Novara β Urology, University of Padova
LUTS / Benign Prostatic Hyperplasia
Lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH)
LUTS (Lower Urinary Tract Symptoms) are symptoms arising from the lower urinary tract. Historically considered exclusive to prostatic hyperplasia, they are now recognised to have a much broader aetiology. The modern classification divides them according to the phase of the voiding cycle in which they occur: storage, voiding, and post-micturition.
π LUTS classification by voiding phase
Most patients present with symptoms in more than one phase simultaneously. Even the archetypal BPH patient β who "should" have only voiding symptoms β reports storage symptoms in 50% of cases.
Storage phase
Urgency: compelling desire to void, difficult to defer (pathological β β physiological urge)
Frequency: >8 voids/day during waking hours
Nocturia: β₯1 void interrupting sleep
Urgency incontinence: leakage preceded by urgency
Stress incontinence: leakage with increased intra-abdominal pressure
Mixed incontinence: urgency + stress (the most difficult to treat)
Overflow incontinence: leakage from an overdistended bladder in chronic retention
Voiding phase
Hesitancy: waiting before the stream starts
Weak stream: reduced stream force compared to previously
Intermittency: stream that stops and restarts
Terminal dribbling: final phase reduced to drops
Post-micturition phase
Feeling of incomplete emptying
Double voiding: need for a second void within seconds
Post-micturition dribble: residual drops in the urethra (typical in males)
Post-micturition urgency: persistent urge to void at the end of micturition
π¬ Benign prostatic hyperplasia β pathophysiology and epidemiology
The central and periurethral zone of the prostate may enlarge due to reduced cellular apoptosis, with accumulation of senescent cells that organise into macronodules. This is not a neoplastic process. When hyperplasia is pronounced, it may give rise to a median prostatic lobe impressing on the bladder neck. The obstructive mechanism is mechanical and predominantly causes voiding symptoms.
40%
Histological prevalence at age 50
70%
At age 60
80%
At age 70
90%
At age 80
~50%
Of patients with BPH are symptomatic
The aetiology is unknown. The condition is ubiquitous: all elderly men have BPH, but only approximately half are symptomatic.
β οΈ Complications of prostatic hyperplasia
π¨Acute retentionSevere pain, bladder unable to empty within hours. Requires urgent catheterisation.
πChronic retentionPainless, bladder may hold 3β5 L, bilateral hydroureteronephrosis. More serious than acute retention.
Bladder up to 3β5 L, bilateral hydroureteronephrosis
Suprapubic cystostomy preferred (lower infection risk than transurethral catheter)
Staged drainage: 500 mL immediately, then 200 mL/hour
Mandatory hospitalisation: risk of post-obstructive diuresis and electrolyte disturbances
Catheter not removed β surgery or long-term catheterisation
π« Post-obstructive diuresis: following drainage of chronic retention, the kidney recovers its filtration capacity before its concentrating ability. A massive diuresis may develop with potentially fatal electrolyte disturbances. Continuous electrolyte monitoring and replacement of approximately two-thirds of urinary output are required.
π Diagnostic assessment
1
History + IPSS questionnaire
7 questions referring to the past month: score 0β7 mild, 8β19 moderate, β₯20 severe. Always includes a quality-of-life impact question: a surgeon with IPSS 9 may be far more bothered than a manual worker with IPSS 15.
2
Erectile function assessment (IIEF-5)
LUTS and erectile dysfunction are highly co-prevalent: ~80% in patients with severe LUTS at age 60. Essential for choosing pharmacological therapy (e.g. tadalafil vs alpha-blocker).
3
Physical examination: digital rectal examination, suprapubic palpation, genitalia
Suprapubic palpation rules out a palpable bladder. Digital rectal examination estimates prostate volume and excludes suspicious areas for malignancy.
4
Urinalysis + urinary tract ultrasound
Ultrasound estimates prostate volume, assesses renal and bladder morphology, detects calculi, and measures post-void residual volume. Serial trends matter more than a single measurement (indicative threshold: >200 mL persistently).
5
PSA
Only in patients with β₯10-year life expectancy in whom detection of prostate cancer would alter management. Can be used as a proxy for prostate volume (PSA >1.5 ng/mL = prostate likely >40 mL).
6
Uroflowmetry
An excellent screening test (normal flow = no obstruction), but a poor diagnostic test: it cannot distinguish the obstructed patient (high pressure, low flow) from the hypocontractile one (low pressure, low flow). Both produce a similar trace, but management is radically different.
7
Pressure-flow urodynamic study
Indicated in selected cases: young patients, age >70 with possible detrusor damage, residual >200 mL, known neurological disease, prior pelvic surgery or radiotherapy, failed previous surgery. Definitively distinguishes obstructed from hypocontractile bladder.
π§ Behavioural measures β first-line at zero cost
These are as effective as alpha-blocker therapy in some randomised trials. No cost, no side effects.
π§ Fluid restriction
Target: 1,500 mL urine output per day. Note that fruit and vegetables are composed of 60β70% water.
π Fluid timing
Nocturia β shift fluid intake to the morning and early afternoon. Antihypertensive diuretics should be taken in the morning, not the evening.
β Caffeine and alcohol
Tea, coffee, cola drinks, and beer have a diuretic effect beyond their fluid volume. Limit intake in the evening hours.
π Pharmacological treatment
The bestseller is the alpha-blocker: it works rapidly (2β3 days), at any prostate volume, with real but not dramatic clinical efficacy (β3β4 IPSS points, β2β3 mL/s Q-max vs placebo). The median duration of response is approximately 3 years.
Antagonists of Ξ±1-adrenoceptors in the bladder neck and detrusor
Efficacy within 2β3 days, valid at any prostate volume
Silodosin: more selective for the urinary tract β less hypotension, more ejaculatory dysfunction. Ideal for elderly polypharmacy patients
Alfuzosin: less selective β more orthostatic hypotension, less ejaculatory dysfunction. Ideal for sexually active younger men
No impact on erectile function
β οΈ Discontinue at least 4 weeks before cataract surgery (Intraoperative Floppy Iris Syndrome)
π
5Ξ±-reductase inhibitors (5-ARIs)
Finasteride, dutasteride
Only for prostates β₯40 mL (the larger the gland, the more effective)
Block conversion of testosterone to dihydrotestosterone β progressive reduction in prostate volume
Clinical efficacy after 6β12 months (not short-term)
Reduce long-term risk of acute retention and surgery (MTOPS trial: NNT 28 to prevent one surgical procedure over 5 years)
β οΈ Cause persistent erectile dysfunction even after discontinuation. Use only in patients without sexual interest or in whom pelvic surgery carries excessive risk
π
Tadalafil 5 mg/day (PDE5 inhibitor)
Efficacy on LUTS equivalent to alpha-blockers
Does not impair ejaculatory function
Also improves co-existing erectile dysfunction
Ideal in patients with LUTS + erectile dysfunction + preserved sexual interest
β οΈ Not reimbursed for this indication in many healthcare systems (~β¬50/month for generic)
π
Antimuscarinics as add-on
When storage symptoms persist after alpha-blocker
Safe if Q-max β₯5 mL/s (risk of acute retention negligible)
Contraindicated as monotherapy in untreated BPH (but safe as add-on)
πͺ Surgical treatment
Indicated in patients who: do not want medication, fail or do not tolerate medical therapy, or present with complications (refractory retention, bladder stones, diverticula, recurrent infections, gross haematuria). The choice of procedure depends on: prostate volume, patient general condition, anticoagulation status, wish to preserve ejaculation.
Prostate 30β80 mL Β· Standard
Bipolar TURP
Endoscopic transurethral resection. Saline irrigation (bipolar β no dilutional hyponatraemia). Patient dischargeable the following day. Loss of ejaculation ~100%. Risk of stress incontinence ~0% in experienced hands. Erectile function not impaired.
Prostate >80 mL Β· Gold standard
HoLEP / ThuLEP (holmium/thulium laser)
Transurethral laser enucleation of the adenoma, then endovesical morcellation. Excellent deobstruction, suitable for any volume. Very long learning curve (hundreds of cases). Risk of stress incontinence is initially higher with inexperienced surgeons.
Anticoagulated patient
GreenLight laser vaporisation
Vaporises tissue without cutting β minimal bleeding. Ideal when anticoagulation cannot be suspended. Less deobstructive than other lasers. No histological specimen obtained.
Prostate >100β200 mL
Robotic simple prostatectomy
Open-like enucleation of the adenoma via robotic laparoscopy. Excellent for very large prostates, associated bladder stones, and diverticula. Minimal learning curve for surgeons already proficient with the robot. Transperitoneal approach β general anaesthesia.
Minimally invasive Β· Frail patient / wishes to preserve ejaculation
Urolift
Titanium implants that hold open the prostatic urethra. Quick procedure, preserves ejaculation. Long-term efficacy inferior to other approaches.
Minimally invasive Β· Frail patient / wishes to preserve ejaculation
RezΕ«m (water vapour therapy)
High-temperature steam injections into the adenoma β coagulative necrosis. ~8-minute procedure, minimal anaesthesia. Postoperative course is uncomfortable (2 weeks of catheterisation, analgesia). Excellent results at 3 months. Preserves ejaculation in many cases.
π Before surgery: always assess detrusor contractility with urodynamic study in patients with high residual volume, neurological disease, or prior failed surgery. A hypocontractile patient will not benefit from deobstruction.
β Frequently asked questions
Not necessarily. Nocturia (waking to void at night) can have many causes other than the prostate. In many cases it is due to nocturnal polyuria: the kidney produces more than one-third of the daily urine output during the night. This occurs, for example, when diuretics are taken in the evening, or in patients with cardiac disease or lower limb oedema that reabsorbs during recumbency. A voiding diary (recording times and volumes for 3 days) helps distinguish a true reduction in bladder capacity from a non-urological cause.
Alpha-blockers primarily improve voiding symptoms (stream, hesitancy), but have a more limited effect on storage symptoms (frequency, urgency). If these persist, additional agents exist (antimuscarinics or beta-3 agonists) that act specifically on the often co-existing overactive bladder. Another common cause is simply excessive fluid intake: too much fluid overall, or too much in the evening. A voiding diary helps to identify the underlying cause.
Yes, this is a real side effect of alpha-blockers, known as Intraoperative Floppy Iris Syndrome. Alpha-blockers relax the iris dilator muscle, making it flaccid. This causes no problems in daily life, but becomes relevant during cataract surgery, where the ophthalmologist may have difficulty achieving adequate pupillary dilatation. If you are due to have eye surgery, always inform your ophthalmologist that you are taking this medication and discontinue it at least 4 weeks before the procedure.
For TURP (the most common procedure), the risk of erectile dysfunction is approximately 5%, so very low. Erectile function is largely preserved. What is almost always lost (in approximately 100% of cases) is ejaculation: semen no longer exits externally during orgasm but flows back into the bladder (retrograde ejaculation). This causes no pain or health consequences, but should be discussed with patients who have an interest in fertility. Minimally invasive treatments (Urolift, RezΕ«m) can preserve ejaculation, but their long-term efficacy is inferior to TURP.