Lower urinary tract symptoms that significantly impair quality of life in men may result from benign prostatic hyperplasia, overactive bladder, or a combination of both conditions. The diagnosis of benign prostatic hyperplasia, a voiding dysfunction due to outlet obstruction, can be made with a thorough history and physical examination. A validated questionnaire should be used to make an accurate initial diagnosis and to monitor treatment effect over time. Selective alpha-1 blockers are an appropriate first-line drug choice for most patients; however, 5-alpha reductase inhibitors and phosphodiesterase type 5 inhibitors may also be used, alone or in combination with each other, depending on symptom severity and if alternative treatment options are needed. If medical therapy is ineffective, surgical and interventional procedures aimed at opening the prostatic urethra are available to ameliorate symptoms. Overactive bladder manifests with urinary urgency, frequency, and nocturia with or without incontinence. The diagnosis of this storage dysfunction due to detrusor overactivity can be made with a thorough history, physical examination, urinalysis, and assessment of the residual volume of urine in the bladder after voiding. First-line treatment for overactive bladder includes beta-3 agonists as well as pelvic floor physical therapy and behavioral interventions. If left untreated, benign prostatic hyperplasia and overactive bladder can result in significant social isolation and relationship strain.
Irwin G. Common Male Genitourinary Issues: Benign Prostatic Hyperplasia and Overactive Bladder. FP Essent. 2026;567:14-22.
Case 2. JZ is a 53-year-old patient who presents with concerns of urinary frequency, urgency, and a sensation of incomplete emptying of the bladder. He reports no fevers, chills, flank pain, or dysuria, and has not had pyuria or hematuria. He drinks two cups of caffeinated coffee and one energy drink per day, as well as water throughout the day. He states that his symptoms are negatively affecting his life; he avoids long car rides and has to interrupt work meetings to urinate. Physical examination results are unremarkable, urinalysis is negative, and his bladder postvoid residual volume is 5 mL.
Definitions, Epidemiology, and Pathophysiology
Benign prostatic hyperplasia (BPH) occurs when there is proliferation of smooth muscle and epithelial cells within the prostatic transformation zone.1 It is a histologic diagnosis. Clinically, men with BPH present with voiding symptoms such as hesitancy (difficulty initiating a urine stream), straining, intermittency, or weak stream as well as urine dribbling, dysuria, sensation of incomplete voiding, urinary frequency, nocturia, urinary urgency, enuresis, or incontinence.2 The prevalence of BPH increases with age, with approximately 25% of men in their 50s affected, increasing to 50% of men in their 80s.3 Lower urinary tract symptoms are considered moderate or severe in more than one-half of affected men, although only one-third seek and receive treatment for symptoms.2 Many men do not seek treatment because of cost, embarrassment, lack of information about available options, mistaken belief that the symptoms are part of normal aging, or simple resignation.4
Overactive bladder (OAB) presents with urinary symptoms of urgency, frequency, and nocturia with or without urinary incontinence.5 OAB should be considered in the differential diagnosis for lower urinary tract symptoms alongside BPH. Approximately 14.5% of men in the United States have been diagnosed with OAB.6 Prevalence of OAB, like that of BPH, increases with age, with 4.5% of men ages 20 to 39 years, 13.5% of those 40 to 59 years, and 29.1% of those 60 years and older affected in one study.6
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