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Benign prostatic hyperplasia (BPH) commonly causes lower urinary tract symptoms (LUTS) through narrowing of the urethra and disruption of innervation of the gland. BPH is common in older men. Risk factors include Black race, Hispanic ethnicity, obesity, type 2 diabetes, high levels of alcohol consumption, physical inactivity, and a family history of BPH. The degree of LUTS can be assessed using the American Urological Association Symptom Index (AUASI). Watchful waiting is recommended for men with mild symptoms. Alpha1-adrenergic blockers or 5-alpha reductase inhibitors can be used to manage more severe symptoms. (This is an off-label use of some alpha1-adrenergic blockers.) Alpha1-adrenergic blockers typically are the initial choice. Combination therapy is more effective than monotherapy. Anticholinergics and beta3-adrenergic agonists can be used to manage irritative LUTS if the postvoiding residual urine volume is low. (This is an off-label use of anticholinergics and beta3-adrenergic agonists.) The phosphodiesterase type 5 inhibitor tadalafil is a second-line pharmacotherapy. There is insufficient evidence to support use of integrative medicine therapies. Physicians should consult with a urology subspecialist when patients do not benefit from medical therapy or have refractory LUTS, recurrent urinary tract infections, gross hematuria, bladder stones, or renal insufficiency.

Case 2. Richard is a 62-year-old man who comes to your office reporting increasing nocturia. He currently urinates 2 to 4 times per night. He also has a weak urinary stream and hesitancy, particularly with the first void of the morning. He thinks he may not always completely empty the bladder when voiding. He reports no fevers, chills, flank pain, or dysuria. He is married and monogamous. He has no history of kidney disease.

Benign prostatic hyperplasia (BPH) is a benign neoplasm commonly encountered in aging men.43 It can produce a variety of obstructive and irritative urinary symptoms that are collectively known as lower urinary tract symptoms (LUTS).

The pathophysiology of BPH is not completely understood,44 but may be a combination of androgen-dependent hyperplasia of the periurethral zone and stromal elements in the transitional zone of the prostate, and changes in the alpha-adrenergic, muscarinic, and phosphodiesterase type 5 (PDE5) receptors of the gland. The size of the prostate, whether determined by physical examination or ultrasonography, does not correlate with the severity of LUTS.43

Benign prostatic hyperplasia is common in older men,45 with symptoms typically manifesting after age 40 years. In the primary care setting, symptomatic BPH affects approximately 3% of men ages 45 to 49 years and 24% of men older than 80 years.45 Risk factors include Black race, Hispanic ethnicity, obesity, type 2 diabetes, high levels of alcohol consumption, physical inactivity, and a family history.44,46

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