This article assesses the reported prevalence and incidence rates for benign prostatic hyperplasia and lower urinary tract symptoms (BPH/LUTS) by age, symptom severity, and race/ethnicity. BPH/LUTS prevalence and incidence rates increase with increasing age and vary by symptom severity. The BPH/LUTS relationship is complex due to several factors. This contributes to the range of reported estimates and difficulties in drawing epidemiologic comparisons. Cultural, psychosocial, economic, and/or disease awareness and diagnosis factors may influence medical care access, symptom reporting and help-seeking behaviors among men with BPH/LUTS. However, these factors and their epidemiologic association with BPH/LUTS have not been thoroughly investigated.
Key points
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Prevalence and incidence rates for benign prostatic hyperplasia and lower urinary tract symptoms (BPH/LUTS) have not previously been summarized in the literature by age group, symptom severity, and/or race/ethnicity.
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BPH/LUTS prevalence rates ranged from 50% to 75% among men 50 years of age and older to 80% among men 70 years of age and older. Overall incidence rates ranged from 8.5 to 41 cases/1000 person–years.
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BPH/LUTS epidemiologic estimates generally increased with increasing age. Unmeasured cultural, psychosocial, economic, and/or medical reporting differences may contribute to reported differences by age and symptom severity.
Introduction
Benign prostatic hyperplasia (BPH) is a prevalent condition in aging men that represents a substantial disease burden. It can be associated with various other health outcomes that can have significant negative impacts on quality of life. Many men with BPH will never see a doctor, nor will they need treatment for the condition. BPH becomes a clinical entity when lower urinary tract symptoms (LUTS) associated with it are bothersome enough for a patient to seek medical care. LUTS is the preferred terminology to describe symptoms potentially caused by multiple pathologic conditions, including bladder storage symptoms and voiding difficulties such as increased urgency, frequent urination, weak urinary stream, and urine leakage. BPH/LUTS, or benign prostatic hyperplasia associated with lower urinary tract symptoms, affects more than 20% of American men aged 30 to 79 years, or roughly 15 million men. This prevalence appears to increase with increasing age, as approximately 80% of men are affected by BPH/LUTS by 70 years of age. Most men, if living long enough, will develop some histologic features consistent with BPH in their lifetime.
To date, no reviews have focused on the prevalence and incidence of BPH/LUTS overall or by disease severity, patient age, and/or race/ethnicity. The primary aim of this article is to assess the full body of published literature in regard to BPH/LUTS estimates as well as to determine if the differences reported by disease severity, age, and race/ethnicity are consistent between studies and/or comparable. The variation in disease definition and assessment used for studies of BPH/LUTS prevalence and incidence rates may make comparing reported rates between studies complicated and sometimes, impossible.
Introduction
Benign prostatic hyperplasia (BPH) is a prevalent condition in aging men that represents a substantial disease burden. It can be associated with various other health outcomes that can have significant negative impacts on quality of life. Many men with BPH will never see a doctor, nor will they need treatment for the condition. BPH becomes a clinical entity when lower urinary tract symptoms (LUTS) associated with it are bothersome enough for a patient to seek medical care. LUTS is the preferred terminology to describe symptoms potentially caused by multiple pathologic conditions, including bladder storage symptoms and voiding difficulties such as increased urgency, frequent urination, weak urinary stream, and urine leakage. BPH/LUTS, or benign prostatic hyperplasia associated with lower urinary tract symptoms, affects more than 20% of American men aged 30 to 79 years, or roughly 15 million men. This prevalence appears to increase with increasing age, as approximately 80% of men are affected by BPH/LUTS by 70 years of age. Most men, if living long enough, will develop some histologic features consistent with BPH in their lifetime.
To date, no reviews have focused on the prevalence and incidence of BPH/LUTS overall or by disease severity, patient age, and/or race/ethnicity. The primary aim of this article is to assess the full body of published literature in regard to BPH/LUTS estimates as well as to determine if the differences reported by disease severity, age, and race/ethnicity are consistent between studies and/or comparable. The variation in disease definition and assessment used for studies of BPH/LUTS prevalence and incidence rates may make comparing reported rates between studies complicated and sometimes, impossible.
Disease description/terminology
Benign Prostatic Hyperplasia
Clinical BPH is a histologic diagnosis of a progressive enlargement of the prostate gland resulting from nonmalignant proliferation of smooth muscle and epithelial prostate cells. BPH disease progression can lead to growth in the transition zone of the prostate gland, called benign prostatic enlargement (BPE), which results from proliferation of fibroblasts and epithelial glandular elements near the urethra. Men with clinical BPH typically have prostate volumes of at least 20 mL.
Lower Urinary Tract Symptoms
Fifty percent of men with BPH develop BPE, which can contribute to LUTS that include a broad range of symptoms and etiologies. Clinical diagnosis of BPH/LUTS is a multistep process, with the definition used in the literature and in clinical studies varying widely. LUTS are presently divided into either bladder storage symptoms, such as daytime urinary frequency, urgency, and nocturia; or emptying and voiding difficulties, such as straining, starting the stream of urine, intermittent stream, and incomplete emptying. Not all men with storage or voiding difficulties will be bothered by these symptoms and so may not seek medical attention. However, early BPH/LUTS detection and appropriate management may improve quality of life outcomes and help to prevent more severe disease consequences. Despite this, men generally do not seek BPH treatment until the corresponding LUTS significantly reduce their quality of life.
One way to assess BPH/LUTS severity in men is by using the validated, self-administered International Prostate Symptom Score (IPSS). The IPSS is the present international standard evaluating 7 of the most common storage and voiding LUTS. It is also known as the American Urologic Symptom Index (AUA-SI). Severity is traditionally classified as
No more than 7 points = none or mild
8 to 20 points = moderate
20 to 35 points = severe
A strong correlation between symptom severity and frequency as measured by IPSS and other measures, such as the BPH Impact Index and the Symptom Problem Index, have been documented. IPSS can be used to diagnose LUTS in conjunction with a transrectal ultrasound of the prostate, a measurement of maximal urinary flow rate (Qmax) and/or a measurement of postvoid residual volume assessed by ultrasound, serum prostate-specific antigen levels, or urinalysis.
Risk factors and comorbidities
Medical and lifestyle predictors of BPH/LUTS have been primarily studied despite the high disease burden that should prompt researchers to assess population-level BPH/LUTS sociodemographic and environmental risk factors.
Known risk factors associated with BPH/LUTS include
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Age
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Sedentary lifestyle
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Lack of exercise
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Smoking
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Excessive alcohol consumption
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Hypertension
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Type II diabetes
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Depression
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Cardiovascular disease
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Hyperlipidemia
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Central obesity/waist circumference
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Hypogonadism
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Prostate disorder
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Inflammation
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Genetic predisposition
Risk factors have been shown to increase the risk of BPH/LUTS include
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Age
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Diabetes
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Hypertension
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Obesity
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Hypogonadism
Risk factors shown to decrease the risk of BPH/LUTS include
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Increased physical activity
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Moderate or decreased alcohol intake
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Increased vegetable consumption
The comorbidities often associated with BPH/LUTS include
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Erectile dysfunction
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Ejaculatory dysfunction
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Hypertension
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High cholesterol
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Digestive tract disorder
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Arthritis
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Heart disease/heart failure
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Diabetes
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Depression/anxiety/sleep disorder
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Allergies/cold/influenza/congestion
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General pain/inflammation
Prevalence/incidence
Disentangling BPH, LUTS, and BPH/LUTS prevalence and incidence rates reported in the literature is difficult due to the varying disease definitions and assessment methods used between studies. Because of these differences in disease definitions and reporting methods such as self-report qualitative and/or quantitative symptoms or diagnoses versus medical record reviews performed by trained medical professionals, BPH, LUTS, and BPH/LUTS estimates in the literature should be interpreted with caution, as inappropriately comparing or combining estimates of the different conditions could lead to potentially inaccurate conclusions.
Prevalence
Overall and by age
An estimated 15 million men in the United States over the age of 30 years are affected by BPH/LUTS. Large variations in existing prevalence rates are reported due to differences in BPH/LUTS definitions, assessment methods, and geographic regions. As presented in Fig. 1 , BPH/LUTS prevalence estimates also vary by age. Among men over the age of 50 years, 50% to 75% experience BPH/LUTS. For the majority of these men, without treatment, voiding and storage symptoms will significantly worsen with increasing age and time. Among men over the age of 70 years, 80% on average are impacted by BPH/LUTS.
As presented in Fig. 1 , the BPH/LUTS prevalence estimates reported in the literature vary. Despite this variation, the histologic prevalence of BPH/LUTS typically increased with increasing age in each study as androgens and aging are necessary for the development of BPH/LUTS. Prostate enlargement, peak flow rate, and LUTS have all been shown to be age-dependent conditions and are conditions that play a substantial role in BPH/LUTS development among aging men. Urinary symptoms of urgency, nocturia, weak stream, intermittency, and incomplete emptying are the most strongly correlated with age, and prevalence estimates rise to as high as 88% to 90% by 81 years of age or greater.
By disease severity
BPH/LUTS severity varies within each reported overall prevalence rate. The BPH Registry and Patient Survey, a prospective observational disease registry documenting BPH/LUTS practices and patient outcomes among 6909 men in the United States, reported that 33% of men had mild LUTS; 52% of men had moderate LUTS, and 15% of men had severe LUTS. The average IPSS at baseline was 11.6 (range 0–35). Another study based in the United States reported that 72.3% of men sometimes have LUTS, and 47.9% often have LUTS when LUTS were self-reported on a 5-point Likert scale. Bosch and colleagues reported moderate LUTS among 24% and severe LUTS among 6% of men in a community-based population survey of men between the ages of 55 and 74 years. In France, when LUTS were assessed via IPSS, 67% of men scored 1≤IPSS less than 8 (mild), 13% scored 8≤IPSS less than 19 (moderate), and 1.2% scored 20≤IPSS (severe). Another cross-sectional study supported these results, with a reported prevalence of mild symptoms among all symptomatic men equal to 75%, moderate symptoms equal to 21%, and severe symptoms equal to 4%. Among only men aged 40 to 49 years, these prevalence estimates for mild, moderate, and severe symptoms were 89%, 9%, and 2%, respectively. This increased to 55% with mild, 37% with moderate, and 8% with severe LUTS among men over the age of 70 years.
The reported differences in BPH/LUTS severity could be caused by differences in disease etiology that are currently poorly understood. Approximately 10% of men ≤30 years old, 20% of men 30 to 40 years old, 50% to 60% of men 40 to 60 years old, and greater than 80% of men 80 or more years old have enlarged prostates. Prostate volume generally increases with age, although rates vary at the individual level, and prostate volume is associated with BPH/LUTS. Men with significant prostate enlargement (>50 cm 3 ) are 3.5 times more likely to have age-adjusted moderate-to-severe LUTS than men without prostate enlargement. However, in another study only a weak correlation between IPSS, peak flow, and postvoid residual urine volumes and prostate volume was observed due to the simple fact that most men, regardless of LUTS severity, have prostate volumes less than 50 mL. Looking further into the BPH/LUTS disease etiology is an area of research that should be focused on in the future.
Prevalence estimates for BPH/LUTS by symptom severity should also be further studied, as men with more severe symptoms are more likely to seek treatment, which may bias estimates, especially in studies utilizing convenience samples of urology patients. This extends to studies that utilize medical record reviews, as most tend to include only men with moderate-to-severe symptoms as those are the men seeking treatment and, therefore, receiving BPH/LUTS diagnoses for data extraction.
By race/ethnicity
BPH/LUTS prevalence estimates are infrequently reported by race/ethnicity. Many studies included in this article have primarily racially homogenous populations and are, therefore, unable to draw conclusions on racial or ethnic differences in disease prevalence. However, there are a select few published articles of heterogeneous populations that are able to assess this difference, and these studies tend to indicate that the prevalence of BPH/LUTS may vary by race/ethnicity. The Prostate Cancer Prevention Trial reported the highest prevalence of BPH to be among Hispanic men, followed by black, white, and Asian men. This mirrored the results of the California Men’s Health Study and the Research Program in Genes, Environment and Health, which reported the highest prevalence of LUTS among Hispanic men, followed by black, white, and Asian men. Additionally, black men had an estimated moderate-to-severe LUTS prevalence of 39.6% in the Flint Men’s Health Study. Other studies reported that Japanese, Chinese, and Indian men have significantly lower prostate volumes than Australian or American men, which could contribute to BPH/LUTS prevalence differences. Additionally, the Third National Health and Nutrition Examination Survey (NHANES) reported some LUTS prevalence estimates by race/ethnicity. However, these NHANES estimates did not include the full spectrum of urinary symptoms as assessed by IPSS and are, therefore, unfortunately, not comparable to other BPH/LUTS race/ethnicity estimates presented here.
Incidence
Overall
Fig. 2 shows the overall incidence rates reported by 4 BPH/LUTS longitudinal cohort studies: The Prostate Cancer Prevention Trial, The Olmstead County study, The Health Professionals Follow-up Study, and a database review in the Netherlands.
Related posts:
Diagnostic Work-Up of Lower Urinary Tract Symptoms
Alpha-blockers for the Treatment of Benign Prostatic Hyperplasia
Antimuscarinics, β-3 Agonists, and Phosphodiesterase Inhibitors in the Treatment of Male Lower Urinary Tract Symptoms
Bipolar, Monopolar, Photovaporization of the Prostate, or Holmium Laser Enucleation of the Prostate
Robotic-Assisted Simple Prostatectomy
Sexual Side Effects of Medical and Surgical Benign Prostatic Hyperplasia Treatments
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