Health and Prostate

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Epidemiology

Early population studies of benign prostatic hyperplasia included those by Jensen in Denmark, and Wattanabe in Japan, both in 1986. Berry, reporting on a series of five necropsy studies, showed hyperplasia to exist almost exclusively in glands greater than 20 gms in weight and in men over 30 years of age. Further evidence from the Baltimore Longitudinal Study of Ageing showed a good level of agreement with autopsy prevalence rates. The first large community study, published by Garraway in 1991, showed lower prevalence rates than the autopsy studies in men selected as having either urinary flow rates of below 15 ml/sec, or specific levels of lower urinary tract symptoms (LUTS), or both. A parallel study, done in Omstead County, USA, by the Mayo Clinic, showed similar levels to the Scottish Community Study. Much higher levels of benign prostatic enlargement (BPE) were found in the second Stirling BPH study where no clinical thresholds were applied before measuring prostate size (Table 1), rising to 913 per 1000 (95% CI 798-1000) at age 70-79 years. BPE is so frequent as to be considered as much a normal part of ageing as grey hair or wrinkles.

Symptoms and signs: BPE, LUTS, and urinary flow

Having established that benign prostatic enlargement (BPE) is almost universal in men over the age of 70 years, we must turn to the other symptoms and signs for the diagnostic criteria of the clinical syndrome benign prostatic hyperplasia.

Lower urinary tract symptoms (LUTS), commonly sought in evaluating the clinical condition, include hesitancy in the initiation of micturition, a weak force of stream, stopping and re-starting or interruption of the stream, and terminal dribbling. These symptoms are sometimes classified ‘obstructive’. Symptoms of nocturia — frequency, urgency, dysuria and a sensation of incomplete voiding — represent ‘irritative’ symptoms. The evidence is poor for this pragmatic division; only urgency and urge incontinence correlate with the presence of a detrusor instability. Abrams has recently argued cogently that the term ‘filling symptoms’, for frequency nocturia urgency and urge incontinence, would be preferable to the term ‘irritative’ since the latter term implies some form of inflammation, and the term ‘voiding symptoms’, to include hesitancy, slow stream and intermittency, and a feeling of incomplete emptying, terminal dribbling and post micturition dribble, would be better than the term ‘obstructive’.

Then there is the urinary flow measurement. The trace produced by a uroflow machine has to be read in a similar way to an electrocardiograph tracing rather than simply accepting the mathematical data. However, ‘QMax’ (maximal flow) is generally regarded as the most useful measure of flow.

The presence of BPE, LUTS, and reduced uroflow in a variety of combinations, provide the basis for diagnosis of benign prostatic hyperplasia. However, BPE, LUTS and uroflow do not have any significant relationship. Part of the explanation for this lies in the variety of ways in which the gland enlarges, with predominant enlargement, particularly later in life, being in the transition zone. BPH is not a simple condition where rigid threshold criteria can be easily applied to establish a diagnosis.

Difficulties for clinicians are increased by two further factors: failure of men to consult about either their symptoms or slow stream until the changes are advanced, and lack of clarity about the natural history of benign prostatic hyperplasia. The low level of knowledge about prostatic disease found in European men may be improving. However, as symptoms and reduced flow are accepted as a normal part of ageing, only pain, haematuria and acute retention are perceived as reasons for seeking medical help.

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