LUTS, BPH, BPE, BPO: A Plea for the Logical Use of Correct Terms

Editorial

EDITORIAL LUTS, BPH, BPE, BPO: A Plea for the Logical Use of Correct Terms Paul Abrams, MD, FRCS Bristol Urological Institute, Southmead Hospital Bristol, England [Rev Urol 1(2):65, 1999] n a leading article in the British Medical Journal in 1994, the traditional terms associated with older men who have bladder symptoms were attacked. Numerous studies have shown the lack of association between symptoms, prostatic size, and urodynamic evidence of obstruction. Furthermore, women have been shown to have symptoms indistinguishable from those of men. These data mean that terms such as “prostatism,” “irritative symptoms,” and “obstructive symptoms” are, at best, meaningless and, worse, misleading, since they have a spurious diagnostic authority. For these reasons, the term “lower urinary tract symptoms” (LUTS) was proposed. In the BMJ article, it was suggested that LUTS should be divided into storage (filling) symptoms and voiding symptoms; these terms would replace the misleading terms irritative and obstructive symptoms. A similar problem exists with the way patients are described with respect to the prostate. The terms “patient with BPH” and “clinical BPH” are as meaningless as “prostatism.” BPH is a histologic diagnosis. How, then, does the doctor know the patient has BPH before getting a histologic report? If the patient were 70 to 80 years old, statistically the doctor would have a good chance at being correct: 70% of men of 70 years and 80% of men of 80 years will have histologic BPH. Meanwhile, the patient doesn’t care about his prostate histology so long as the doctor doesn’t suspect cancer. The way most doctors attempt to treat patients is by reducing or removing the bladder outlet obstruction (BOO) that an enlarged prostate may cause. Therefore, our focus should be on determining whether a patient has benign prostatic obstruction. To communicate, there is a need for all of us to be precise in our use of terms: • BPH—benign prostatic hyperplasia, a term that should be used exclusively to describe the histologic changes characteristic of BPH. I • BPE—benign prostatic enlargement, a term describing increased size of the gland usually secondary to BPH. The precise size that determines the lower limit of BPE remains to be defined; 20 mL has been suggested. Approximately 50% of men with histologic BPH develop BPE. • BPO—benign prostatic obstruction, a term used to describe BOO secondary to BPE and, therefore, usually due to BPH. It has been estimated that only 50% of men with BPE have associated BOO. The appropriate and accurate use of terms is essential so that patients get effective assessment and treatment. The old terms prostatism and clinical BPH allowed the uncritical urologist to submit all men with LUTS to prostate surgery. As the average age of men presenting with LUTS becomes younger, the proportion of men with BOO is less. When the mean age of men with LUTS was 67, the population with obstruction was 67%; now only 50% of men presenting with LUTS are obstructed. Patients need and deserve proper scientific thought processes from their physicians: • Does the patient have troublesome symptoms? • Is the gland benign and enlarged? • Does the patient have obstruction? While it would be very convenient to have a single term to cover all patients, the clinical situation is not so simple. The patient initially presents with LUTS; after simple assessment, he may become a man with troublesome LUTS and BPE (from digital rectal examination or transrectal ultrasound); and after flow studies or pressure-flow studies, he may become a man with troublesome LUTS and BPO. This approach will maximize the beneficial effects of treatments developed to help men who present with LUTS suggestive of BPO. Reference Abrams P: New words for old: Lower urinary tract symptoms for “prostatism.” Br Med J 69:929-930, 1994. SPRING 1999 REVIEWS IN UROLOGY 65