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Voiding dysfunction in men: pathophysiology and risk factors

International Journal of Impotence Research volume 20, pages S2–S10 (2008)Cite this article

Benign prostatic hyperplasia (BPH) refers to histologic changes within the prostate. Benign prostate growth induces physiological changes in men that in some cases lead to bothersome lower urinary tract symptoms (LUTS). These LUTS exert their effects in an individual's life by disrupting their daily activities and can be associated with a diminishing quality of life. Although a benign prostatic obstruction is relatively common in those with LUTS, in approximately one-third of men with significant LUTS, there is no evidence of a benign prostatic obstruction.1 To further understand the relationship between LUTS, BPH and bladder outlet obstruction, the physiological changes that occur as a man develops BPH must be understood. Although the precise relationship is the focus of future research, understanding both the physiology and the risk factors associated with prostate growth can assist in understanding some of the interactions between the three components. By understanding the changes that occur as a male develops BPH, we can try to identify risk factors and the most efficient measurements used to diagnose individuals with this condition. Identifying these may allow for more efficient diagnosis of individuals suffering from this disease.

A more robust understanding of male voiding dysfunction is predicated on the use of rare terminology. The challenge is to change the terms to make them more pragmatic and user friendly. In the past, the term ‘prostatism’ was used to describe a wide variety of LUTS, making it relatively nonspecific and the source of a substantial amount of confusion. This changed in the early 1990s when Abrams2 introduced more specific terminology. He explained that BPH should be used to describe only histologic changes of hyperplasia. Benign prostate enlargement should refer to the gross enlargement of the prostate gland, which is typically determined through a digital rectal examination (less accurate) or a transrectal ultrasound. Benign prostatic obstruction should be used to describe urodynamic confirmation of bladder outlet obstruction caused by the prostate. BPH, benign prostate enlargement and LUTS can coexist or occur independently. The term LUTS encompasses voiding (painful urination, weak stream, hesitance and intermittency), post-micturition (terminal dribble and feeling of incomplete emptying) and filling (nocturia, frequency, urgency and urgency incontinence) symptoms and was proposed in 1994 by Abrams.3 Although LUTS can result from BPH, it can originate from many other sources, including alterations in bladder function, comorbities or neurological disorders. To clarify terminology, the fourth International Consultation on BPH suggested using ‘LUTS’ or ‘LUTS suggestive of BPH’ instead of ‘prostatism’ when referring to men with urinary symptoms and the possibility of an enlarged prostate.4 Moreover, the types of urinating symptom need to be properly explained. In the past, obstructive and irritative symptoms were the most common terms utilized. Currently, the more appropriate terms are voiding (that is, decreased urinary stream, sense of incomplete bladder emptying and hesitancy) and storage symptoms (urgency, frequency, nocturia and urge incontinence).

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  1. Department of Urology, Weill Cornell Medical College, Cornell University, New York, NY, USA

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Scofield, S., Kaplan, S. Voiding dysfunction in men: pathophysiology and risk factors. Int J Impot Res 20 (Suppl 3), S2–S10 (2008). https://doi.org/10.1038/ijir.2008.54

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