New words for old: lower urinary tract symptoms for “prostatism”BMJ 1994; 308 doi: http://dx.doi.org/10.1136/bmj.308.6934.929 (Published 09 April 1994) Cite this as: BMJ 1994;308:929
- P Abrams
Extraordinary interest currently exists in the treatment of men over 45 who are referred with the label “prostatism.” This has been generated partly by commercial interest and patients' increased awareness and expectations and partly by the advent of new treatments. Several new drugs to relieve bladder outflow obstruction, including (alpha) adrenergic blockers and 5-(alpha) reductase inhibitors, have been or are about to be licensed. Drug companies have expended huge efforts in increasing patients' and doctors' awareness of prostatic disease.
New techniques to destroy part or all of the prostate have been developed, including thermotherapy, thermal ablation, high intensity focused ultrasonography, transurethral needle ablation, and laser prostatectomy. Added to this are the techniques of intraurethral prostatic stenting and balloon dilatation of the prostate.1
Surveys have shown that urinary symptoms are very common in older men, with prevalences varying from 11% for straining up to 78% for nocturia.2 Interestingly, British and American research has suggested that symptoms are also very common in elderly women.3,4 Historically, we have used the terms “prostatism” and “symptoms of benign prostatic hyperplasia” to describe lower urinary tract symptoms in men. Yet because these symptoms are also common in women of similar age these terms become less sensible.
Other arguments exist against their use. Although the term prostatism implies a prostatic cause for symptoms, almost no evidence exists for such a cause. Most attempts to correlate either individual symptoms or groups of symptoms with objective measurements have failed to show any significant associations. (The exception has been the association between the symptoms of daytime frequency, urgency of micturition, and urge incontinence with the urodynamic finding of detrusor instability.5) The conclusion follows that no symptoms are specific to either benign prostatic hyperplasia or one of its complications - bladder outflow obstruction.
Benign prostatic hyperplasia is a precise histological term, yet many older men with lower urinary tract symptoms are described as suffering from the symptoms of benign prostatic hyperplasia or from clinical benign prostatic hyperplasia. The use of the specific histological term is confusing in everyday clinical practice.
Why is this seemingly pedantic discussion important? There are several reasons. Firstly, terms such as prostatism and clinical benign prostatic hyperplasia carry a spurious diagnostic authority, which may be translated into treatment without a proper diagnosis. Secondly, about one third of men with prostatism do not have bladder outflow obstruction secondary to prostatic enlargement.6 Some 30 000 prostatectomies are performed each year in Britain,7 and although increasingly urologists are defining bladder outflow obstruction objectively (usually by urine flow studies), many men with prostatism without bladder outflow obstruction are still being subjected to prostatectomy. The outcome of operations on such men is unsatisfactory.8 Additionally, transurethral resection of the prostate is associated with low but important morbidity and mortality: some men may die unnecessarily.
If we reject the term prostatism and restrict the use of the term bladder outflow obstruction, is there an alternative? I believe that we should use the term “lower urinary tract symptoms.” This describes patients' complaints without implying their cause. This is important as the symptoms are neither sex, age, nor disease specific. Hence, lower urinary tract symptoms could be used as a collective noun for any constellation of symptoms at any age, in either sex.
“Filling symptoms” would be a better term than “irritative symptoms” as irritative implies a pathological finding such as infection, stone, or tumour. The symptoms of frequency, urgency, and urge incontinence (traditionally grouped together as irritative symptoms) almost always indicate a functional abnormality rather than a structural fault or inflammatory process.
“Voiding symptoms” could replace the term “obstructive symptoms” (which include hesitancy, poor stream, straining, a feeling of incomplete emptying, and intermittency). We know that up to one third of men with low flow rates do not have bladder outflow obstruction but have detrusor underactivity as a cause of their reduced stream.9 This seems part of aging and may be common to men and women.10 Furthermore, two of the alleged obstructive symptoms - straining to micturate and intermittency of urinary stream - probably have no association with bladder outflow obstruction (J Reynard, personal communication).
Benign prostatic enlargement is a preferable term to benign prostatic hyperplasia as enlargement can be assessed, to some degree, by digital rectal examination and precisely defined by transrectal ultrasonography. Benign prostatic enlargement does not, however, imply the presence of bladder outflow obstruction, and many patients with enlargement do not have obstruction.
Benign prostatic obstruction is probably the condition that most urologists want to treat. The term can be taken to mean that cancer of the prostate has been excluded so far as possible by digital rectal examination with the possible addition of an estimation of prostatic specific antigen and transrectal ultrasonography. Benign prostatic obstruction also implies that objective evidence of obstruction exists. In patients with symptoms this evidence would be reduced flow rates or raised voiding pressures in combination with low flow rates.
If we can rid ourselves of imprecise and improperly used terms we will be better able to evaluate our elderly male patients. Any filling or voiding symptoms can be documented for what they are, and, if the symptoms are sufficiently bothersome, further evaluation can be discussed with the patient. The patient can be told that when further evaluation (urine flow studies or pressure flow studies) is carried out and patients are selected for surgery according to their results then the results of surgical procedures are excellent. If the suggestions above are followed patients who will benefit from surgery will be identified more accurately and our limited resources will be used to better the twin goals of improved quality of life and cost effectiveness.