Lower urinary tract symptoms (LUTS) in men are highly prevalent among those aged >50 yr. Contemporary analyses of claim databases in the Western world have shown that LUTS generate millions of prescriptions and thousands of surgical interventions each year, representing a huge economic burden  . Moreover, the field of LUTS management is rapidly evolving due to new drug treatment indications and various innovative surgical therapies (eg, laser techniques, urethral lift)  . Consequently, it makes sense to produce guidelines for assessing the grade of recommendation for each therapeutic option  . In this month's issue ofEuropean Urology, Gratzke et al deliver guidelines for the assessment of non-neurogenic male LUTS including benign prostatic obstruction (BPO)  . This approach is of critical importance because the initial diagnostic work-up of the patient presenting LUTS:
BPO is the ghost hidden behind virtually every male patient presenting voiding symptoms. In their paper, Gratzke et al point out the difficulties of determining BPO without urodynamic evaluation (for most authors, that is not necessary in every case)  . They are correct in stating that uroflowmetry has several pitfalls, including the issue of maximum urinary flow rate (Qmax) cut-off; however, if low Qmaxmight not be fully specific for BPO, it also must be stated that a correct value (typically >15 ml/s) also might not perfectly reflect the absence of obstruction. Uroflow pattern, but also average flow, may be at least as important as Qmax. There is probably an urgent need to question the relevance of Qmaxalone, which, unfortunately, is the cornerstone of inclusion criteria and efficacy outcomes for all contemporary randomized controlled trials in this area. New alternative methods have been presented to check obstruction using noninvasive methods (eg, penile cuff, computational flow modeling), but there is no definitive answer yet  .
If not perfectly ascertained, BPO is mostly suspected in the absence of an alternative diagnosis. Once proposed, BPO can be characterized to choose the best option for therapeutic management. It has been postulated rather recently that several types of BPO exist (because of a “median lobe,” lateral lobes, or both), with the main approach for characterization being median lobe description and index of prostatic protrusion (IPP) by examination with transrectal ultrasound  . This concept, however, is still vague because the anatomy, shapes, and dynamics of the posterior lobe of the prostate are still not well understood. No clear distinction has been made to date between a posterior lobe prominent in the lumen (protuberance typewith a potential rolling-ball effect) and a posterior lobe spreading regularly from one side to another (posterior wall typewith a potential valve effect). The latter may not even necessarily lead to increased IPP. Urethrocystoscopy may play a substantial role, notably, by assessing the morphologic details of the posterior lobe (posterior wall or protuberance) and the shape of the structures related to IPP during retrovision. Indeed, the mechanisms of BPO provoked by a solitary prominent central median lobe are different from those due to a global, circumferential protrusion of the entire gland in the bladder.
A supplementary innovative approach calledvoiding urethrocystoscopyhas been described recently and allows recording of the movements of the prostatic lobes during micturition  . In this work, we were able to characterize different profiles of BPO: complete nonopening of the lateral lobes (type 1A), partial opening of the lateral lobes limited to apex (type 1B), complete lateral lobe opening but obstruction by immobile median posterior wall (type 2A), or a mobile median posterior lobe rolling within the urethral lumen during micturition (type 2B). Consequently, voiding urethrocystoscopy might be able to further characterize BPO in men. The next step is to identify situations in which partial surgery could be attempted to remove only the part of the prostate responsible for obstruction.
Several data show that each case is different regarding the degree and mechanism of BPO but also regarding medical background and comorbidities, age, prostate size, prostate shape, underlying bladder function, and patient expectations. During initial LUTS assessment, the urologist should try to gather all information with enough detail to offer the best treatment for each particular patient.
Sexuality is one of the main aspects of this evaluation in men aged ≥40 yr because (1) all treatments have potential adverse events on sexual function and (2) patients may be willing to find a trade-off between BPO relief and ejaculation preservation and . Thanks to a new armamentarium, it is now possible to propose elective surgery and conservation of sexual function (notably, with minimally invasive nonablative options and laser techniques)  . Our duty is to offer the patient the best solution, including partial BPO surgery, even if the ideal profiles have yet to be determined.
A tailored treatment approach seems much more valuable than a “one size fits all” attitude, particularly for BPO relief; however, there is still a long way to go in this area. Until recently, α-blockers, 5α-reductase inhibitors, transurethral resection of the prostate, and open prostatectomy were the sole treatment options. The numerous innovations that emerged over the past 10 yr will necessarily lead the urologic community to rethink approaches to LUTS and BPO. By shedding light on clinical assessment, through formal detailed guidelines, a first step has been taken in the right direction.
Jean-Nicolas Cornu has received research funding from Assistance Publique Hôpitaux de Paris, the French Ministry of Health, Oak Ridge Associated Universities, the Association Française d’Urologie, and GSK; has received consultancies and travel grants from Bard, AMS, EDAP-TMS, Coloplast, Pfizer, MundiPharma, Astellas, Bouchara-Recordati, Biocompatibles UK, and Takeda; and is proctor for AMS. Bertrand Lukacs has nothing to disclose.