BPH Prevalence
Prevalence increases with each decade of life; histological evidence confirms that BPH occurs in 50% of men aged 51-60 years, 79% of men aged 71-80 years, and 85% of men older than 80 years.30 Moderate-to-severe LUTS are observed in 19% of men in their fifties and in more than 30% of men beyond this age, and their frequency increases with age.31 Using a definition of BPH which encompasses prostatic enlargement (>30cc)and an IPSS>7, the overall prevalence in men aged 55-74 was shown to be 19%.32 The major difficulties in accurately establishing the prevalence of BPH have been the lack of a common definition of BPH and the lack of widely accepted diagnostic criteria. The definition of BPH is often based solely on the symptoms or the volume of the prostate.However, LUTS, benign prostatic enlargement (BPE) and BOO co-exist, and could, as a group, be considered to define the disease BPH.
The UrEpiK Study was designed to obtain a better understanding of the major benign urological conditions, particularly LUTS, and to determine the impact of BPH on the quality of life of the patient, as well as the spouse, through a variety of ongoing individual studies. These urological epidemiological studies were prospective and crosssectional, and were based in centres in the UK, France, The Netherlands and Korea.33
Data have been analysed from one UrEpiK study that investigated the international variation in the prevalence of LUTS in men aged 40-79 years.31 In this multicentre, randomised study involving 4,800 men, prevalence was determined by evaluating symptoms using a questionnaire based on the AUA-SI. The study concluded that the prevalence of LUTS increases with age, as does the level of bother owing to LUTS. The prevalence of severe LUTS (AUA-SI 20-35) was more common in men aged 70-79 years, than in men aged 40-49 years (8.4% and 5.3%, respectively).
BPH Bother
Using the BII questionnaire to determine the degree of bother from LUTS, significant bother (BII 7-13) was greater in men aged 70-79 years, than in those aged 60-69 years (5.0% and 3.3%, respectively). No marked cultural variation was found among populations.
BPH - Impact on Quality of life
Patients with moderate to severe LUTS have rated their health similarly to patients with other chronic diseases. Using the EuroQoL (EQ-5D) questionnaire,35 in which patients rank their health from 0 ('death') to 1 ('perfect health'), patients in the United Kingdom with moderate LUTS rated their health at a similar level to that of non-smoking asthma sufferers (see below).36,37
| Condition | Mean EuroQoL Score |
| BPH-related condition36 | |
| Mild LUTS (IPSS<8) | 0.87 |
| Moderate LUTS (IPPS 8-19) | 0.79 |
| Severe LUTS (IPSS 20-35) | 0.71 |
| Other chronic conditions | |
| Non-smoking asthmatics37 | 0.80 |
| Smoking asthmatics37 | 0.76 |
Using the most widely applied health-related quality of life (HRQoL) questionnaire, the SF-36, US patients with severe LUTS rated their health status as similar to or worse than patients with chronic obstructive pulmonary disease (COPD).38,39 These patients reported similar ratings for physical functioning and mental health; however, patients with severe LUTS reported lower scores on general health, emotional and physical roles, vitality, social functioning, and bodily pain relative to patients with COPD.
The negative impact of BPH on HRQoL can be tremendous. It is largely related to how bothered patients are by their LUTS and there appears to be a definite relationship between symptom severity and HRQoL. In a US observational study of men with LUTS, moderate-to-severe urinary symptoms were found to have a significant impact on men's lives in terms of degree of bother, worry, interference with daily living, and psychological well-being.40 Men with moderate-to-severe LUTS reported, on average, four to six times the degree of bother and interference with daily activities and twice the level of worry relative to men with mild symptoms.
In a study examining the impact of LUTS and HRQoL in observational studies across four countries (Scotland, US, France, and Japan), HRQoL worsened with increases in age.41 When adjusting for age, the disease-specific measures were significantly worse with increasing symptom severity. In particular, bother and interference with daily activities due to urinary symptoms were highly correlated with urinary symptoms measured by the IPSS. Worsening HRQoL (general health status, sexual satisfaction and sexual drive) with increasing symptom severity was also seen. However, the correlation was not as high. In addition, the relationships were stronger in the US and Japan, where prevalence of symptoms is higher.
In an observational study of 1627 men in Scotland, about half of men with BPH reported interference with at least one activity of daily living as a result of urinary dysfunction, compared with 28% of men who did not have BPH.42 In 17% of men of working age (40-64 years), this interference occurred most or all of the time for at least one activity, compared with only 3% of men in the same age group who did not have BPH. Overall, bothersome symptoms (including nocturia, hesitancy, urgency, straining, intermittence, dribbling, incomplete emptying and weak stream) disproportionately affected patients with BPH.
A recent study in The Netherlands of 475 men with confirmed BPH found that weak urinary stream, frequency, and urgency were the most prevalent symptoms, while the most bothersome symptoms were urgency, nocturia, and hesitancy.43
Prostate size is also a factor in determining HRQoL. In a random sample of men from the US Olmsted study, bother and activity interference were about 50% worse for men with enlarged prostates (volume >40cc) compared with men with smaller prostates, after adjusting for age.44 Men with enlarged prostates were nearly 3 times as likely to have moderate-to-severe symptoms, and about twice as likely to have bother or activity interference compared with men with smaller prostates, after adjusting for age. In addition to having a significant impact on the patient, BPH can also have a significant impact on the patient's partner.45,46 Mitropoulos et al found that partners of patients with BPH, experience significant morbidity due to their partner’s condition. This morbidity, although not always related to the severity of symptoms, included: fear of surgery or prostate cancer, psychological burden, inadequate sex life, disruption of social and home life and sleep disturbance. The authors concluded that partners of patients with symptomatic BPH experience significant morbidity because of their partner's condition. The severity of patients' symptoms, however, is not always related to partners' morbidity.46
BPH Economic Impact
With average life expectancy approaching 80 years in many countries, and the likely continued trend of an ageing population, it is expected that there will be a significant worldwide increase in the number of men affected by BPH, and thus the burden on healthcare resources will escalate.47 In addition, the progressive nature of BPH is likely to cause costs to rise as a result of the increasing requirement for treatment over time.14
BPH is a progressive disease associated with significant financial costs; Figures from Europe estimate the cost of prescriptions to manage BPH, coupled with the cost of surgery, to be €123-458 million annually.49,50 Surgical procedures in particular are costly, making up 50–65% of the estimated medical costs in Europe. The US treatment costs in 1989 were estimated at US$4 billion (€4.1 billion).48
Although, with the advent of effective drug therapy for BPH, the number of surgical procedures is declining. As mentioned by Vela et al in a recent paper, significantly more patients are having open surgery, perhaps because the progressive increase in prostate volume was not affected by the most predominant medical therapy used during this decade – alfa adrenergic antagonists (Vela Navarrete BJUI 20051). In addition, due to the ageing population and the availability of effective medication, it is expected that the overall BPH costs will be an ongoing concern.
Other direct costs to consider are those associated with diagnosis and acute management, and with post-treatment monitoring. However, it is also important to consider the indirect costs associated with BPH treatment in active working patients. These include, time lost from work, reduced productivity and interference with activities of daily living.
Additional Reference:
1. Vela et al. The impact of medical therapy on surgery for benign prostatic hyperplasia: a study comparing changes in a decade (1992–2002). BJU International, 2005. 96; 1045-1048.