Controversies in the diagnosis and management of benign prostatic hypertrophy

The prevalence of BPH ensures a continuing need for internists to be aware of the issues regarding the evaluation and treatment of prostatism, while the developing role of nonoperative therapy and the growing recognition of the importance of patient preferences have opened the way for an expanded involvement of the primary care practitioner in the management of these patients. Prostatism remains a difficult clinical problem since many of the symptoms and diagnostic tests are nonspecific, especially in the elderly. Basic questions regarding the role of bladder outlet obstruction (BOO) in the development of symptoms and in predicting outcome from surgery await further study. Against this background of uncertainty, however, is the reassurance that the natural history of the process results in serious complications in only the minority of patients. Important work is under way that will incorporate quality of life outcomes, compare surgery with "watchful waiting," and randomize patients to surgical and nonsurgical treatments. In the interim, the internist may help patients with prostatism significantly by appreciating the natural history of the condition, treating the conditions that mimic or exacerbate it, understanding the clinical utility and limitations of current evaluation methods, becoming aware of the growing array of nonsurgical and minimal-surgery options, and assisting patients in weighing therapeutic risks and benefits with their concerns about symptoms.