Unsolved Issues in Managing Benign Prostatic Hyperplasia

which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Benign prostatic hyperplasia (BPH) is one of the most common health issues related to quality of life in aged males. In the past, voiding symptoms and storage symptoms were all classified as BPH. During the past 20 years, most of the concepts and perspectives concerning the treatment modality of BPH have evolved. Currently, we recognize multiple aspects of BPH, such as anatomical enlargement of the periurethral gland, lower urinary tract symptoms (LUTS), and functional obstruction of the bladder outlet. Although these aspects may coexist, each is dealt with independently during treatment. Nocturia is regarded as another separate entity. At present, LUTS are considered to be the primary domain of BPH, and thus the primary treatment goal for BPH is directed toward relieving LUTS. According to the recent guideline from the European Urological Association , severe conditions including urinary retention, gross hematuria, urinary tract infection, and bladder stones are current indications for surgery [1]. " LUTS refractory to medical treatment " is also considered to be an indication for surgery. Otherwise, managements based on pharmaceutical agents currently constitute the baseline treatment strategy. Therefore, clinical practice patterns based on controlling LUTS occupy the bulk of BPH management. Consequently, the number of BPH surgeries declined significantly after the 1990s with the popularization of medical management while bigger prostates have become more common. This trend is true even in developing countries, where the aged population is increasing dramatically. In this situation, is it justifiable to continue to follow up with medication when managing LUTS in BPH patients regardless of the degree of obstruction or prostatic enlarge-ment? In other words, is it all right to prescribe medication or to watchfully wait for LUTS in patients with obvious bladder outlet obstruction (BOO) who do not complain of significant LUTS? It is clear that, from the perspective of a long-term period, medical management in BPH, by its nature , has a role in maintaining the status quo of BPH, which is similar to the medical management of diabetes or hyper-tension, but does not have a role in curing BPH. Therefore, at this point, we need to recognize at least two critical characteristics of BPH patients. First, there is only one direction of clinical progression, which is increasing prostate size as men age. Second, the chances for multiple morbid-ities such …