Behavior Modification May Be a Useful Strategy for Treating Men with Lower Urinary Tract Symptoms Thought to be Due to “BPH”

Lee P1, Daniel R2, Khosla L1, Vizgan G2, Prishtina L2, Farooq M2, Blaivas J3, Bushman W4

Research Type


Abstract Category

Conservative Management

Abstract 473
ePoster 7
Scientific Open Discussion ePoster Session 32
Sunday 22nd November 2020
10:55 - 11:00 (ePoster Station 1)
Exhibition Hall
Benign Prostatic Hyperplasia (BPH) Voiding Diary Male
1. State University of New York Downstate Health Sciences University, 2. Institute for Bladder and Prostate Research, 3. Icahn School of Medicine at Mount Sinai, 4. University of Wisconsin School of Medicine and Public Health

Philip Lee



Hypothesis / aims of study
Behavioral modification (Bmod) is recommended as an initial management strategy in men with a clinical diagnosis of benign prostatic hyperplasia (BPH). BPH in this context refers to any male over the age of 50 who comes in with lower urinary tract symptoms (LUTS) and their provider suspects this is due to an enlarged prostate and labels their symptoms as BPH. This study was done to determine the magnitude and clinical characteristics of a subpopulation of men with lower urinary tract symptoms (LUTS) for whom fluid restriction and Bmod would be a useful strategy.
Study design, materials and methods
An established online database was queried for men who completed a 24-hour bladder diary (24HBD) and Lower Urinary Tract Symptom Score (LUTSS) between 2015 and 2019 using a mobile app* [1]. If a patient had more than one bladder diary and LUTSS, only the first submission was used. Women and patients with incomplete or flawed entries were excluded. Age, gender, uroflow (Qmax), post-void residual urine (PVR), and voided volume were obtained from the patient’s electronic medical records (EMR). Patients were divided into three groups based on the 24HBD: polyuria (>2.5 L/24 H), oliguria (<1L/24 H) and normal (1 to 2.5 L/24 H) [2]. Those with polyuria were the focus of the study. This data was analyzed via the SPSS statistics software utilizing a one-way ANOVA looking at LUTS scores, bladder diary data, and urodynamic data between the three urinary groups. In addition, independent two-tailed sample t-tests were run comparing the polyuria and oliguria groups. The p-value was considered significant when it was ≤.05. Data for all three groups were gathered and analyzed but only the polyuria group is presented in table 1.
The initial cohort had 504 patients (331 men and 173 women, mean age 59 SD 18). After applying exclusion criteria, there were 331 men of whom 86 (26%) had polyuria, 42 (13%) had oliguria and 203 (61%) had normal 24H VV. There was no difference in total or any of the 6 symptom LUTSS sub-scores between the men with polyuria, oliguria, and normal 24H VV. All LUTSS, 24HBD, and Urodynamic data was analyzed but only the most pertinent data for our discussion are presented in Table 1. In the polyuria group, 37 patients had contemporaneous Qmax, Voided Volume, and PVR. It is important to note that voided volume refers to the volume associated with the uroflow (Qmax) data and is distinct from 24H VV. Lastly, there was no statistically significant difference in terms of LUTSS subscores between the three urinary groups. There was also no difference when comparing the polyuria to the oliguria group.
Interpretation of results
The rationale for considering fluid restriction and Bmod as a viable treatment for men with BPH symptoms is empirically based on the following criteria – 24H VV large enough so that fluid restriction does not pose a health threat, sufficient bladder capacity, a large number of voids per 24 H and low likelihood of severe urethral obstruction. In this series, 26% of BPH patients had polyuria. These men had a mean 24H VV of 3480 mL, a sufficient MVV of 473 mL, voided a mean of 13 times per day and had a mean Qmax of 18 mL/S, thus fulfilling all of the criteria cited above. In addition, those with polyuria were, on average, younger (mean age = 55 compared to 65 years) in the oliguria group. This suggests that younger patients may drink out of habit or because of increased health consciousness. 

The fact that there was no difference in any of the LUTSS subscores amongst the three groups (polyuria, oliguria and normal) indicates that there is no ready way to make the distinctions alluded to above based on symptoms; a bladder diary is crucial.
Concluding message
Voiding diaries reveal that a large fraction of men (26% in this study) presenting with BPH symptoms exhibit polyuria.  These men are symptomatically indistinguishable from those with normal 24 hour voided volume and even from men with oliguria, yet, they are the group in which fluid restriction and Bmod is more likely to be efficacious.  This highlights the essential role of a 24-hour voiding diary in the behavioral management of men with BPH.
Figure 1
  1. Blaivas JG, Tsui JF, Mekel G, et al. Validation of the lower urinary tract symptom score. The Canadian Journal of Urology. 2015 Oct;22(5):7952-7958
  2. Hashim H, Blanker MH, Drake MJ, Djurhuus JC, Meijlink J, Morris V, Petros P., Wen JG, & Wein A. 2019. International Continence Society (ICS) report on the terminology for nocturia and nocturnal lower urinary tract function. Neurourology and urodynamics, 38(2), 499–508.
Funding Institute for Bladder and Prostate Research Clinical Trial No Subjects None