In Japan, surgical procedure for the treatment of benign prostatic hyperplasia (BPH) is usually considered when (1) drug therapy is ineffective, (2) lower urinary tract symptoms are moderate-to-severe, and (3) complications such as urinary retention, urinary tract infection, hematuria, and bladder stones are present. The decision to treat BPH surgically is mainly based on the severity of voiding symptoms, such as urinary retention. Nocturia is a urinary storage symptom associated with BPH. To our knowledge, no study has evaluated whether nocturia influences the decision to treat BPH surgically. We used the international consultation on incontinence (ICIQ)-nocturia quality of life (N-QOL) questionnaire and evaluated the impact of nocturia on the decision to treat BPH surgically.

Patients who visited our institution for the treatment of BPH between June 2022 and March 2023 were enrolled in the study. We evaluated N-QOL of the patients at the time of the initial visit. In addition, we evaluated their international prostate symptom score (IPSS) and overactive bladder symptom score (OABSS). The validated Japanese version of the N-QOL questionnaire consisted of 13 questions. The sleep/energy domain included questions on concentration, energy, naps, productivity, leisure activity, and nighttime sleep. The bother/concern domain included questions on water intake, disturbance to the family, waking up to urinate, deterioration, lack of effective therapy, and disturbance owing to nocturia. The final question related to overall obstacles in daily life. We examined the relationship between decision for surgical intervention and N-QOL, subscale domains, and each of the scores. Questions on nocturia in the IPSS and OABSS were also evaluated. The unpaired t-test or Mann-Whitney non-parametric test was used to evaluate the relationship between surgery and each score using SPSS® Statistics version 20.

Of the 53 patients identified with BPH, 44 were eligible for inclusion in the study. Nine patients did not complete the N-QOL, IPSS, or OABSS entirely. The mean age, total prostate-specific antigen level, and prostate volume were 74.0 years, 4.18 ng/mL, and 49.52 mL, respectively. Twelve patients underwent surgical treatment with holmium laser enucleation of the prostate (HoLEP) (Group 1). Conservative treatment with alpha-blockers was administered to 32 patients (Group 2). Mean N-QOL total score of Group 1 was significantly lower than that of Group 2 (51.7 ± 4.8 vs. 67.4 ± 3.8, p = 0.018). Mean bother/concern domain score was also significantly lower in Group 1 (47.2 ± 4.4 vs. 64.8 ± 4.5, p = 0.014) compared with that in Group 2. In contrast, IPSS question 7 relating to nocturnal voiding frequency showed no significant difference (3.0 ± 0.4 vs. 2.6 ± 0.2, p = 0.364). Comparison of the individual scores revealed that the scores were significantly worse in Group 1 for the following parameters; worried about water intake, deterioration, and lack of effective therapy (p = 0.020, 0.015, 0.040; respectively) (See Table for details).

The indications for surgery in BPH are not as clearly defined as those for other malignant diseases. Although surgery is considered when complications such as repeated urinary retention are observed, there is considerable ambiguity regarding the indication criteria, which include inadequate response to drug therapy and moderate-to-severe symptoms. In current clinical practice, the indication for surgery is rarely based on N-QOL scores; however, we used the N-QOL to evaluate which symptoms influence the decision for surgical treatment of nocturia. In this study, nocturnal voiding frequency was not found to be associated with surgical decisions for BPH. This study revealed that the QOL related to nocturia, particularly worsening symptoms and anxiety regarding treatment options, influenced the decision to opt for surgical treatment. Based on the results of this study, the indications for surgery for BPH need to be evaluated objectively by assessing not only the IPSS, but also N-QOL.

Examination of the indications for surgical intervention for BPH, with a focus on nocturia, revealed that QOL factors, such as deterioration and anxiety regarding treatment options influenced the surgical decision rather than nocturnal voiding frequency.