Definition of at-risk patients: dynamic variables

Benign prostatic hyperplasia (BPH) is a progressive disease, mainly characterized by a deterioration of symptoms over time, but also the occurrence in some patients of serious outcomes such as acute urinary retention (AUR) and the need for BPH-related surgery. The goals of therapy are not only to improve symptoms and restore an acceptable quality of life, but also to identify patients at risk of disease progression, to optimize their management. Baseline variables such as age, severe lower urinary tract symptoms (LUTS), a low peak flow rate, increased postvoid residual urine volume (PVR), enlarged prostate and high serum prostate-specific antigen (PSA) levels have been identified as predictors of AUR and BPH-related surgery in community-based longitudinal studies. In the placebo arm of controlled studies, baseline serum PSA level and to a lesser extent prostate size consistently predict the risk of AUR and BPH-related surgery, while quantitative variables such as baseline symptom severity and peak flow rate behave paradoxically and are poor predictors of BPH progression. There is increasing evidence from longitudinal community-based studies and the Medical Therapy of Prostatic Symptoms study that dynamic variables (e.g. symptom and PVR worsening) serve as good predictors of AUR in men with LUTS suggestive of BPH. The 'real-life' practice study Alf-One also suggests that men not responding to alfuzosin treatment (International Prostate Symptom Score stable or worsening, and bother score > 3 under treatment) have a greater risk of having AUR or requiring BPH-related surgery. First-line treatment with alfuzosin might thus help to select patients at risk of BPH progression, to optimize their management.