The clinical manifestations of benign prostatic hyperplasia (BPH) include lower urinary tract symptoms (LUTS) poor bladder emptying urinary retention detrusor instability urinary tract infection hematuria and renal insufficiency. remains the improvement of quality of life for the patient. Key terms: Benign prostatic hyperplasia Prostate-specific antigen American Urological Association Sign Index International Prostate Sign Score The term benign prostatic hyperplasia (BPH) offers different connotations to the pathologist urodynamicist training urologist and individual. To the pathologist BPH is definitely a microscopic analysis characterized by cellular proliferation GTx-024 of the stromal and epithelial elements of the prostate.1 To the training urologist it signifies a constellation of lower urinary tract symptoms (LUTS) that develop in the male population in association with aging and prostatic enlargement presumably caused by bladder outlet obstruction (BOO).2 To the urodynamicist the hallmark of BPH is the observation of synchronous elevated voiding pressure and a low urinary flow Mmp2 rate in the absence of additional disease processes that cause BOO.3 The patient is typically concerned about the impact of BPH about quality of life rather than the presence of cellular proliferation prostatic enlargement or elevated voiding pressures. Because of the varied connotations associated with the term it is necessary to define BPH as microscopic BPH macroscopic BPH or medical BPH. Microscopic BPH represents histologic evidence of cellular proliferation of the prostate. Macroscopic BPH refers to enlargement of the prostate resulting from microscopic BPH. Clinical BPH represents the LUTS bladder dysfunction hematuria and urinary tract infection (UTI) resulting from macroscopic BPH. Abrams4 offers suggested using the more clinically descriptive terms benign prostatic enlargement (BPE) BOO and LUTS to replace BPH. Microscopic BPH identifies a proliferative process of the stromal and epithelial elements of the prostate.5 The proliferative course of action originates in the transition zone and the peri-urethral glands.6 It is rarely recognized in men younger than 40 GTx-024 years.7 GTx-024 The autopsy incidence of BPH is age-dependent with the GTx-024 proliferative process being present in approximately 70% and 90% of men in their seventh and ninth decades of life respectively. The development of microscopic BPH requires aging and the testes as the source of androgens.8 Androgens play a passive role in the proliferative course of action. The GTx-024 specific biochemical event that initiates and promotes microscopic BPH offers yet to be recognized and characterized. Growth factors presumably are involved through autocrine and paracrine stromal epithelial relationships.9 Macroscopic BPH denotes an “enlarged” prostate. Digital rectal exam (DRE) provides a relatively crude estimate of prostate size compared with measurements acquired using transrectal ultrasonography (TRUS).10 Although knowledge of prostate size may be clinically relevant in some cases justifying the cost of obtaining a precise measurement of gland volume in all cases is questionable. A strong correlation is present between serum prostate-specific antigen (PSA) levels and prostate volume.11 There is no consensus concerning the degree of enlargement required to establish the analysis of macroscopic BPH. There is evidence that males with prostate quantities exceeding 40 cm3 have a greater response to 5-α-reductase inhibitors.12 Therefore some specialists limit the analysis of BPH to males with prostate quantities exceeding 40 cm3. The medical manifestations of BPH include LUTS poor bladder emptying urinary retention detrusor instability UTI hematuria and renal insufficiency.13 The overwhelming majority of males present with LUTS only. Historically the pathophysiology of medical BPH was attributed to BOO secondary to macroscopic enlargement of the prostate gland.14 This hypothesis was supported by epidemiologic data suggesting the prevalence of microscopic BPH macroscopic BPH and clinical BPH is age-dependent and therefore causally related.15 This simplistic concept of the pathophysiology of BPH has been challenged by more recent reports demonstrating weak relationships GTx-024 among prostate size severity of BOO and severity of symptoms.16-19 BPH: Differential Analysis The complex of symptoms now commonly referred to as LUTS and previously termed “prostatism” is not specific for BPH. Ageing men with a variety of lower urinary tract pathologies may show similar if not identical symptoms (Table 1). Table 1 Differential Analysis of.