Nicole L. Miller, MD, FACS, on persistent LUTS after BPH treatment

In this video, Nicole L. Miller, MD, FACS, discusses how clinicians can distinguish persistent lower urinary tract symptoms (LUTS) related to bladder dysfunction from symptoms caused by benign prostatic hyperplasia (BPH), particularly when considering retreatment. Miller is a professor in the department of urology at Vanderbilt University in Nashville, Tennessee.

Miller emphasizes the importance of evaluating symptom patterns alongside objective measures of bladder emptying and prostate size. Patients with predominantly irritative or storage symptoms, a relatively normal uroflowmetry pattern, and complete bladder emptying may be more likely to have a primary bladder problem rather than persistent obstruction from prostate enlargement, she noted. Cystoscopic findings such as bladder wall thickening and trabeculation can also provide insight into bladder health.

“Understanding prostate size is critical here as well,” Miller says, noting that clinicians should consider both the prostate and the condition of the bladder when evaluating persistent symptoms.

When symptoms remain difficult to attribute to the prostate or bladder based on history, validated symptom instruments, uroflowmetry, and cystoscopy, urodynamic testing can help guide decisions about retreatment. Miller notes that clinicians should be particularly cautious about pursuing another outlet procedure without evidence of persistent obstruction. She also explains that approximately 70% to 80% of patients with storage symptoms are expected to experience improvement after a bladder outlet procedure when the outlet is the underlying cause. For patients whose irritative symptoms persist, medical therapies such as β3-adrenergic agonists and anticholinergics may be incorporated into ongoing management.