The Role of the Aging Bladder in Lower Urinary Tract Symptoms: Pathophysiology and Therapeutic Implications in Patients with Benign Prostatic Hyperplasia.

Background and

Objectives

Lower urinary tract symptoms (LUTS) are highly prevalent among aging men and have traditionally been attributed primarily to benign prostatic hyperplasia (BPH) and bladder outlet obstruction (BOO). However, growing evidence suggests that bladder-related mechanisms play a critical and often underrecognized role. This review aims to summarize current evidence on the contribution of the aging bladder to LUTS pathophysiology and to explore the therapeutic implications in men with BPH. Materials and

Methods

A comprehensive literature search was conducted in PubMed/MEDLINE, Scopus, and Web of Science for studies published between January 2010 and April 2025. Search terms included combinations of "aging bladder", "detrusor dysfunction", "LUTS", "BPH", "bladder outlet obstruction", "ischemia", "overactive bladder", and "detrusor underactivity". Eligible studies included narrative reviews, systematic reviews, meta-analyses, clinical studies, and translational research addressing bladder aging and its clinical implications. A narrative synthesis approach was used due to heterogeneity in study design and outcomes.

Results

A total of 43 studies were included in the qualitative synthesis. The evidence indicates that LUTS in older men result from multifactorial processes involving not only prostatic enlargement but also bladder dysfunction. Aging-associated changes include detrusor remodeling, impaired compliance, neural alterations, and vascular insufficiency, particularly chronic ischemia and oxidative stress. These mechanisms contribute to both detrusor overactivity and underactivity, providing a unifying framework for storage and voiding symptoms. Importantly, the severity of LUTS does not consistently correlate with prostate size or degree of obstruction.

Conclusions

LUTS in aging men should be considered a complex condition involving both bladder and outlet factors. A bladder-centered perspective may improve patient stratification and therapeutic outcomes. Integrating bladder-targeted therapies with conventional BPH management supports a more personalized and effective approach to care.