Benign prostatic hyperplasia (BPH) is a nonmalignant proliferative disorder of the prostate that becomes increasingly prevalent with advancing age. Although histological enlargement and clinical disease are distinct entities, BPH is a major contributor to lower urinary tract symptoms (LUTS) in middle-aged and older men. LUTS include storage symptoms such as frequency, urgency, and nocturia, together with voiding symptoms such as hesitancy, weak urinary stream, intermittency, and incomplete emptying. The clinical burden is important because progressive disease can impair quality of life and, in a subset of patients, lead to acute urinary retention or the need for surgical intervention [1,2]. Evaluation of men with suspected BPH requires integration of symptoms with objective indicators of prostatic enlargement. The International Prostate Symptom Score (IPSS), derived from the American Urological Association symptom index, is a validated seven-item instrument that quantifies symptom severity and permits classification into mild, moderate, and severe categories [3]. However, symptom intensity does not always correspond closely to anatomical enlargement. Bladder function, dynamic smooth-muscle tone, age-related changes, coexisting metabolic conditions, and individual perception of urinary bother can influence the clinical presentation. Consequently, prostate volume and symptom scores provide related but nonidentical information. Serum prostate-specific antigen (PSA) is primarily used in the evaluation of prostate cancer risk, but PSA concentration is also influenced by benign glandular volume. Large clinical datasets have demonstrated a positive relationship between serum PSA and prostate volume in men with BPH after exclusion of overt malignancy [4]. PSA and prostate volume have also been linked to the subsequent risk of acute urinary retention and BPH-related surgery [5]. Studies across different populations have supported the use of PSA as a practical surrogate marker of prostate enlargement when direct measurement is unavailable or when treatment decisions depend on gland size [6-9]. Nevertheless, the strength of these relationships differs according to age, ethnicity, method of prostate-volume estimation, and patient selection. The association between anatomical prostate size and LUTS severity is less consistent. Some studies have reported little or no correlation between prostate volume and IPSS [7,10,11], whereas other clinical observations suggest that larger glands are more frequently associated with greater symptom burden or progression risk. Such variation highlights the importance of examining prostate volume, PSA, and LUTS concurrently within defined clinical populations rather than relying on any single parameter. The present study was therefore undertaken to evaluate men with BPH attending a tertiary-care teaching hospital in Bangalore. The objectives were to determine the distribution of prostate volume, serum PSA, and LUTS severity; assess differences in PSA and IPSS across prostate-volume categories; compare prostate volume and PSA across LUTS-severity groups; and examine correlations among age, prostate volume, PSA, and IPSS.

Study design and setting: This hospital-based cross-sectional observational study was conducted at Dr BR Ambedkar Medical College, Kadugondanahalli, Bangalore, Karnataka, India. The institution provides tertiary-level clinical services and receives adult patients with urological complaints from Bangalore and surrounding areas. Data collection was carried out over seven months, from June 2019 to December 2019. Study participants: Eligible participants were enrolled after clinical evaluation. The authors should confirm and report the informed-consent procedure exactly as documented in the approved study protocol. Clinical assessment: Demographic information, duration of LUTS, history of hypertension and diabetes mellitus, previous acute urinary retention, and family history of BPH were recorded using a structured case-record form. LUTS severity was assessed with the International Prostate Symptom Score, a validated seven-item symptom instrument [3]. Total IPSS was categorized as mild (0-7), moderate (8-19), or severe (20-35). A focused physical examination, including digital rectal examination when clinically indicated, formed part of the routine evaluation. Laboratory and imaging assessment: Serum total PSA was measured from venous blood using the laboratory assay routinely available at the institution. PSA values were analyzed as a continuous variable and were additionally categorized as <4 ng/mL and ≥4 ng/mL for descriptive presentation. Prostate volume was measured by ultrasonography using standard ellipsoid-based volume estimation. For analysis, prostate volume was classified as <40 mL, 40-59 mL, and ≥60 mL. The established relationship between PSA and benign prostate volume provided the clinical rationale for concurrent evaluation of these parameters [4,6,8]. Statistical analysis: Data were entered into a computerized database and analyzed using standard statistical procedures. Continuous variables were summarized as mean ± standard deviation, and categorical variables as frequencies and percentages. Mean PSA and IPSS values were compared across prostate-volume categories, while mean prostate volume and PSA were compared across LUTS-severity categories using one-way analysis of variance. Associations between categorical prostate-volume groups and LUTS severity were assessed using the chi-square test. Pearson correlation coefficients were calculated for prostate volume versus PSA, prostate volume versus IPSS, PSA versus IPSS, age versus prostate volume, and age versus PSA. A two-sided p-value <0.05 was considered statistically significant. Ethical considerations: The study should be reported in accordance with institutional ethical requirements and the principles governing research in human participants. Necessary Permissions were obtained before starting the study.

A total of 80 men with benign prostatic hyperplasia were included in the final analysis. The mean age of the study population was 64.8 ± 8.1 years, and the mean duration of lower urinary tract symptoms was 3.7 ± 2.4 years. Hypertension was present in 31 (38.8%) participants, while 21 (26.3%) had diabetes mellitus. The demographic and baseline clinical characteristics are presented in Table 1. Table 1. Baseline demographic and clinical characteristics of patients with BPH (n = 80) Characteristic n (%) / Mean ± SD Age, years 64.8 ± 8.1 Age group, years 50–59 27 (33.8) 60–69 28 (35.0) ≥70 25 (31.3) Duration of LUTS, years 3.7 ± 2.4 Hypertension 31 (38.8) Diabetes mellitus 21 (26.3) Previous acute urinary retention 10 (12.5) Family history of BPH 8 (10.0) The mean prostate volume was 48.6 ± 18.9 mL, while the mean serum PSA concentration was 3.62 ± 2.01 ng/mL. Nearly two-thirds of the patients, 52 (65.0%), had serum PSA levels below 4 ng/mL. The mean IPSS was 18.7 ± 7.3. Moderate LUTS represented the predominant symptom category in 43 (53.8%) patients, followed by severe LUTS in 24 (30.0%) and mild LUTS in 13 (16.3%) patients (Table 2). Table 2. Distribution of prostate volume, serum PSA, and LUTS severity (n = 80) Parameter n (%) / Mean ± SD Prostate volume, mL 48.6 ± 18.9 Prostate volume category <40 mL 29 (36.3) 40–59 mL 33 (41.3) ≥60 mL 18 (22.5) Serum PSA, ng/mL 3.62 ± 2.01 Serum PSA category <4 ng/mL 52 (65.0) ≥4 ng/mL 28 (35.0) IPSS 18.7 ± 7.3 LUTS severity according to IPSS Mild (0–7) 13 (16.3) Moderate (8–19) 43 (53.8) Severe (20–35) 24 (30.0) Both PSA levels and symptom severity increased progressively with prostate volume. Patients with prostate volumes below 40 mL had a mean PSA concentration of 2.41 ± 1.18 ng/mL and a mean IPSS of 14.1 ± 5.8. In comparison, men with prostate volumes ≥60 mL had substantially higher mean PSA levels (5.52 ± 2.20 ng/mL) and IPSS values (25.8 ± 5.9). Differences across prostate-volume categories were statistically significant for both PSA and IPSS (p<0.001). Similarly, increasing LUTS severity was accompanied by larger prostate volume and higher serum PSA levels (Table 3). Table 3. Association of prostate volume and LUTS severity with serum PSA and IPSS Clinical category n Prostate volume, mL Mean ± SD PSA, ng/mL Mean ± SD IPSS Mean ± SD Prostate volume category <40 mL 29 — 2.41 ± 1.18 14.1 ± 5.8 40–59 mL 33 — 3.65 ± 1.47 18.8 ± 6.4 ≥60 mL 18 — 5.52 ± 2.20 25.8 ± 5.9 p-value <0.001 <0.001 LUTS severity Mild 13 34.8 ± 11.2 2.31 ± 1.21 — Moderate 43 46.2 ± 15.4 3.37 ± 1.65 — Severe 24 60.4 ± 20.1 4.83 ± 2.31 — p-value <0.001 0.001 A clear relationship was also observed between prostate size and categorical LUTS severity. Among patients with prostate volumes ≥60 mL, 12 of 18 (66.7%) had severe LUTS, whereas severe symptoms were present in only 2 of 29 (6.9%) patients with prostate volumes <40 mL. The association between prostate-volume category and LUTS severity was statistically significant (p<0.001). Correlation analysis demonstrated a strong positive relationship between prostate volume and serum PSA (r=0.64, p<0.001). Prostate volume was also positively correlated with IPSS (r=0.57, p<0.001), while PSA showed a moderate correlation with IPSS (r=0.41, p<0.001). Age showed weaker but significant associations with prostate volume and serum PSA (Table 4). Table 4. Association of prostate volume with LUTS severity and correlation among study variables Analysis Mild LUTS Moderate LUTS Severe LUTS / p-value Prostate volume and LUTS severity, n (%) <40 mL 9 (31.0) 18 (62.1) 2 (6.9) 40–59 mL 4 (12.1) 19 (57.6) 10 (30.3) ≥60 mL 0 (0.0) 6 (33.3) 12 (66.7); p<0.001 Correlation analysis r p-value Prostate volume vs. PSA 0.64 <0.001 Prostate volume vs. IPSS 0.57 <0.001 PSA vs. IPSS 0.41 <0.001 Age vs. prostate volume 0.32 0.004 Age vs. PSA 0.29 0.009 Overall, increasing prostate volume was significantly associated with higher serum PSA levels and greater LUTS severity. The strongest relationship was observed between prostate volume and PSA, followed by the association between prostate volume and IPSS. These findings indicate that prostate enlargement, biochemical changes reflected by PSA, and symptom burden are interrelated clinical features among men with BPH.

The present study demonstrated a coherent relationship among prostate volume, serum PSA, and LUTS severity in men with BPH. Mean prostate volume was 48.6 mL, mean PSA was 3.62 ng/mL, and the average IPSS was in the moderate symptom range. More than half of the participants had moderate LUTS, while almost one-third had severe symptoms. Importantly, both mean PSA and mean IPSS increased progressively across prostate-volume categories, indicating that anatomical enlargement was accompanied by greater biochemical activity and higher symptom burden in this study population. The strongest observed association was between prostate volume and serum PSA (r=0.64). This agrees with the large analysis by Roehrborn et al., which showed a strong age-dependent relationship between PSA and prostate volume in men with BPH [4]. Mochtar et al. similarly reported that PSA could estimate prostate enlargement with sufficient accuracy for clinical management [6]. Vesely et al. observed a positive correlation between prostate volume and PSA, while Chung et al. demonstrated an age-dependent PSA-volume relationship in a large multicentre Korean cohort [7,8]. Pinsky et al. also found that both prostate volume and age were independently associated with PSA levels [9]. The present findings therefore support PSA as an indirect marker of benign prostate enlargement, although PSA remains nonspecific and requires appropriate clinical interpretation. Prostate volume also correlated positively with IPSS (r=0.57), and severe LUTS became increasingly common as gland volume increased. Two-thirds of men with prostate volumes of at least 60 mL had severe LUTS, compared with only 6.9% of those with volumes below 40 mL. This pattern suggests that larger glands were associated with greater symptom burden in the present cohort. However, the literature is not uniform. Agrawal et al. found no significant overall correlation between prostate volume and IPSS in men with BPH [10], and Udeh et al. likewise reported no significant relationship in an African population [11]. Vesely et al. also observed that symptom scores did not closely track objective measures of benign prostatic enlargement [7]. Differences in bladder compensation, dynamic obstruction, detrusor function, ethnicity, case selection, and methods of volume assessment could explain these contrasting observations. Age showed weaker but significant correlations with both prostate volume and PSA. Comparable age-related trends have been reported by Vesely et al., Pinsky et al., and Putra et al. [7,9,12]. These findings are biologically plausible because benign prostate enlargement and PSA concentrations generally rise with advancing age, although the magnitude varies between populations. The clinical importance of evaluating prostate volume and PSA extends beyond cross-sectional association. Larger prostate size and higher PSA have been identified as predictors of BPH progression, acute urinary retention, and the need for intervention [2,5,13,14]. Thus, simultaneous assessment of IPSS, prostate size, and PSA can provide a broader picture of symptom burden and progression risk than any single measure alone. The present study adds supportive data from a tertiary-care Indian setting and emphasizes the complementary nature of these commonly available clinical parameters. Limitations This study has several limitations. Its cross-sectional design prevents assessment of temporal changes or causal relationships among prostate enlargement, PSA, and symptom progression. The single-center setting and modest sample size restrict external generalizability. Prostate volume was assessed by ultrasonography without comparison with magnetic resonance imaging, and urodynamic parameters were not incorporated. Residual confounding from age, medications, metabolic factors, and bladder dysfunction also remains possible.

In this cross-sectional study of 80 men with benign prostatic hyperplasia, increasing prostate volume was significantly associated with higher prostate-specific antigen concentrations and greater lower urinary tract symptom severity. Prostate volume showed the strongest correlation with PSA, followed by its correlation with IPSS, while PSA also correlated positively with symptom scores. Men with prostate volumes of 60 mL or greater had a markedly higher frequency of severe LUTS. These findings support combined use of prostate volume, serum PSA, and IPSS during assessment rather than interpretation of any parameter in isolation. Integrated evaluation can improve characterization of disease burden and support risk-based decisions regarding follow-up, medical therapy, and timely urological intervention.

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