Guidelines for diagnosis and treatment of male >45 years of age with symptoms of lower urinary tract dysfunction (LUTD) commonly recommend second-line treatment when initial management, that was based on signs and symptoms, fails. When the patients reports that the symptom burden is high and when the uroflow(rate) is considered abnormal, invasive treatments are recommended as the second line treatment. Guidelines also recommend considering urodynamics (UDI) in selected cases, however without further specifying in which cases this should be considered. Furthermore, it is not recommended how the result of UDI, if done, should be incorporated in management. Based on the commonly accepted pathophysiologic mechanism of voiding problems in these men and, based on good clinical reasoning it is e.g., not logical to invasively ‘des-obstruct’ a not obstructing prostate. Also, it is known that symptoms do not adequately predict the existence of outflow obstruction. Clinical strategies, based on objective assessment of dysfunction(s) in these men are however scarcely described in the scientific literature. We report a large series of men, referred with symptoms of LUTD that all have had objective (UDI) grading of BOO in addition to uroflowmetry and transrectal ultrasound prostate volume measurement. The aim of our evaluation is to uncover how the results of objective assessment have affected our management and the outcomes.

138 randomly selected (from our ‘BPH-database’) men aged 64,6y (s.d. 10,2) with IPSS 17,8 (6,7) and QuOL 3,4 (1,4) at referral, had prostate size 70,0 cm3 (30,5) and (free flow) Qmax 10,4 mL/s (6,2) and a voided volume of 159,0 mL (128,7) with PVR of 79.0 mL (104). Most patients (81; 58,7%) had pharmacological treatment at referral. (32%: alpha-blocker only, 12% others had used these, but stopped; and 8% had polypharmacy for various reasons). 75 (54,3%) men were not satisfied with their LUTS- medication. 34 (24,6%) had not received earlier specific treatment for their LUTS. Some had UTI, pain or AUR in the past and 4 (2%) had prostate carcinoma and LUTS during expectative management for their prostate carcinoma. Two patients were initially referred with erythrocyturia.
UDI was performed according to the 2006 ICS standard with a 7F double lumen catheter and, a water filled external pressure recording system. Voiding was allowed in privacy and in the preferred (usually standing) position with the flowmeter funnel near to the meatus. 
Pressure flow study (PFS) resulted in mean outflow obstruction grade URA: 37,9 cmH2O (s.d. 20,4) and BOOI 52,7 (34,1). Also, a mean detrusor voiding contraction grade Wmax of 15,0 w/m2 (10,6) and BCI 116,0 (32,0) were measured. 40 patients had no BOO (ICS nomogram) and normal contraction; 37 had no BOO and weak contraction; 53 had BOO with normal contraction and 8 had BOO and weak contraction. Prostate volume correlated weak but significant with age (Pearson r: 0,302). Free flow Qmax correlated with URA (r: -0,326) and (weak) with (PFS) PVR (r: -0,261). (PFS-) PVR correlated with URA and Wmax (r: 0,468 and r: -0,320). No correlations were found with IPSS apart from a weak but significant total-IPSS with (IPSS-)QuOL (r:0,497). 
After second-line diagnosis, the patients without BOO were offered continuation or adaptation /personalization of medication or conservative management. Of note: 111 (55%) had DO during cystometry and medication was adapted for this in a proportion of patients. The other patients, with BOO were offered surgery or, as the alternative: to start, change, or continue medication or conservative management.

Table 1 shows the overall results: 16% ‘chronic urology’ can be considered failure: 13 returned to urological follow up. 9 other patients (also returned) had repeat UDS-PFS. No patient (in this sub-cohort) had (acute) urinary retention after referral. In the column ‘other’ (10%): 10 died and (new) prostate carcinoma was found in 2. Two others had a diagnosis of other major disease. 45 (32,6%) patients returned to primary care after reconfirmation or adaption of conservative management. 57 (41,3%) had surgery. 
The Kaplan Meier graphs (figure 1) shows the time to events. 
Graph A: Time to surgery (total 45 patients, surgery).
Graph B (cohort ‘surgery’): Time (months) to surgery based on the UDS-PFS diagnosis. 
Graph C: Time of Conservative treatment for all (total 57 patients, not surgery) 
Graph D (cohort ‘not surgery’): Time to end of conservative urological management (return to primary care) with or without UDS- PFS diagnosis of BOO (45 patients).

41% of the referred patients had surgery in the 10 years follow up period. Nearly 33% returned to primary care with conservative management. 16% returned or remained to urological care. Most of the patients (40%) that had surgery were operated within 24 months; 50% of the patients with BOO and 30% of the patient without BOO. 40% of patients returned to primary care within 24 months; 50% of these without BOO and 30% of these with BOO.
Patients in the cohort surgery versus not-surgery did not significantly differ in age, months of follow up, free flow Qmax or PVR, and Wmax or BCI. 
URA: respectively 44,9 cmH2O (s.d.22,7) (surgery) and 31,7 cmH2O (s.d.16,5) (not surgery) as well as BOOI: respectively 64,5 (s.d.37,3) and 42,3 (s.d.32,0) were significantly different  (both p 0.002) between the two cohorts.
For one out of 3 patients the result of the UDI, the objective diagnosis, was so enlightening that they could accept further drug treatment. However, for a small of patients, drug therapy merely delayed surgical intervention. It is not clear, at present whether there are good predictors for drug treatment failure in men with demonstrated non-severe bladder outflow obstruction. On the other hand also many men with outflow obstruction accepted continuation of medication and over a 10 years period only less than half needed surgery, whereas the guidelines recommended this for all these patients. A larger study may better show better predictors for staging and grading of dysfunction and stratification of management.

Our cohort demonstrates that treatment of men with LUTS, stratified on the basis of objective assessment is very feasible in the second line care and seems to reduce the need for surgery (and thus also operating theatre time, costs and risks). Better stratification and grading of disfunction and individualisation of management in elderly men is very well possible. Guidelines should include recommendations for referred male 'LUTS-BPH' -patients that have no, intermediate or moderate outflow obstruction or for men having detrusor overactivity.