DIVERSITY: Association of Race and Education With Benign Prostatic Hyperplasia Knowledge Among Male Urology Patients

By: Suruchi Ramanujan, AB, Case Western Reserve University School of Medicine, Cleveland, Ohio; Peace Orji, BS, Case Western Reserve University School of Medicine, Cleveland, Ohio; Austin Chiu, BA, Case Western Reserve University School of Medicine, Cleveland, Ohio; William Jevnikar, BS, Wright State University Boonshoft School of Medicine, Fairborn, Ohio; Bailey Cox, BS, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Ohio; Drogo Montague, MD, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Ohio; Nima Almassi, MD, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Ohio; Byron Lee, MD, PhD, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Ohio; Anna Zampini, MD, MBA, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Ohio; James Bena, MS, Lerner Research Institute, Cleveland Clinic Foundation, Ohio; Shannon Morrison, MS, Lerner Research Institute, Cleveland Clinic Foundation, Ohio; Petar Bajic, MD, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Ohio; Smita De, MD, PhD, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Ohio | Posted on: 06 Apr 2023


Benign prostatic hyperplasia (BPH) is one of the most common diseases in aging men with prevalence increasing throughout the course of late adulthood. BPH can result in lower urinary tract symptoms that affect patient quality of life as well as severe complications. There remains a gap in the literature regarding patient knowledge about BPH and its associated symptoms, long-term sequelae, and management. Racial disparities in the diagnosis and management of BPH represent an area of debate with conflicting evidence in the literature. Fowke et al found that while Black men were less likely than White men to be diagnosed with BPH, they were more likely to undergo surgical intervention typically employed for more severe cases.1 In contrast, a more recent 2022 study by Antoine et al concluded that Black men were less likely to receive surgery for BPH.2 To date, many studies have supported the positive relationship between education and health outcomes; however, little research has been done on the relationship between patient education and awareness of BPH.

This study seeks to assess differences in patient familiarity with BPH, its treatment options, and trends in health information-seeking behavior. Furthermore, we examine the role of race and education on patient knowledge about BPH.


Male patients new to our large tertiary care system were identified and asked to complete an Institutional Review Board–approved 26-question survey either in person or over the phone prior to their first appointment with the urology department. The survey included multiple choice questions on demographics (ie, race, marital status, education, etc), BPH symptoms and complications (ie, hematuria, bladder stones, etc), and BPH treatment options (ie, various medications and surgical procedures). Descriptive statistics were performed with categorical variables summarized as percentages and continuous variables reported as means with standard deviations. For questions with “correct” answers (ie, “Can an enlarged prostate make you unable to pee?”), we calculated a score representing the percentage of correct answers. The relationship between percentage of correct answers and demographic predictors was assessed using ANOVA tests, and pairwise comparisons with Bonferroni adjustment were performed for significant results comparing more than 2 groups. In addition, a multivariable regression was performed with race, education, insurance, and referral type to predict patient knowledge about BPH. Less than 2% of patients were missing demographic data, so multivariable analysis was based on those with complete information.


The 152 respondents available for this analysis had a mean age of 61 years. As seen in Table 1, 83.2% of the patients identified as White and 61.9% had a college degree or higher. On average, patients were able to correctly answer 60% of the BPH knowledge questions; 79.6% of patients believed that BPH is associated with cancer or were unsure of its association with cancer. When asked about the long-term complications of BPH, patients were least likely to associate BPH with bladder stones (17.1%); 36.8% of patients had never heard of any surgical interventions for BPH and 30.3% were unaware of any commonly prescribed medications for BPH.

Table 1. Demographics

Age, No./mean±SD, y 147/60.7±14.5
How do you identify, No. (%) 149
 White 124 (83.2)
 Black 15 (10.1)
 Other (Latino/Hispanic, Asian, Other) 10 (6.7)
Highest level of education, No. (%) 152
 Did not finish high school 2 (1.3)
 High school diploma 56 (36.8)
 College degree 58 (38.2)
 Graduate/professional degree 36 (23.7)
Health insurance type, No. (%) 151
 Private insurance (ie, Cigna, Blue Cross/Blue Shield, etc) 80 (53.0)
 Medicare/Medicaid 52 (34.4)
 Multiple types 18 (11.9)
 Uninsured 1 (0.66)
Who referred you to the urologist?, No. (%) 151
 MD referral 80 (53.0)
 Other referral (friend/family, self-referral, other) 71 (47.0)
Abbreviations: MD, Doctor of Medicine; SD, standard deviation.

Patients with a graduate degree were more knowledgeable about BPH and its treatment options than those with a college education or less (P < .001; Table 2). Due to the small number of non-White patients in our cohort, Black, Asian, and Latino patients were grouped together and did not demonstrate a difference in BPH knowledge compared to White patients. However, patients with an education level of high school degree or less were less likely to be White than patients with college degrees (P = .039). Those who were either self-referred or referred by a nonphysician were significantly more likely to answer questions correctly (P = .009). Insurance type had no significant effect on patient knowledge about BPH. Finally, when asked about their preferred sources of health information, 92.8% of patients preferred acquiring health information from their doctors.

Table 2. Multivariable Analysis of Various Demographic Parameters and Total Percent Correct Responses

Parameter Class level Estimate (95% CI) P value
Race Non–White race REF
White race 9.13 (−0.89, 19.14) .074
Highest level of education High school diploma or less College degree REF 2.60 (−5.92, 11.11) 0.55
Graduate/professional Degree 18.28 (8.62, 27.93) < .001
Who referred you to the urologist? MD referral REF
Other referral 9.92 (2.56, 17.27) .009
Abbreviations: CI, confidence interval; MD, Doctor of Medicine; REF, reference value.


Our study outlines the gaps in patient awareness about BPH, including the disease’s long-term complications and management. While patients are relatively aware of BPH and its associated symptoms, their knowledge of long-term sequelae and treatment options are lacking.

Race was not found to be a significant factor in this analysis but the overall percentage of non-White patients in this cohort was low (16.8%). However, patients with a higher level of education were significantly more knowledgeable about BPH, and race was found to be associated with education level. Kosilov et al previously noted that BPH patients with a higher level of education experienced higher health-related quality of life across all age groups.3 Interestingly, patients who were self-referred or were recommended urology evaluation by a friend/family in this study had a greater understanding of BPH complications and treatment options. As we are a tertiary referral center, it is possible that these patients were more likely to research their condition and/or doctors prior to making an appointment.

Finally, our findings suggest that patients are not only lacking in knowledge about BPH, especially its treatments and complications, but also have several misconceptions. Given that 92.8% of patients prefer to receive health information from their doctors, the onus is on us to improve patient awareness of this common condition, especially amongst those with less education. As there are strong connections between socioeconomic status, level of education, and health outcomes, our findings support further research into the drivers of racial and economic disparities in the treatment and diagnosis of BPH.

  1. Fowke JH, Murff HJ, Signorello LB, Lund L, Blot WJ. Race and socioeconomic status are independently associated with benign prostatic hyperplasia. J Urol. 2008;180(5):2091-2096.
  2. Antoine SG, Carmichael H, Lloyd GL. The impact of race, ethnicity and insurance status on surgery rates for benign prostatic hyperplasia. Urology. 2022;163:44-49.
  3. Kosilov K, Loparev S, Kuzina I, Kosilova L, Ivanovskaya M, Prokofyeva A. Health-related quality of life’s dependence on socio-economic status and demographic characteristics among men with benign prostatic hyperplasia. Andrologia. 2018;50(3):e12892.