The risk factors for LUTS progression leading to retention fall into the two categories of fixed (e.g., race, age) and modifiable (e.g., prostate volume, prostate morphology, Qmax, weight, diet, exercise). AUR from an inciting event or condition is covered in Statement 57. The strongest risk factor for LUTS progression is older age.73-77 In the Olmsted County study of urinary symptoms, men 40-79 years of age were followed over 12 years, and the average increase in IPSS was 0.18 points per year, ranging from 0.05 points per year for men in their 40s to 0.44 points per year for those in their 60s.78 The Prostate Cancer Prevention Trial (PCPT) demonstrated that Black and Hispanic men are at increased risk of developing BPH.79 Community-based studies in the U.S., Japan, and Netherlands have also measured the mean change in surrogates of obstruction, including prostate volume, PSA, and Qmax to show a decrease in Qmax of 2% per year and a median prostate growth of 1.9% per year.80-90 Interestingly, age-related changes in LUTS are weakly correlated with these measures.84 Intravesical prostatic protrusion (IPP) ≥10 mm is associated with a higher risk of treatment resistance, AUR, or the need for prostatic surgery.91 In a study of 1,740 community-dwelling U.S. men ≥65 years of age without any LUTS/BPH treatments, numerous non-prostatic modifiable risk factors were identified for stable (1,277 men; 73%), progressing (345 men; 20%), remitting (98 men; 6%), and mixed (20 men; 1%) LUTS trajectories over 6.9 (±0.4) years. Men in progressing compared with stable trajectories were more likely to have mobility limitations (odds ratio [OR]: 2.0; 95% confidence interval [CI]: 1.0 to 3.8), poor mental health (OR: 1.9; 95% CI: 1.1 to 3.4); body mass index (BMI) ≥25.0 kg/m2 (OR:1.7; 95% CI: 1.0 to 2.8), hypertension (OR: 1.5; 95% CI: 1.0 to 2.4), and back pain (OR: 1.5; 95% CI: 1.0 to 2.4). Men in remitting compared with progressing trajectories more often used central nervous system medications (OR: 2.3; 95% CI: 1.1 to 4.9) and less often had a history of excessive alcohol consumption (OR: 0.4; 95% CI: 0.2 to 0.9).92 There is a growing appreciation for the role of frailty as a risk factor for LUTS development and progression, and AUR. A multicenter prospective cohort study of men >65 years of age demonstrated that greater phenotypic frailty was associated with non-linear increases in LUTS severity over time, independent of age and comorbidities.93 Frail and pre-frail men with LUTS due to suspected BPH are also more likely to experience clinical BPH progression, particularly worsening LUTS and AUR, despite drug therapy.94 Although there is not a single established method to assess frailty (<a href="https://frailtyscience.org/frailty-assessment-instruments/">https://frailtyscience.org/frailty-assessment-instruments/</a>), the Timed-Up-and-Go Test (TUGT) has been used effectively in the academic urology clinic setting.95 Automated electronic health record based frailty indices and frailty-based risk calculators are also being developed.96, 97 The electronic frailty index (eFI), an automated digital marker for frailty integrated within the electronic health record, can facilitate preoperative frailty screening.98 Studies have suggested that greater BMI is associated with increased risk of both LUTS and BPH diagnosis79, 99 with obesity further associated with LUTS progression.100-103 Risk of BPH development with increased BMI is further positively correlated to Triglyceride Glucose-Body Mass Index (TyG-BMI).104 Men who are physically inactive are more likely to develop BPH and to experience symptom progression.77, 79, 100, 101, 105-109 Data has shown that walking 2-3 hours/week yielded a 25% lower risk of BPH.110 In a Boston Area Community Health (BACH) survey, the odds of urological symptoms developing were consistently increased for subjects who reported poor sleep quality and sleep restriction at baseline, but only baseline nocturia was positively associated with incident sleep-related problems at follow-up.111 Constipation is associated with increased risk of LUTS and may contribute to urinary retention in some men, particularly in cases of severe constipation or pelvic floor dysfunction, but it is not a universal cause. The bladder and rectum are embryologically connected neighboring organs that share motor nerve supply.112 In patients, particularly in the elderly, improvement in LUTS is noted after relief of constipation.113 LUTS in adult males were independently associated with stool type and consistency.33 In a study of 3,077 men in the National Health and Nutrition Examination Survey (NHANES), bowel habits (e.g., frequency and consistency) affected LUTS.33 In a meta-analysis of testosterone replacement therapy (TRT) for late-onset hypogonadism (LOH), the change in IPSS was similar among men receiving TRT versus placebo, suggesting that TRT treatment does not worsen LUTS among men with LOH.114