Perceived partner responsiveness between benign prostatic hyperplasia’s symptom index and aging male symptoms

Abstract

Benign prostatic hyperplasia (BPH) is common among aging men and often overlaps with aging male symptoms (AMS), which include somatic, psychological, and sexual complaints. These conditions can have serious consequences, potentially leading to falls, depression, and costly hospitalizations. Although attachment theory proposes that perceived partner responsiveness (PPR) can mitigate the negative effects of chronic health conditions, the precise relationship between the benign prostatic hyperplasia symptom index (BPHSI), PPR, and AMS has not been clearly established. This cross-sectional study recruited 412 men aged 50 or older with confirmed BPH. Participants completed questionnaires, including the Benign Prostatic Hyperplasia Symptom Index Scale, Aging Male Symptoms Scale, and Perceived Partner Responsiveness Scale. Structural equation modeling and bootstrapped mediation analyses were used to assess direct and indirect effects. BPHSI was significantly associated with AMS, indicating that greater BPH symptom severity was related to more severe aging-related symptoms. BPHSI was positively associated with perceived partner responsiveness among participants with severe symptoms but not among those with moderate symptoms. Mediation analyses showed that PPR did not mediate the relationship between moderate BPHSI and AMS. For severe BPHSI, a statistically significant but small indirect effect through PPR was observed, indicating partial mediation with limited explanatory contribution. Higher BPHSI severity was associated with higher AMS scores. Although perceived partner responsiveness demonstrated a limited mediating role among men with severe symptom burden, its contribution was modest compared with the direct effects of BPHSI. These findings suggest that effective management of urinary symptoms should remain the primary clinical priority, while psychosocial and partner-focused interventions may serve as complementary approaches for selected patients.

Introduction

Benign prostatic hyperplasia (BPH) is a common age-related condition. Its prevalence rises significantly with age^1,2. Histologically, BPH is found in about 50% of men in their 50 s. It increases to over 80% in men in their 80 s³. The primary characteristic of BPH is the overgrowth of prostate tissue. This situation leads to lower urinary tract symptoms (LUTS)⁴. These symptoms are classified as either voiding or storage. They include urinary frequency, urgency, nocturia, incomplete bladder emptying, and a weak or interrupted urinary stream⁵. Although BPH symptoms are not life-threatening, their chronic and progressive nature can significantly impact daily functioning and well-being. The Benign Prostatic Hyperplasia Symptom Index (BPHSI) is linked to distress, social withdrawal, sleep disruption, and a lower quality of life⁶. Given the high prevalence and significant impact of these symptoms, it is crucial to examine both the psychosocial and physiological consequences of BPH symptom severity in aging men^7,8. The BPHSI should be considered a diagnostic tool and a potential factor affecting broader aspects of men’s health, including emotional and relational outcomes⁹.

The Aging Male Symptoms (AMS) include reduced well-being, fatigue, sleep disturbances, irritability, and decreased libido^10,11. These symptoms are often associated with age-related hormonal changes, especially a drop in testosterone levels¹². Addressing AMS is important clinically and socially, as these symptoms can significantly reduce quality of life and negatively affect personal relationships. BPHSI and AMS are common in aging men, but the literature does not clearly understand their connection^13,14. While they are recognized as distinct aspects of men’s health, a comprehensive association analysis is missing. Most research evaluates their symptomatic burden independently, with little attention to their potential interrelationship. This study, therefore, aims to investigate the specific relationship between BPHSI severity and AMS to develop a more integrated model of men’s health and geriatric care.

Existing research often examines BPHSI and AMS as independent phenomena. This approach overlooks the psychosocial factors that may connect them. It also overlooks intervening variables that might explain the relationship. Attachment theory, particularly perceived partner responsiveness, provides a robust framework for understanding this connection¹⁵. According to attachment theory, a supportive and responsive social environment, especially from a close romantic partner, is a key resource for coping with health challenges and enhancing well-being¹⁶. Perceived partner responsiveness (PPR) is the belief that one’s partner is available, understanding, and supportive during times of need^17,18. When someone with severe BPH symptoms feels their partner is responsive, it may lessen psychological distress and physical strain from the condition^19,20. This responsiveness can lead to more effective coping strategies, reduced stress, and enhanced emotional well-being. As a result, it may protect against the development or worsening of other aging symptoms such as fatigue, irritability, and sexual dysfunction. In contrast, a lack of perceived responsiveness could increase the negative impact of BPHSI, resulting in greater psychological burden and worse AMS¹⁹. Therefore, based on the principles of attachment theory, this study hypothesizes that perceived partner responsiveness acts as a mediating variable, explaining the link between the severity of BPH symptoms and the extent of AMS. This research will examine how perceived partner responsiveness affects the relationship between the BPHSI and the AMS.

The primary objective of this research is to investigate whether PPR mediates or moderates the relationship between BPHSI severity and AMS in aging men. By framing this inquiry as a testable question—Does PPR mediate or moderate the BPHSI–AMS link?—the research invites specific hypotheses and focused exploration. The findings have both theoretical and practical significance. Theoretically, this research extends attachment theory to the context of men’s health by providing insight into the influence of social support on age-related health outcomes. The results underscore the relevance of supportive partner relationships in managing BPH and AMS symptoms. These findings may inform clinical practice by encouraging healthcare providers to consider the relational context of patients. The integration of couple-based interventions and counseling may improve treatment outcomes and enhance the well-being of aging men.

Method

Study design, setting, and participants

A cross-sectional design was employed. Participants were recruited via convenience sampling from multiple hospitals in Hangzhou between July 2022 and May 2025. Inclusion criteria specified men aged 50 years or older with a clinical diagnosis of benign prostatic hyperplasia (BPH) confirmed by a licensed urologist. Participants were required to possess sufficient literacy to complete standardized self-report questionnaires independently and to provide informed consent. Exclusion criteria included a diagnosis of prostate cancer, neurogenic bladder, or other severe urological diseases; significant cognitive impairment or primary psychiatric disorders that could affect questionnaire completion; current use of androgen replacement therapy, antidepressants, or medications known to alter hormonal or mood states substantially; and the presence of acute urinary tract infection or recent urological surgery.

To ensure adequate statistical power for structural equation modeling (SEM), the sample size was determined using the guideline of 10 cases per estimated parameter^21,22. This calculation indicated that a minimum of 360 participants was necessary.

Measures

The survey incorporated standardized instruments to assess Aging Male Symptoms (AMS), Benign Prostatic Hyperplasia Symptom Index (BPHSI), and Perceived Partner Responsiveness (PPR). Demographic variables collected included fall risk, age, and body mass index (BMI).

The symptom index was measured using the 8-item American Urological Association Symptom Index for benign prostatic hyperplasia²³. The questionnaire has been adapted and used by Chinese researchers²⁴. This questionnaire had the International Prostate Symptom Scale and the Quality-of-Life Scale. The total questionnaire scores ranged from 0 to 41. The International Prostate Symptom Scale uses a 5-point Likert scale. Scores of 0–7 indicate mild symptoms, 8–19 moderate, and 20–35 severe. A sample item is whether the urine does not feel (in five times). The 1-item quality of life score measures a patient’s perception of anterior lower urinary tract symptoms over life. It mainly asks if patients with BPH can tolerate symptoms and how much they suffer. For example, “What do you think if you have urination symptoms for the rest of your life?” This scale scores 0–6. Higher scores indicate greater distress. The Cronbach’s alpha coefficient for the whole scale is 0.85, and the composite reliability is 0.87, showing good reliability and validity. The Cronbach’s coefficient in this study was 0.807.

Aging-related symptoms were assessed using the Aging Males’ Symptoms (AMS) Scale developed by Heinemann et al.²⁵. The AMS consists of 17 items covering three domains: psychological symptoms (5 items), somatic symptoms (7 items), and sexual symptoms (5 items). Each item is rated on a 5-point Likert scale ranging from 1 (no symptoms) to 5 (extremely severe symptoms), yielding a total score ranging from 17 to 85. Higher scores indicate more severe aging-related symptoms. The AMS has been widely used in studies of aging men and demonstrates satisfactory reliability and validity²⁶. In the present study, Cronbach’s α was 0.91.

PPR was measured using Reis’s 12-item Perceived Partner Responsiveness Scale²⁷. Chinese researchers have adapted and used the questionnaire²⁸. This one-dimensional questionnaire uses a 5-point Likert scale, with total scores ranging from 12 to 60. Higher scores mean higher PPRS. A sample item is ‘Respect all I am, including my flaws.’ The questionnaire’s internal consistency was 0.90, and test–retest reliability was 0.73. The Cronbach’s coefficient in this study was 0.923.

Statistical analysis

Data were analyzed using SPSS 25.0 and structural equation modeling software (AMOS/Mplus/lavaan). Preliminary descriptive statistics were calculated (mean, standard deviation, range). Pearson’s correlations examined inter-variable associations. Assumptions of multicollinearity and normality were tested using variance inflation factors (all VIFs = 1.104 < 2), skewness, and kurtosis. A confirmatory factor analysis (CFA) tested the measurement model with three latent constructs (BPHSI, PPRS, AMS). Model fit indices indicated satisfactory fit: χ²/df = 2.98, CFI = .957, TLI = .947, RMSEA = .069 (90% CI = .058–.080), and SRMR = .041. Standardized loadings ranged from 0.66 to 0.84 for BPHSI, 0.64 to 0.87 for PPRS, and 0.62 to 0.83 for AMS parcels. Composite reliability values were 0.88 for BPHSI, 0.91 for PPRS, and 0.89 for AMS. Average variance extracted (AVE) values were 0.55, 0.58, and 0.51 for BPHSI, PPRS, and AMS, respectively, indicating convergent validity. Discriminant validity was supported. AVEs exceeded squared inter-construct correlations (maximum r² = .34 between BPHSI and AMS). For hypothesis testing, the PROCESS macro (Model 4) with ordinary least squares regression was used to test the mediating role of PPRS between BPHSI and AMS²⁹. Indirect effects were estimated with 5000 bootstrap samples. Mediation was considered significant when the 95% confidence interval did not exclude zero.

Ethics statement

All participants were informed about the study’s purpose and provided electronic consent before participating. Responses were anonymous, confidentiality was guaranteed, and participants were free to withdraw at any stage. The Ethics Committee of Hangzhou Linping District Integrated Traditional Chinese and Western Medicine Hospital (Approval no. 2025-L-008) approved this study.

Results

This study investigated 412 men with benign prostatic hyperplasia, aged 68.89 ± 9.73 years. Regarding fall risk, 307 (74.5%) were at low risk, 79 (19.2%) at intermediate risk, and 26 (6.3%) at high risk. Regarding risk status, 308 (74.8%) had no risk, and 104 (25.2%) had a risk. For BMI categories, 17 (4.1%) were underweight, 234 (56.8%) were normal, 129 (31.3%) were overweight, and 32 (7.8%) were obese.

The total score for the AMS was 67.08 ± 14.11 (AMS ≥ 50 indicates severe symptoms); the BPHSI was 12.27 ± 5.72 (BPHSI 8–19 indicates moderate symptoms); and the PPR was 20.7 ± 4.70 (PPR ≥ 18 indicates high resilience) (Table 1).

Table 1.

The total scores (N = 412).

Variable	Mean	SD
AMS	67.08	14.11
PPR	20.7	4.70
BPHSI	12.27	5.72

Pearson correlation analyses showed that BPHSI was significantly associated with PPR (r = .130, p = .005). BPHSI was also significantly associated with AMS (r = − .306, p < .001), indicating that greater BPH symptom severity was related to more severe aging male symptoms. In addition, PPR was negatively associated with AMS (r =  − .412, p < .001), suggesting that higher perceived partner responsiveness was associated with fewer aging-related symptoms (Table 2).

Table 2.

Variable relationships.

Correlation	PPR	BPHSI	AMS
PPR	1	.130*	− .412**
BPHSI	.130*	1	− .306**
AMS	− .412**	− .306**	1

All correlations were significant, **p < .001,*p < .005.

BPHSI was treated as an independent variable with three categories. Initial analyses assessed overall mediation effects. The total effect was significant (f = 37.81, p < 0.01), as was the direct effect (f = 18.36, p < 0.01). The 95% Bootstrap confidence interval for the total mediation effect was [− 1.41, − 0.87]. Both moderate and severe BPHSI demonstrated a significant negative predictive effect on AMS compared with mild BPHSI. Next, we adjusted for Perceived Partner Responsiveness (PPR) to determine whether resilience had altered this relationship. This association remained significant after adjustment for PPR, indicating that the effect of BPHSI on AMS is robust to the level of resilience. However, Moderate BPHSI did not predict PPR (Table 3).

Table 3.

Results of the mediation model test (N = 412).

Outcome variables	Predictors	Fit index		Coefficient significance		Confidence interval
		R2	F	t	β	LLCI	ULCI
AMS	Mild BPHSI (Sample)	0.29	18.36
	Moderate BPHSI			− 3.87	− 0.55	− 11.79	− 3.85
	Severe BPHSI			− 6.05	− 1.19	− 22.39	− 11.41
PPR		0.15	4.52
	Moderate BPHSI			0.51	0.07	− 1	1.73
	Severe BPHSI			2.66	0.54	0.67	4.45
AMS		0.48	37.81
	Moderate BPHSI			− 3.98	− 0.52	− 11.06	− 3.75
	Severe BPHSI			− 5.39	− 0.98	− 19.06	− 8.87
	PPR			− 8.36	− 0.38	− 1.41	− 0.87

Bootstrap mediation analyses indicated that the indirect effect of moderate BPHSI on AMS through PPR was not statistically significant because the 95% confidence interval included zero (Boot 95% CI =  − 0.14 to 0.08). Therefore, PPR did not mediate the relationship between moderate BPHSI and AMS. The 95% Bootstrap confidence interval for the relative direct effect was [− 11.06, − 3.75]. After excluding the mediating effect, moderate BPHSI continued to impact AMS significantly. PPR did not serve as a partial mediator between moderate BPHSI and AMS. The relative total effect was significant (χ²: − 7.82). For severe BPHSI, the indirect effect through PPR was statistically significant because the bootstrap confidence interval excluded zero (Boot 95% CI =  − 0.38 to − 0.03). However, the direct effect remained statistically significant, indicating partial mediation. These findings suggest that PPR explains only a small proportion of the association between severe BPHSI and AMS, whereas the majority of the effect remains direct. The 95% Bootstrap confidence interval for the relative direct effect was [− 19.06, − 8.87]. After excluding the mediating effect, severe BPHSI still significantly affected AMS. PPR partially mediated the relationship between severe BPHSI and AMS (Table 4).

Table 4.

The mediating effects of PPR in BPHSI and AMS.

	Effect	BootSE	BootLL CI	BootUL CI
Moderate BPHSI
Total effect	− 7.82
Indirect effects	− 0.02	0.05	− 0.14	0.08
Direct effect	− 7.4	1.85	− 11.06	− 3.75
Severe BPHSI
Total effect	− 16.9
Indirect effects	− 0.2	1.15	− 0.38	− 0.03
Direct effect	− 13.96	2.61	− 19.06	− 8.87

Discussion

This study examined the interaction between the benign prostatic hyperplasia symptom index, aging male symptoms, and perceived partner responsiveness. Our findings clarify the connection between urological health, psychosocial support, and male aging-related well-being.

The severity of prostate symptoms is a negative predictor of male symptoms

This study found that the severity of benign prostatic hyperplasia negatively predicted aging male symptoms. The findings are consistent with the study of Chapple and Xiong^30,31. Both biological and psychological mechanisms can explain this. From a biological standpoint, LUTS associated with benign prostatic hyperplasia disrupt key functions, including urination, sleep, and sexual performance³². Referencing the International Prostate Symptom Score and Chapple’s work on symptom burden, we observe that chronic nocturia leads to fragmented sleep, resulting in fatigue and reduced vitality, typically beginning around an IPSS score of 8^30,32. Urinary dysfunction, often marked by a weaker stream, scores above 20 on the IPSS scale, and can directly affect erectile function and sexual satisfaction, overlapping with the core domains of AMS³³. From a psychological perspective, worsening urinary symptoms undermine men’s sense of bodily control and autonomy³⁴. Frequent urination, incontinence, or a weak stream may foster embarrassment and social withdrawal. These experiences reinforce perceptions of aging and decline^35,36. These outcomes align with identity theories of aging, which suggest that bodily dysfunction accelerates subjective aging processes³⁶. Therefore, the causal pathway linking LUTS severity to aging male symptoms involves physical impairment, psychological stress, and social consequences³⁷.

Moderate prostate symptoms did not predict perceived partner responsiveness, while severe prostate symptoms did.

The distinction between moderate and severe symptoms clarifies the threshold at which health conditions affect relational perceptions. At a moderate level, prostate symptoms are typically manageable³⁸. Men often adapt through behavioral strategies, including fluid restriction or planning restroom access, and may not communicate their distress to partners³⁹. Consequently, their partner responsiveness perception remains unchanged. Relational dynamics are generally unaffected by moderate symptoms⁴⁰. The findings are consistent with the study of Bilgic and Siegel^39,40.

In contrast, severe LUTS often intrude on daily life, sexual intimacy, and sleep quality. These symptoms create visible disruptions in both partners’ routines. At this stage, men may rely more on their partners for emotional reassurance or practical assistance^41,42. This situation includes adjusting travel, social activities, or nighttime caregiving. Increased dependence makes them more sensitive to their partner’s empathy or irritation⁴³. Thus, severe—but not moderate—symptoms predict PPR because men move from self-management to relational dependence⁴⁰.

The underlying mechanism likely involves both health burden and interpersonal dynamics. Severe lower urinary tract symptoms can compromise perceptions of masculinity and sexual function, which are closely linked to partner relationships^31,44. In these circumstances, men may attribute anxieties about aging and intimacy to the relationship, becoming more aware of partner support or criticism⁴⁵. This dynamic explains why perceived partner responsiveness emerges as a significant factor only among those with severe symptoms.

Perceived partner responsiveness did not mediate the relationship between moderate prostate symptoms and aging male symptoms, while severe prostate symptoms did

The mediation analyses demonstrated that perceived partner responsiveness did not mediate the relationship between moderate BPHSI and AMS. Although a statistically significant indirect effect was observed among participants with severe BPHSI, the magnitude of this effect was relatively small compared with the direct pathway. These findings suggest that aging male symptoms are primarily influenced by the physiological burden associated with severe lower urinary tract symptoms rather than by interpersonal mechanisms. While supportive partner relationships may provide emotional benefits, their capacity to offset symptom-related impairment appears limited in the context of BPH⁴⁶. At moderate symptom levels, relational buffering through PPR appears insufficient. The findings are consistent with the study of Omeye and Liu^34,47. These findings contrast with research on other chronic illnesses, including dementia caregiving and pelvic pain, where partner responsiveness has been identified as a significant link between disease burden and well-being^34,40. In those contexts, partner support alleviates distress and promotes resilience. Unlike BPH, dementia caregiving involves progressive dependency, and consistent emotional support is often crucial as the condition worsens. Pelvic pain often includes elements of chronic discomfort, where empathy and understanding from partners can directly alleviate feelings of isolation. In the present study, men experiencing moderate BPHSI symptoms predominantly engaged in self-management strategies, adjusting their behaviors and infrequently utilizing partner-focused coping^42,48. Perceived partner responsiveness remained stable and did not influence AMS.

However, PPR showed a partial mediating role in the severe symptom group. Severe LUTS intrude on sleep, intimacy, and daily routines, thereby increasing men’s reliance on their partners for both emotional and instrumental support³⁷. At this stage, the relational context becomes salient: men are more attuned to whether their partners respond empathetically or critically, which can either buffer or amplify distress⁴⁰. Some men reported that empathetic responses included nighttime reassurance during frequent bathroom trips, while critical responses manifested as expressions of frustration. Still, the magnitude of mediation was modest compared to the direct effects of LUTS, suggesting that biological impairments such as nocturia-induced sleep disruption and sexual dysfunction are not easily offset by psychosocial mechanisms alone³⁷. Collectively, these findings delineate the limitations of social support models in the context of physiologically driven conditions such as BPH. Social support acts as a cushion that offers comfort, yet it cannot cure the physiological realities of BPH³⁴. Illnesses with psychological or social etiologies may be more amenable to relational interventions, whereas BPH provides limited opportunity for partner responsiveness to alter health outcomes⁴⁹. This distinction accounts for the absence of mediation by PPR in moderate cases and its only partial mediation in severe cases. The finding is consistent with the study of Urganci³¹. Theoretical frameworks in men’s health should be refined to reflect these boundaries. While PPR remains essential for relational well-being, its capacity to mitigate biologically based symptoms is constrained.

Practical and theoretical implications

From a clinical perspective, the findings suggest that effective management of lower urinary tract symptoms should remain the primary therapeutic target for aging men with BPH. Healthcare professionals should routinely assess symptom severity and provide timely pharmacological or surgical interventions when appropriate. Although partner responsiveness may contribute to psychological adaptation among men with severe symptoms, relationship-focused interventions should be viewed as complementary rather than substitute strategies. Integrating symptom management with psychosocial support may provide a more comprehensive approach to care^50,51. However, they should complement—not replace—direct medical care. Theoretically, this study challenges the generalizability of social support buffering models. Perceived partner responsiveness mediates outcomes in some chronic illnesses³¹. Its absence here suggests that not all health conditions respond equally to relational factors. BPH is a case where physiological burden dominates. This finding highlights the need for condition-specific psychosocial models. To enhance future studies, researchers might consider using advanced analysis methods, such as multilevel modeling or Cox regression, particularly when dealing with longitudinal and dyadic data. This insight refines biopsychosocial approaches to male aging and encourages future research to examine the circumstances under which partner responsiveness plays a meaningful role.

Limitations

This study has several limitations. First, the cross-sectional design precludes causal inference and prevents conclusions regarding temporal relationships among BPHSI, PPR, and AMS. Longitudinal studies are required to establish causal pathways. Second, all variables were measured using self-report instruments, which may introduce recall bias and social desirability bias. Third, participants were recruited from hospitals in a single geographic region of China, potentially limiting generalizability to other populations and cultural settings. Fourth, although perceived partner responsiveness was examined, only patient-reported perceptions were collected. Future studies should incorporate partner-reported assessments and dyadic analytical approaches to better understand reciprocal relationship processes. Finally, unmeasured factors such as comorbidities, hormonal status, and treatment history may have influenced the observed associations.

Conclusion

The present study demonstrates that greater BPH symptom severity is associated with more severe aging male symptoms. Although severe BPHSI was associated with perceived partner responsiveness, PPR contributed only minimally to explaining the relationship between BPH symptoms and aging-related outcomes. These findings suggest that physiological symptom burden remains the predominant determinant of AMS. Clinical management should therefore prioritize effective treatment of urinary symptoms while recognizing the complementary role of supportive partner relationships in promoting psychological well-being among aging men.

Abbreviations

BPH

Benign prostatic hyperplasia

AMS

Aging male symptoms

PPR

Perceived partner responsiveness

BPHSI

Benign prostatic hyperplasia symptom index

LUTS

Lower urinary tract symptoms

Author contributions

SYZ, XL, DHQ, JXL, YT, LYH, WQG, and LHY contributed to the conceptualization, data curation, formal analysis, investigation, methodology, project administration, software, resources, supervision, validation, visualization, writing—original draft. YXC and QZ contributed to the conceptualization, data curation, formal analysis, investigation, methodology, project administration, software, resources, supervision, validation, visualization, writing—original draft, writing—review & editing.

Funding

No funding was received for this research.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

This cross-sectional study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki (https://www.wma.net/policies-post/wma-declaration-of-helsinki/). The Ethics Committee of Hangzhou Linping District Integrated Traditional Chinese and Western Medicine Hospital (Approval no. 2025-L-008) approved this study. We explained the purpose of the study to the participants before distributing the questionnaire. In addition, we ensured that participants were voluntary and anonymous and allowed participants to opt out at any time. We stored the data securely, and only research team members could access, store, and process the data. All participants signed the informed consent form and completed the questionnaires.

Consent for publication

All authors agree for publication.