Cystoscopic Grading of BPH
Cystoscopy does not provide a formal grading system for BPH, but rather assesses prostatic anatomy—specifically the configuration of lateral versus middle lobes—to guide treatment selection in patients who have already decided to proceed with invasive therapy. 1
Role of Cystoscopy in BPH Assessment
Cystoscopy is an optional test, not part of routine initial evaluation. 1 The AUA guidelines are explicit that urethrocystoscopy should not be used in the initial evaluation of patients solely to determine the "need for treatment" and is not routinely necessary prior to watchful waiting or medical therapy. 1
When Cystoscopy Is Appropriate
Cystoscopy may be appropriate in specific clinical scenarios:
- Patients with hematuria (microscopic or gross) 1
- History of urethral stricture or risk factors such as prior urethritis or urethral injury 1
- History of bladder cancer 1
- Prior lower urinary tract surgery, especially transurethral resection of the prostate (TURP) 1
- Patients who have already decided to proceed with invasive therapy, where anatomical assessment may guide treatment choice 1
What Cystoscopy Reveals (Not a "Grade")
The endoscopic appearance of the prostatic urethra and bladder does not predict the response to BPH therapy. 1 However, cystoscopy provides valuable anatomical information:
- Lateral lobe configuration versus middle lobe presence can forecast response to minimally invasive and surgical therapies 1
- Intravesical prostatic protrusion (IPP) can be visualized, though this is better measured by transabdominal ultrasound 2
- Presence of intravesical lobes may impact the choice of therapy 1
The shape of the prostate (e.g., presence of a middle lobe) may predict response or lack thereof to certain minimally invasive or medical therapies. 1
Alternative Assessment Methods
Transabdominal ultrasound is preferred over cystoscopy for anatomical assessment when minimally invasive or surgical interventions are chosen. 1 Ultrasound can measure:
- Prostate volume (PV) for selecting between TUIP versus TURP 1
- Intravesical prostatic protrusion (IPP) which correlates with bladder outlet obstruction 2
- Anatomical features such as intravesical lobes 1
Research suggests that IPP and prostate volume measured by ultrasound can be used to grade (phenotype) prostatic adenoma, with good correlation to benign prostatic obstruction and disease progression. 2
Common Pitfalls
- Do not perform cystoscopy routinely in the initial evaluation of uncomplicated BPH—it adds cost without improving outcomes 1
- Do not use cystoscopic appearance alone to predict treatment response—it is unreliable for this purpose 1
- Reserve cystoscopy for specific indications (hematuria, stricture history, prior surgery) or when invasive therapy is already planned and anatomical details will influence the surgical approach 1