What is the diagnostic approach for Benign Prostatic Hyperplasia (BPH)?

Diagnostic Approach for Benign Prostatic Hyperplasia

The diagnosis of BPH requires a mandatory initial evaluation consisting of medical history with symptom documentation, digital rectal examination, urinalysis, and the AUA Symptom Index (IPSS), with PSA measurement offered to men with at least 10 years life expectancy. 1

Mandatory Initial Assessment

History and Symptom Documentation

• Document the specific onset, duration, and severity of lower urinary tract symptoms (LUTS), including both obstructive symptoms (weak stream, incomplete emptying, straining) and irritative symptoms (frequency, urgency, nocturia). 1
• Administer the AUA Symptom Index (identical to the seven symptom questions of the IPSS) at the initial visit to objectively quantify symptom severity, with scores ranging from mild (<7) to moderate (8-19) to severe (≥20). 1, 2
• Include the Disease Specific Quality of Life question to measure how bothered the patient is by symptoms, as this guides treatment decisions. 1
• Review all current medications systematically to exclude drug-induced voiding dysfunction as an alternative cause (anticholinergics, antihistamines, decongestants, opioids). 1
• Assess risk factors including family history of prostate disease and the patient's fitness for potential surgical procedures. 1
• Consider voiding diaries specifically in patients where nocturia is the predominant symptom to document frequency and volume patterns. 1

Physical Examination

• Perform digital rectal examination (DRE) to assess prostate size, consistency, and symmetry, and to exclude locally advanced prostate cancer—this is mandatory, not optional. 1, 2
• The DRE in BPH typically reveals an enlarged, smooth, firm, non-tender prostate, distinguishing it from prostatitis (tender) or cancer (nodular/asymmetric). 2
• Conduct a focused neurologic examination assessing mental status, ambulatory status, lower extremity neuromuscular function, and anal sphincter tone to exclude neurogenic bladder. 1
• Assess for bladder distention by palpation and percussion to identify urinary retention. 3

Laboratory Testing

• Perform dipstick testing or microscopic examination of urine sediment to screen for hematuria and urinary tract infection—this is mandatory. 1
• Offer PSA measurement to men with at least 10 years life expectancy for whom knowledge of prostate cancer would change management, as PSA also predicts prostate growth and BPH progression risk. 1, 2
• Urine culture is not routinely needed unless infection is suspected based on urinalysis findings. 2

Follow-Up Monitoring

• Readminister the IPSS at each follow-up visit to objectively assess symptom changes and treatment response. 1

Optional Diagnostic Tests (Not Required Initially)

Uroflowmetry and Post-Void Residual

• Uroflowmetry and post-void residual (PVR) measurement are not necessary prior to watchful waiting or medical therapy. 1
• Consider these tests in patients with complex medical history or those desiring invasive therapy. 1
• Men with maximum flow rate (Qmax) <10 ml/sec are more likely to have urodynamic obstruction and benefit from surgery. 1

Pressure-Flow Urodynamic Studies

• Pressure-flow urodynamic studies are only indicated when invasive therapies are being considered, not for routine diagnosis. 1

Cystoscopy

• Urethrocystoscopy is appropriate only in specific circumstances: history of microscopic or gross hematuria, urethral stricture or risk factors (history of urethritis or urethral injury), bladder cancer history, or prior lower urinary tract surgery. 1, 4
• Cystoscopy should not be used in the initial evaluation of patients without these specific risk factors. 4
• Cystoscopy should not be performed solely to determine the "need for treatment" or to predict treatment response. 4
• The endoscopic appearance of the prostatic urethra does not predict response to BPH therapy, though anatomical features (lateral versus middle lobes) may guide therapy selection once invasive treatment is chosen. 4

Imaging Studies

• Transrectal or transabdominal ultrasound may be appropriate when minimally invasive or surgical interventions are chosen, as it helps assess prostate size and anatomical features. 1, 4
• Upper urinary tract imaging (ultrasound or excretory urography) is not recommended unless hematuria is present. 1

Tests NOT Recommended

• Filling cystometrography (CMG) is not recommended for typical BPH patients. 1
• Routine cystoscopy as part of initial BPH evaluation adds unnecessary cost and invasiveness without improving outcomes. 4
• Upper tract imaging without hematuria is not indicated. 1

Common Pitfalls to Avoid

• Do not perform cystoscopy routinely—reserve it only for patients with specific risk factors (hematuria, stricture history, bladder cancer history, prior surgery) or when invasive therapy is already planned. 4
• Do not skip the DRE thinking imaging will suffice—it is mandatory and provides critical information about prostate characteristics and excludes cancer. 1, 2
• Do not order uroflowmetry or PVR for every patient—these are optional and most useful when considering invasive therapy or in complex cases. 1
• Do not forget to readminister the IPSS at follow-up visits, as objective symptom tracking is essential for monitoring disease progression and treatment response. 1