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

Diagnostic Approach for Benign Prostatic Hyperplasia

The diagnostic evaluation of BPH should begin with mandatory tests including medical history with symptom quantification using the AUA Symptom Index/IPSS, digital rectal examination, urinalysis, and selective PSA testing in men with ≥10-year life expectancy, followed by optional tests like uroflowmetry and post-void residual only when considering invasive therapy or in complex cases. 1

Mandatory Initial Evaluation

Medical History

• Obtain detailed history focusing on: onset and duration of lower urinary tract symptoms (LUTS), previous urologic surgeries, neurologic conditions affecting bladder function, current medications (especially those that may worsen urinary symptoms), and family history of prostate disease including both BPH and cancer 1, 2
• Document whether symptoms are primarily obstructive (hesitancy, weak stream, incomplete emptying) or irritative (frequency, urgency, nocturia) 2

Symptom Quantification

• Administer the AUA Symptom Index (identical to IPSS) to all patients to objectively measure symptom severity: mild (0-7), moderate (8-19), or severe (20-35) 1
• Include the disease-specific quality of life question from the IPSS to assess how bothersome symptoms are to the patient—this is critical because intervention may be more appropriate for a moderately symptomatic patient who finds symptoms bothersome than for a severely symptomatic patient who tolerates them 3
• Consider additional validated instruments like the BPH Impact Index to measure interference with daily activities 3

Physical Examination

• Perform digital rectal examination (DRE) on all patients to assess prostate size, consistency, and nodularity, and to exclude locally advanced prostate cancer 1, 4
• Conduct focused neurologic examination to identify conditions that may affect bladder function 1
• Assess for bladder distention by palpation or percussion 2

Laboratory Testing

• Perform urinalysis (dipstick or microscopic) on all patients to screen for hematuria, urinary tract infection, or glucosuria 1
• Offer PSA testing to men with ≥10-year life expectancy when knowledge of prostate cancer would change management or when PSA may influence treatment decisions for voiding symptoms 1
• Note that approximately 25% of men with BPH have PSA >4 ng/mL, so elevated PSA alone does not indicate cancer 1

Tests NOT Routinely Recommended

• Do not routinely measure serum creatinine in the initial evaluation, as baseline renal insufficiency is no more common in BPH patients than in the general population 1
• Do not perform upper urinary tract imaging unless the patient has hematuria, UTI, renal insufficiency, or history of urolithiasis or urinary tract surgery 1

Optional Diagnostic Tests (Selective Use)

When to Consider Optional Testing

• Optional tests are not required for watchful waiting or initiating medical therapy 3, 5
• Consider these tests when: initial evaluation suggests non-prostatic cause of symptoms, patient selects invasive therapy, patient has complex medical history (neurologic disease, prior BPH treatment failure), or results would change management 3

Uroflowmetry (Qmax)

• May predict surgical response: men with Qmax <10 mL/sec are more likely to have urodynamic obstruction and improve with surgery 3
• Men with normal flow rates but significant symptoms likely have non-prostatic causes requiring further investigation 3
• Important caveat: Flow rate does NOT predict response to alpha-blocker therapy, so it's unnecessary before starting medical management 3
• Test-retest variability is high, and no specific "cut-point" exists for decision-making 3

Post-Void Residual (PVR) Volume

• Large PVR volumes (e.g., 350 mL) may indicate bladder dysfunction and predict slightly less favorable treatment response 3
• Large PVR may herald disease progression 3
• Important caveat: Elevated PVR is NOT a contraindication to watchful waiting or medical therapy 3
• High test-retest variability limits establishment of specific cut-points for decision-making 3

Cystoscopy

• Do not perform cystoscopy routinely—it is not necessary before watchful waiting or medical therapy and should not be used to determine need for treatment 5
• Consider cystoscopy only in specific situations: hematuria, history of urethral stricture, history of bladder cancer, prior lower urinary tract surgery, or when patient has already decided on invasive therapy 5
• Key limitation: Endoscopic appearance of prostatic urethra does not predict response to BPH therapy 5
• Useful information from cystoscopy: Lateral lobe configuration versus middle lobe presence can forecast response to minimally invasive and surgical therapies; intravesical lobes may impact therapy choice 5

Prostate Imaging

• Transabdominal ultrasound is preferred over cystoscopy for anatomical assessment when minimally invasive or surgical interventions are chosen 5
• Ultrasound can measure prostate volume and identify anatomical features like intravesical lobes 5
• Not routinely necessary for watchful waiting or medical therapy 1

Urine Cytology

• Consider in men with predominantly irritative symptoms, especially with smoking history or other bladder cancer risk factors 1

Pressure-Flow Studies

• Optional before invasive therapy, particularly for men with flow rates >10 mL/sec when surgery is being considered 1
• Useful in patients with neurological conditions affecting bladder function 1
• Can exclude patients less likely to benefit from prostatic surgery by providing information on detrusor function 6

Common Pitfalls to Avoid

• Do not over-test: Cystoscopy adds cost without improving outcomes in uncomplicated BPH and should not be performed routinely 5
• Do not rely on cystoscopic appearance alone to predict treatment response—it is unreliable for this purpose 5
• Do not use symptom scores alone to determine need for intervention—always assess how bothersome symptoms are to the individual patient 3
• Do not withhold treatment based solely on elevated PVR—it is not a contraindication to conservative or medical management 3
• Do not order uroflowmetry before starting alpha-blockers—symptom response to alpha-blockers is not dependent on baseline flow rate 3