Workup for Benign Prostatic Hyperplasia
The initial workup for BPH requires relevant medical history, physical examination with digital rectal examination (DRE), urinalysis, and serum PSA (when life expectancy >10 years and diagnosis of prostate cancer would modify management), with additional testing reserved for complicated cases. 1
Recommended Initial Tests
Mandatory Components
Medical history should focus on symptom severity, duration, and impact on quality of life, including assessment of both voiding symptoms (hesitancy, weak stream, intermittency, incomplete emptying) and storage symptoms (frequency, urgency, nocturia) 1
Physical examination including DRE is essential to assess prostate size, consistency, and exclude nodules or suspicious findings 1, 2
Urinalysis must be performed to exclude infection and hematuria in all patients 1, 2
Serum PSA testing should be obtained when life expectancy exceeds 10 years and if the diagnosis of prostate cancer would modify management, as PSA helps predict BPH progression risk and excludes malignancy 1, 2
Symptom Assessment Tools
International Prostate Symptom Score (IPSS) should be administered to quantify symptom severity and distinguish voiding from storage symptoms, with scores ranging from 0-35 where higher scores indicate greater severity 2, 3, 4
The IPSS "bother" question helps determine impact on quality of life, with a score ≥3 indicating moderate bother 5
Additional Testing for Specific Scenarios
When Nocturia Predominates
Frequency-volume chart (3-day bladder diary) should be obtained to differentiate small-volume frequent voids from normal/large-volume voids and assess for polyuria or nocturnal polyuria 1, 2
If 24-hour urine output exceeds 3 liters, lifestyle and fluid intake modifications should be recommended, with consideration of desmopressin for nocturnal polyuria 1
Indications for Specialized Management (Complicated LUTS)
Refer for specialized evaluation when any of the following are present: 1
- Suspicious DRE findings (nodules, asymmetry, induration)
- Hematuria on urinalysis
- Abnormal PSA values
- Pain associated with urinary symptoms
- Infection on urinalysis
- Palpable bladder on examination
- Neurological disease affecting the lower urinary tract
Optional Advanced Testing
Post-void residual (PVR) measurement: Elevated PVR >100 mL indicates bladder outlet obstruction from BPH, while normal PVR suggests overactive bladder 2
Uroflowmetry: Maximum flow rate <10 mL/second indicates significant obstruction from BPH 2, 6
Pressure-flow studies: Reserved for cases where diagnosis remains uncertain or when considering surgical intervention 1
Clinical Pitfalls and Caveats
Terminology matters: The term "BPH" should be reserved for histological findings; use "lower urinary tract symptoms (LUTS)" to describe the clinical presentation, as LUTS may result from multiple etiologies including bladder dysfunction, neurological disease, or cardiovascular/respiratory/renal conditions 1
Storage symptoms without prostatic enlargement: If urgency is the predominant symptom and DRE shows no prostatic enlargement, consider overactive bladder rather than BPH as the primary diagnosis 2
PSA interpretation: Finasteride and dutasteride reduce PSA by approximately 50% after 6-12 months of therapy, which must be considered when interpreting PSA values in treated patients 7
Age-related prevalence: While histologic BPH prevalence exceeds 50% by age 60 and reaches 90% by age 85, only approximately half of men with histologic BPH develop moderate to severe LUTS 8