How to Diagnose BPH
The diagnosis of BPH is established through symptom assessment using validated questionnaires (IPSS or AUA Symptom Index), digital rectal examination revealing an enlarged, soft, non-tender prostate, and urinalysis to exclude other pathology. 1
Essential Diagnostic Components
Symptom Assessment
- Quantify symptom severity using the International Prostate Symptom Score (IPSS) or AUA Symptom Index to guide treatment decisions and objectively measure disease burden. 2, 1
- Focus on the pattern of voiding difficulties (weak stream, hesitancy, incomplete emptying) combined with frequency, which represents the typical presentation of BPH-related bladder outlet obstruction. 1
- Assess the impact on quality of life, as treatment decisions should be based on how bothersome the symptoms are to the individual patient. 2
Physical Examination
- Perform digital rectal examination (DRE) to assess prostate size and texture—the hallmark finding is an enlarged, soft, non-tender prostate. 1, 3
- The soft, non-tender texture effectively rules out prostate cancer, which typically presents with a hard, nodular, or indurated gland. 1
- Absence of tenderness excludes prostatitis. 1
Laboratory Testing
- Urinalysis is essential to exclude infection, hematuria, or other urinary tract pathology. 2, 1
- PSA measurement should be offered given the patient's age and presumed >10-year life expectancy, both to exclude prostate cancer and to predict BPH progression risk. 1
Optional Tests Based on Clinical Context
When Nocturia is Bothersome
- Use a frequency-volume chart to exclude nocturnal polyuria, which requires different management than BPH. 2
- Small-volume frequent voids suggest overactive bladder rather than isolated BPH. 4
Post-Void Residual Measurement
- Consider measuring post-void residual to identify significant bladder outlet obstruction, with elevated residual (>250-300 mL) indicating obstruction. 4
Tests to Avoid in Routine Evaluation
Urodynamics and transrectal ultrasound should be limited to situations where results will benefit the patient, such as in selection for surgery. 2
- Imaging and endoscopy of the urinary tract have specific indications such as dipstick hematuria, but are not part of routine BPH diagnosis. 2
- Cystoscopy is not indicated for uncomplicated presentations. 4
Critical Diagnostic Pitfalls to Avoid
- Do not assume all lower urinary tract symptoms in older men are BPH—isolated urgency without voiding symptoms or prostate enlargement indicates overactive bladder, not BPH. 4
- Do not skip the digital rectal examination, as failure to assess prostate size misses the key physical finding distinguishing BPH from other causes of urinary symptoms. 4
- Do not attribute hematuria solely to BPH—bladder stones, bladder cancer, or upper tract pathology must be excluded. 4
- Recognize that the absence of urgency distinguishes BPH from overactive bladder syndrome, which is defined as urgency with or without urgency incontinence. 1
Terminology Note
The term "benign prostatic hyperplasia" (BPH) should technically be reserved for the histological pattern, while "benign prostatic enlargement" describes gland enlargement based on clinical assessment, though BPH remains the commonly used clinical diagnosis. 1