How do you assess Benign Prostatic Hyperplasia (BPH) in a middle-aged to elderly man with symptoms such as urinary frequency, urgency, weak stream, and nocturia?

Assessment of Benign Prostatic Hyperplasia

The assessment of BPH requires mandatory initial evaluation with medical history, the AUA Symptom Index (IPSS), digital rectal examination, and urinalysis, with selective PSA testing for men with ≥10-year life expectancy, while optional tests like uroflowmetry and post-void residual should be reserved for specific clinical scenarios. 1

Mandatory Initial Evaluation Components

Symptom Assessment with Validated Scoring

• Administer the International Prostate Symptom Score (IPSS), also known as the AUA Symptom Index, to every patient at the first visit to quantify symptom severity on a 0-35 point scale (mild: 0-7, moderate: 8-19, severe: 20-35). 1, 2
• The IPSS evaluates both obstructive symptoms (weak stream, incomplete emptying, hesitancy, intermittency) and irritative symptoms (frequency, urgency, nocturia) using a 0-5 scale for six symptoms and 0-4 for one symptom. 3, 4
• Critically, assess the disease-specific quality of life question from the IPSS to determine how bothersome symptoms are to the patient, as treatment decisions depend on both symptom severity AND patient bother level—a moderately symptomatic but highly bothered patient may warrant intervention more than a severely symptomatic patient who tolerates symptoms well. 1, 2

Medical History

• Obtain detailed history focusing on onset, duration, and severity of lower urinary tract symptoms, 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, 5

Physical Examination

• Perform digital rectal examination (DRE) to assess prostate size, consistency, and exclude locally advanced prostate cancer (palpable nodules or induration require referral). 1, 5
• Include focused neurologic examination to identify conditions that may affect bladder function. 1

Laboratory Testing

• Perform urinalysis (dipstick or microscopic) to screen for hematuria and urinary tract infection as alternative causes of symptoms. 1
• Offer PSA testing to men with ≥10-year life expectancy when knowledge of prostate cancer would change management or when PSA may influence voiding symptom management decisions. 1
• Note that approximately 25% of men with BPH have PSA >4 ng/mL, so elevated PSA does not automatically indicate cancer. 1
• Routine serum creatinine measurement is NOT recommended in initial evaluation, as baseline renal insufficiency is no more common in BPH patients than the general population. 1

Optional Diagnostic Tests (Selective Use)

When to Consider Optional Testing

• Optional tests are NOT required before initiating watchful waiting or medical therapy but may be appropriate when: (1) initial evaluation suggests non-prostatic cause of symptoms, (2) patient selects invasive therapy, (3) patient has complex medical history (neurologic disease, prior BPH treatment failure), or (4) results would change management. 6, 1

Uroflowmetry (Peak Flow Rate)

• Obtain at least 2 flow rate measurements with voided volumes >150 mL each to account for intra-individual variability, with maximum flow rate (Qmax) as the best single measure. 2
• Men with Qmax <10 mL/sec are more likely to have urodynamic obstruction and improve with surgery. 6, 1
• Do NOT order uroflowmetry before starting alpha-blockers, as symptom response to alpha-blockers is independent of baseline flow rate. 1
• Men with normal flow rates but significant symptoms likely have non-prostatic causes requiring more extensive investigation. 6

Post-Void Residual (PVR) Volume

• Measure by non-invasive transabdominal ultrasound and repeat due to marked intra-individual variability. 2
• Large PVR volumes (e.g., 350 mL) may indicate bladder dysfunction and predict slightly less favorable treatment response, potentially heralding disease progression. 6, 1
• PVR is NOT a contraindication to watchful waiting or medical therapy—many patients maintain large residual volumes without UTI, renal insufficiency, or bothersome symptoms. 6, 1
• No specific PVR "cut-point" exists for decision-making due to test-retest variability and lack of outcome studies. 6

Frequency-Volume Charts (Voiding Diary)

• Particularly useful when nocturia is the dominant symptom—have patients record time and voided volume for each void over 3 consecutive 24-hour periods to identify nocturnal polyuria, excessive fluid intake, or 24-hour polyuria. 2

Additional Optional Tests

• 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 considered, or in those with neurologic conditions. 1
• Urethrocystoscopy: Appropriate for men with history of hematuria, urethral stricture, bladder cancer, or prior lower urinary tract surgery. 1
• Prostate ultrasound: May be appropriate when minimally invasive or surgical interventions are chosen, but not routinely necessary for watchful waiting or medical therapy. 1

Tests NOT Recommended

• Upper urinary tract imaging is NOT recommended unless the patient has hematuria, UTI, renal insufficiency, or history of urolithiasis or urinary tract surgery. 1

Complementary Assessment Tools

BPH Impact Index

• Use alongside IPSS to provide more detailed assessment of how symptoms affect daily life, with four questions addressing physical discomfort, worry about health, bothersomeness, and time kept from usual activities. 2

Common Pitfalls to Avoid

• Do not use symptom scores alone to determine need for intervention—always assess how bothersome symptoms are to the individual patient, as bother level is critical for treatment decisions. 1
• Do not withhold treatment based solely on elevated PVR, as it is not a contraindication to conservative or medical management. 1
• Do not order uroflowmetry routinely before starting alpha-blockers, as baseline flow rate does not predict response to this medication class. 1
• Do not assume all lower urinary tract symptoms are due to BPH—consider alternative diagnoses like heart failure, UTI, diabetes, overactive bladder, or bladder cancer, especially in men with normal prostate size or predominantly irritative symptoms. 7, 8
• Do not fail to reassess symptoms with validated tools like IPSS at follow-up visits to objectively track changes. 9