What is the appropriate workup and treatment for a male patient over 50 with symptoms of benign prostatic hyperplasia (BPH), including urinary frequency, urgency, weak stream, and nocturia?

Workup for Benign Prostatic Hyperplasia

Begin with a focused history using the International Prostate Symptom Score (IPSS) or AUA Symptom Index questionnaire to objectively quantify symptom severity (mild 0-7, moderate 8-19, severe 20-35), as this score directly determines treatment indication and guides all subsequent management decisions. 1, 2

Essential Initial Evaluation

Mandatory Components

• Digital rectal examination (DRE) to assess prostate size, consistency, and exclude nodules or induration suggesting malignancy 2
• Urinalysis to exclude urinary tract infection and hematuria 1, 2
• Serum PSA measurement in patients with >10-year life expectancy to exclude prostate cancer and predict BPH progression risk 2
• Post-void residual (PVR) measurement using bladder ultrasound to assess bladder emptying efficiency 1, 2

Symptom-Specific Testing

• 3-day frequency-volume chart (bladder diary) when nocturia is the predominant complaint, to quantify voiding patterns and exclude nocturnal polyuria 2, 3
• Uroflowmetry to objectively assess voiding function and establish baseline flow parameters before considering treatment 2

What NOT to Do: Critical Pitfalls

• Do not order routine serum creatinine unless specific risk factors exist—renal insufficiency from BPH occurs in well under 1% of patients 2
• Do not order upper tract imaging (CT/ultrasound) or cystoscopy in uncomplicated presentations without hematuria, stones, or prior surgery 2
• Do not assume infection based on trace leukocytes alone—negative urine culture definitively excludes bacterial UTI, and empiric antibiotics are not indicated 2
• Do not initiate treatment without documenting symptom severity using a validated questionnaire (IPSS/AUA-SI), as treatment indication depends on symptom bother, not just presence of symptoms 2

Indications for Immediate Urology Referral

Refer urgently if any of the following are present:

• Acute urinary retention 4
• Renal insufficiency attributed to bladder outlet obstruction 4
• Recurrent urinary tract infections 5
• Gross hematuria 5
• Bladder calculi 6, 5
• Suspected prostate cancer based on abnormal DRE or elevated PSA 2

Optional Advanced Testing

These are not routinely indicated but may be useful in specific circumstances:

• Urodynamic studies when diagnosis is uncertain or when considering surgical intervention 1
• Prostate volume measurement via transrectal ultrasound to guide 5α-reductase inhibitor therapy (indicated only if prostate >30-40cc) 4

Follow-Up Timing

• Reassess at 4-12 weeks after initiating any treatment using IPSS/AUA-SI to evaluate symptom improvement 4, 2
• Repeat PVR measurement at 4-12 weeks if initial PVR was elevated 4