Which of the following is part of the recommended initial evaluation for a patient with suspected benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS)?

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Recommended Initial Evaluation for BPH with LUTS

The International Prostate Symptom Score (IPSS) is part of the recommended initial evaluation for patients with suspected BPH and LUTS (Answer: B). 1, 2, 3

Mandatory Components of Initial Assessment

The American Urological Association guidelines clearly delineate which tests are required versus optional in the initial workup:

Required Initial Tests

  • Medical history including onset, duration, and severity of lower urinary tract symptoms 1, 4
  • Physical examination with digital rectal examination (DRE) to assess prostate size and characteristics 1, 2
  • International Prostate Symptom Score (IPSS) or AUA Symptom Index for symptom quantification 1, 2, 3
  • Urinalysis to identify infection, hematuria, or other urinary tract pathology 1, 2, 4

Recommended but Not Mandatory

  • Serum PSA testing is recommended for patients with life expectancy >10 years when knowledge of prostate cancer would change management 1, 2, 5

Why the Other Options Are Incorrect

CT Scan of Abdomen (Option A)

  • Not part of routine initial evaluation 1
  • Imaging is only indicated when history, physical examination, or urinalysis suggest underlying renal disease, urinary retention, or complications 1
  • Routine measurement of serum creatinine is not even recommended, as baseline renal insufficiency from BPH occurs in well under 1% of patients 1

Routine Cystoscopy (Option C)

  • Not recommended as part of initial evaluation 1
  • Cystoscopy is considered an optional test that may aid decision-making when initial evaluation suggests a non-prostatic cause or when the patient selects invasive therapy 1
  • It is not performed routinely on all patients presenting with suspected BPH 1

Prostate Biopsy (Option D)

  • Not part of initial BPH evaluation 6
  • Biopsy is only indicated when there is abnormal PSA or suspicious DRE findings suggesting possible prostate cancer 1, 6
  • Patients with abnormal PSA require referral to a urologist for evaluation before treatment 6

Clinical Significance of IPSS

The IPSS serves multiple critical functions in BPH management:

  • Quantifies symptom severity using seven questions, classifying symptoms as mild (0-7), moderate (8-19), or severe (20-35) 1, 3
  • Superior to unstructured interview for documenting baseline symptoms 1
  • Guides treatment decisions based on symptom severity and bother 1, 2, 3
  • Monitors treatment response at follow-up visits 2, 3
  • Detects symptom progression in patients managed with watchful waiting 1

Common Pitfall to Avoid

Do not rely on symptom scores alone to determine need for intervention. 1 An intervention may be more appropriate for a moderately symptomatic patient who finds symptoms bothersome than for a severely symptomatic patient who finds symptoms tolerable. 1 The degree of bother caused by symptoms is a critical factor in determining management approach, not just the IPSS score itself. 2, 3

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Follow-Up Approach for Patients with Initial BPH Diagnosis

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Initial Management Approach for BPH Based on IPSS

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Management of Elderly Male with Elevated PSA and Severe Lower Urinary Tract Symptoms

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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