2. UroToday Home
  3. Recent Abstracts
  4. Men's Health
  5. BPH - Benign Prostatic Enlargement

Diagnosis & Evaluation

Diagnosis & Evaluation 

  • Clinical BPH represents the lower urinary tract symptoms (LUTS), bladder dysfunction, hematuria, and urinary tract infection (UTI) resulting from macroscopic BPH.
  • The complex of lower urinary tract symptoms referred to as LUTS is not specific for BPH.
  • Aging men with a variety of lower urinary tract pathologic processes may exhibit similar, if not identical, symptoms.
  • The primary objective of the initial evaluation and diagnostic testing is to determine that this is BPH.

Initial Evaluation - History and Physical Examination

  • Medical History to include any history of hematuria, UTI, diabetes, urinary retention, urethral stricture disease and a history of stroke or other ongoing diseases.
  • A history of prior surgeries.
  • Current use of medications.
  • Use a voiding diary to help identify polyuria or nocturia.
  • Digital Rectal Exam - assessing the size of the prostate gland
  • A urinalysis to rule out UTI and hematuria.
  • Urine cytology should always be requested in men with severe irritable symptoms and dysuria, especially if they have a smoking history.
  • The recommendations from the Fifth International Consultation on BPH it was suggested that serum creatinine determination should be optional or secondary.
  • Elevated serum creatinine levels in a patient with BPH is an indication for imaging studies (usually ultrasonography) to evaluate the upper urinary tract.
  • Prostate cancer can lead to LUTS by producing bladder outflow obstruction similar to BPH. Localized prostate cancer commonly coexists with BPH.
  • In the absence of prostate cancer the PSA value provides a guide to prostate volume and an indication of the likelihood of response to therapy with 5α-reductase inhibitors.
  • The International Prostate Symptom Score (IPSS) is recommended as the symptom scoring instrument to be used for the baseline assessment of symptom severity in men presenting with LUTS .
  • Upper urinary tract imaging is not recommended in the routine evaluation of men with LUTS unless they also have one or more of the following: hematuria, UTI, renal insufficiency (ultrasonography recommended), history of urolithiasis, or history of urinary tract surgery.
  • In patients with more severe symptoms or who are being considered for active treatment, urodynamics may be desirable

Urodynamics of BPH - 

  • Decreased mean and peak flow rates, an abnormal flow pattern characterized by a long low plateau
  • Elevated detrusor pressures at the initiation of and during flow
  • May or may not have increased residual urine
  • 50 percent of BPH patients are found to have bladder hyperactivity during filling.
  • Pressure flow urodynamics are necessary to distinguish between patients with obstructive BPH and patients who have inadequate detrusor contractility, the symptoms of which may be identical.
  • The simplest of these, flowmetry and residual urine volume, are recommended by the International Consultation

Indications for Teeatment of BPH - 

  • Indications for surgery has varied widely over time, and the current climate is much more conservative than existed 10 to 20 years ago.
  • Certain absolute or near absolute indications exist
  • Refractory or repeated urinary retention
  • Azotemia due to BPH
  • Significant recurrent gross hematuria
  • Recurrent or residual infection due to BPH
  • Bladder calculi
  • A large residual urine
  • Overflow incontinence
  • Large bladder diverticula due to BPH.
  • Without an absolute or near absolute indication, or combinations of these, the bothersome nature of the symptomatology is generally what prompts the patient to request, or the physician to suggest, treatment. Pathologic urodynamic findings may certainly be influential as well.

References

  • Abrams P: In support of pressure-flow studies for evaluating men with lower urinary tract symptoms. Urology 44:153-155, 1994.
  • Abrams P, Cardozo L, Fall M, et al: The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology 2003; 61(1):37-49.
  • Andersen JT: Prostatism. III. Detrusor hyperreflexia and residual urine: clinical and urodynamic aspects and the influence of surgery on the prostate. Scand J Urol Nephrol 1982; 16(1):25-30.
  • Ball AJ, Fenely RCL, Abrams PH: The natural history of untreated "prostatism " Br J Urol 53:613-616, 1981.
  • Barry MJ: Epidemiology of benign prostatic hyperplasia. AUA Update Series 16:274-279, 1997.
  • Barry MJ, Fowler FJ, Bin L, et al: The natural history of patients with benign prostatic hyperplasia as diagnosed by North American urologists. J Urol 157:10-15, 1997.
  • Barry MJ, Fowler FJ, Jr., O'Leary MP, and the Measurement Committee of the AUA: The American Urological Association symptom index for benign prostatic hyperplasia. J Urol 148:1549-1557, 1992.
  • Barry MJ, Williford WO, Chang Y, et al: Benign prostatic hyperplasia specific health status measures in clinical research: How much change in the AUA symptom index and the BPH impact index is perceptible to patients? J Urol 154:1770-1774, 1995.
  • Bartsch G, Muller HR, Oberholzer M, Rohr HP: Light microscopic stereological analysis of the normal human prostate and of benign prostatic hyperplasia. J Urol 1979; 122(4):487-491.
  • Berry SJ, Coffey DS, Walsh PC, Ewing LL: The development of human benign prostatic hyperplasia with age. J Urol 1984; 132(3):474-479.
  • Boyle P, Gould AL, Roehrborn CG: Prostate volume predicts outcome of treatment of benign prostatic hyperplasia with finasteride: meta-analysis of randomized clinical trials. Urology 1996; 48(3):398-405.
  • Boyle P, Napalkov P: The epidemiology of benign prostatic hyperplasia and observations on concomitant hypertension. Scand J Urol Nephrol Suppl 1995; 168:7-12.
  • Burnett AL, Maguire MP, Chamness SL, et al: Characterization and localization of nitric oxide synthase in the human prostate. Urology 1995; 45(3):435-439.
  • Campbell-Walsh Urology 10th Edition, July 2011 
  • Isaacs JT, Coffey DS: Etiology and disease process of benign prostatic hyperplasia. Prostate Suppl 1989; 2:33-50.
  • Kaplan SA: Update on the American Urological Association guidelines for the treatment of benign prostatic hyperplasia. Rev Urol 2006; 8(Suppl. 4):S10-S17.
  • Lepor H: Nonoperative management of benign prostatic hyperplasia. J Urol 1989; 141:1283-1289.
  • Madersbacher S, Alivizatos G, Nordling J, et al: EAU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines). Eur Urol 2004; 46(5):547-554. 
  • Partin A: Benign prostatic hyperplasia. In: Lepor H, ed. Prostatic diseases, Philadelphia: WB Saunders; 2000:95-105.