ASSESSMENT
History
Generally, men with suspected BPH have a history of frequent urination, urinary urgency, nocturia, straining to urinate, weak stream, hesitancy, dribbling, and an incomplete emptying of the bladder. This group of symptoms is sometimes labeled LUTS, or lower urinary tract symptoms. Distinguish between these obstructive symptoms and irritative symptoms such as dysuria, frequency, and urgency, which may indicate an infection or inflammatory process. A “voiding diary” can also be obtained to determine the frequency and nature of the complaints. Elicit a sexual history because LUTS is an independent risk factor for erectile and ejaculatory dysfunctions. Some patients prefer having a male healthcare practitioner take a sexual history. The International Prostate Symptom Score (IPSS) has been adopted worldwide and provides information regarding symptoms and response to treatment (Box 1). Each question allows the patient to choose one of six answers on a scale of 0 to 5 indicating the increasing degree of symptoms; the total score ranges from 0 (mildly symptomatic) to 35 (severely symptomatic). The eighth question, known as the bother score, refers to quality of life.
Box 1 The International Prostate Symptom Score (International Prostate Symptom Score. [2021]. Urological Sciences Research Foundation. www.usrf.org/questionnaires/AUA_SymptomScore.html)
- Incomplete emptying: Over the past month, how often have you had the sensation of not emptying your bladder completely after you have finished urinating? (Not at all = 0, less than one time in five = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)
- Frequency: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? (Not at all = 0, less than one time in five = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)
- Intermittency: Over the past month, how often have you stopped and started again several times when urinating? (Not at all = 0, less than one time in five = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)
- Urgency: Over the past month, how often have you found it difficult to postpone urination? (Not at all = 0, less than one time in five = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)
- Weak stream: Over the past month, how often have you had a weak urinary stream? (Not at all = 0, less than one time in five = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)
- Straining: Over the past month, how often have you had to push or strain to begin urination? (Never = 0, once = 1, twice = 2, three times = 3, four times or more = 4, five times or more = 5)
- Nocturia: Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? (Not at all = 0, less than one time in five = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)
- How would you feel if you were to spend the rest of your life with your urinary condition just the way it is now? (Delighted = 0, pleased = 1, mostly satisfied = 2, mixed = 3, mostly dissatisfied = 4, unhappy = 5, terrible = 6)
Inspect and palpate the bladder for distention. A digital rectal examination (DRE) reveals a rubbery enlargement of the prostate, but the degree of enlargement does not consistently correlate with the degree of urinary obstruction. Some men have enlarged prostates that extend out into soft tissue without compressing the urethra. Determine the amount of pain and discomfort that is associated with the DRE.
Psychosocial
In addition to discomfort, the symptoms are anxiety producing to men. The patient who is experiencing BPH may voice concerns related to sexual functioning after treatment. The patient's degree of anxiety as well as his ability to cope with the potential alterations in sexual function (a possible cessation of intercourse for several weeks, possibility of sterility or retrograde ejaculation) should also be determined to provide appropriate follow-up care.
| Test | Normal Result | Abnormality With Condition | Explanation |
|---|---|---|---|
| Urinalysis and culture | Minimal numbers of red and white blood cells; no bacteria; clear urine with no occult blood and no protein | Urinary tract infection may occur with the presence of bacteria, blood, leukocytes, protein, or glucose | Urinary retention may lead to infection; voiding may be irritating |
| Uroflowmetry | Males ages 46–65 years have more than 200 mL of urine at a flow rate of 21 mL/sec | Flow rate is decreased | Prostate inflammation leads to a narrowed urethral channel and obstruction of urine outflow |
| Prostate-specific antigen (PSA) | Normal: < 4 ng/mL | May be slightly elevated | Screening for prostate cancer remains controversial and should be done if the physician and patient desire. PSA testing may reduce the likelihood of dying from prostate cancer. Patients should be alerted that PSA testing poses the risk of treatment of prostate cancer that would not have caused ill effects if left undetected. |
Other Tests: Serum creatinine and blood urea nitrogen, electrolytes, postvoid residual volume, diagnostic ultrasound, cystourethroscopy, abdominal or renal ultrasound, transrenal ultrasound. Note that while BPH does not cause prostate cancer, men at risk for BPH are also at risk for prostate cancer. Screening for prostate cancer remains controversial (see diagnostic highlights above).