Slide 1

Benign Prostatic Hyperplasia (BPH)
Patient Evaluation and Diagnosis


Slide 2

BPH Diagnosis and Treatment Algorithm
Initial Evaluation
• History
• DRE & Focused PE
• Urinalysis
• PSA

Presence of
• Refractory retention or any of the
following clearly related to BPH
•Persistent gross hematuria
•Bladder stones
•Recurrent UTIs
•Renal insufficiency

AUA/IPSS Symptom Index
Assessment of Patient Bother
Moderate/Severe Symptoms
(AUA/IPSS 8)

Mild Symptoms
(AUA/IPSS 7) or No
Bothersome Symptoms

Surgery

Optional Diagnostic Tests
• Uroflow
• PVR
Discussion of Treatment Options

Patient Chooses
Noninvasive Therapy
Watchful Waiting
AUA Guideline 2003/updated 2006.

Patient Chooses
Invasive Therapy

Optional Diagnostic Tests
• Pressure flow
• Urethrocystoscopy
• Prostate ultrasound

Medical Therapy
Minimally Invasive Therapies

Surgery


Slide 3

Initial Evaluation
•
•
•
•
•

Detailed medical history
DRE and focused physical exam
Urinalysis
PSA in selected patients*
Symptom assessment
– AUA/IPSS Symptom Index
– Assessment of patient bother

DRE - digital rectal exam
PSA - prostate-specific antigen
*Per physician’s clinical judgment

AUA Guideline 2003/updated 2006.


Slide 4

Further Evaluation Warranted?
• Abnormal DRE

• History of diabetes

• Abnormal PSA

• History of pelvic
surgery/ trauma

• Prior therapy for
LUTS/BPH
• Non-response to
medical therapy

• Neurologic symptoms/
disease

• Renal insufficiency

• <50 years of age
AUA Guideline 2003/updated 2006.


Slide 5

Questions to Ask Relative
to History
• Oral intake
– Timing
– Caffeine
– Alcohol

• Medications
affecting volume
– Diuretics
– Stool-bulking agents

• Medications affecting
voiding
– Antihistamines
– Decongestants

• Diseases
– Diabetes
– Congestive heart failure
– Neurologic
AUA Guideline 2003/updated 2006.


Slide 6

Optional Diagnostic Tests
Following initial evaluation
• Uroflow
– Urinary flow-rate recording (Qmax)

• PVR
If patient chooses invasive therapy
• Pressure flow
• Urethrocystoscopy
• Prostate ultrasound
AUA Guideline 2003/updated 2006.


Slide 7

Standard Questionnaires for Patient’s
Perception of BPH Symptoms

• AUA Symptom Score
• International Prostate Symptom Score (IPSS)
• BPH Impact Index (Bother Score)


Slide 8

AUA Symptom Score Index

• Seven-item questionnaire related to BPH
symptoms
• Validated and reproducible
• Determines disease severity
• Documents response to therapy
• Allows standardized comparisons of symptom
relief when evaluating treatments
AUA Guideline 2003/updated 2006.


Slide 9

AUA Symptom Score

AUA Guideline 2003/updated 2006.


Slide 10

Classification of AUA Symptom Scores

The possible total runs from 0-35 points with higher
scores indicating more severe symptoms. Scores
lower than 7 are considered mild and generally do
not warrant treatment.
Classification ranges
• Mild (0-7)
• Moderate (8-19)
• Severe (20-35)
• Without bother or bothersome
AUA Guideline 2003/updated 2006.


Slide 11

Initial Management and Discussion
Using AUA Symptom Score

Patients with mild symptoms (AUA symptom score ≤ 7)
and
Patients with moderate or severe symptoms (AUA
symptom score ≥ 8) who are not bothered by their
symptoms
– Offer watchful waiting
– Reassure patient
– Reassess periodically


Slide 12

Initial Management and Discussion
Using AUA Symptom Score

Patients with bothersome, moderate to severe
symptoms (AUA Symptom Score ≥ 8)
– Watchful waiting
– Discuss BPH treatment options, including benefits
and risks
– Provide patient education materials


Slide 13

International Prostate Symptom
Score (IPSS)
AUA Symptom Score Index plus additional question on
QOL as a function of urinary symptoms:

“If you were to spend the rest of your life with
your urinary condition just the way it is now, how
would you feel about that?”
– Scale of 0 to 6 (delighted to terrible)
– Note: While symptoms may be prevalent, they may not be
troublesome
O’Leary MP. Urology. 2000.


Slide 14

BPH Impact Index (Bother Score)
None

Only a little

Some

A lot

Not at all
bothersome

Bothers
me a little

Bothers
me some

Bothers
me a lot

A little of
the time

Some of
the time

Most of
the time

All of
the time

1. Over the past month, how much physical
discomfort did any urinary problems cause you?
2. Over the past month, how much did you worry
about your health because of any urinary
problems?

3. Overall, how bothersome has any trouble
with urination been during the past month?
None of
the time
4. Over the past month, how much of the time
has any urinary problem kept you from doing
the kinds of things you would usually do?
AUA Guideline 2003/updated 2006.


Slide 15

References
• American Urological Association Education and Research, Inc. AUA
Guideline 2003/Updated 2006.

• Barry MJ, Fowler FJ, O’Leary MP et al. “The American Urological
Association Symptom Index for benign prostatic hyperplasia”, J Urol.
1992;148:1549-1557.
• O’Leary MP. LUTS, ED, QOL: alphabet soup or real concerns to
aging men? Urology, 2000;56(suppl 5A):7-11.

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