Approach

Take a careful history and carry out a directed physical exam.

Urgently refer men with the following features to a urologist:[16]

  • Microscopic or macroscopic hematuria: increases the possibility of prostate or bladder cancer

  • Neurologic diseases (e.g., Parkison disease, multiple sclerosis, history of cerebrovascular accident, long-standing diabetes, etc.): may suggest neurogenic bladder

  • History of prior urologic surgeries and urethral stricture

  • History of recurrent infection or persistent urinary tract infection (UTI)

  • Retention

  • Palpable bladder

  • Renal impairment that is attributed to lower urinary tract dysfunction

  • Abnormal digital rectal exam suggesting prostate cancer

  • Abnormal prostate-specific antigen (PSA) levels.

History

Take a complete medical history.[17]​ History and symptoms suggestive of BPH include possible voiding and storage symptoms. Voiding symptoms include hesitancy, intermittency, weak stream, straining, incomplete emptying, and postvoid dribbling. Storage symptoms include urinary frequency, nocturia, and urgency.

Symptoms that may suggest an alternative diagnosis (e.g., prostatitis or UTI) include fever, pain, and dysuria. Ask about overall health and fitness, prior procedures that could explain symptoms, sexual history, and use of medication; diuretics, anticholinergics, cholinesterase inhibitors, and adrenergic alpha-agonists may affect urinary flow rate or affect prostate bladder tone mimicking BPH.[17]​ Cardiovascular and renal disease may present with polyuria or nocturia. Sexual dysfunction including erectile dysfunction co-exists frequently in patients with lower urinary tract symptoms (LUTS).

Physical exam

Perform a physical exam, including a digital rectal exam, in order to assess anal sphincter tone and estimate the size of the prostate and to assess for prostate nodules or rectal masses.[17][18]​ During pelvic exams, it may be prudent to check the muscles of the pelvic floor to assess for pelvic floor dysfunction, especially in men presenting with pain as their primary complaint.[19] Also perform bladder palpation and inspection of the external meatus. A neurologic exam may be necessary depending on the patient’s history.

Frequency/volume chart and voiding diary

If the patient has significant nocturia, ask them to complete a frequency/volume chart and voiding diary for at least 3 days. Recording the volume and time of every void, and additional information, such as fluid intake, symptoms, and use of pads, can be a useful tool to objectify symptoms and detect polyuria (>3 liters of urine in 24 hours).[18][20]​ This may then be targeted for reduction by modifying intake or other medical treatment.

Laboratory evaluation

Carry out urinalysis - including checking for glucosuria, proteinuria, hematuria, and infection - in the initial workup.[17][18]​​​​​  Do not diagnose microhematuria by positive dipstick testing alone. Microhematuria is defined as three or more red blood cells per high-powered field on microscopic evaluation of a urine specimen.[21][22]​ Use PSA testing in appropriate circumstances and with shared decision-making. It is generally not recommended in men over the age of 70 years, or with a life expectancy less than 10-15 years. Counsel patients carefully about the potential consequences of PSA testing.[23][24][25]​​​​​​[26] Increased PSA may suggest the presence of underlying prostate cancer or prostatitis. A serum PSA test may be helpful in assessing treatment options and in decision-making (as an approximate indicator of prostate size), or if a diagnosis of prostate cancer would change management.[17][18]

European guidelines advise assessment of renal function via measurement of serum creatinine or estimated glomerular filtration rate (eGFR) in the following circumstances: if renal insufficiency is suspected; in the presence of hydronephrosis; or in anticipation of surgical intervention.[18] Renal insufficiency is not commonly related to isolated BPH.

Symptom score questionnaire

Assess the nature and severity of the patient’s symptoms and the impact on their quality of life using a validated symptom score questionnaire. This should be completed in the initial workup and can be used for re-evaluation during and after treatment.[17][18]

The International Prostate Symptom Score (IPSS), a self-administered questionnaire with 8 questions (7 questions on symptoms and 1 question on quality of life) is most commonly used.​ [ International Prostatism Symptom Score (IPSS) Opens in new window ] ​​ 

Other questionnaires include the International Consultation on Incontinence Questionnaire for Male LUTS (ICIQ-MLUTS), the Danish Prostate Symptom Score (DAN-PSS), and the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN-10). The LURN-10 is closely correlated to the IPSS but includes additional symptoms (incontinence and bladder pain).[27]​​[28]​​​​​[29] ICIQ: International Consultation on Incontinence Questionnaire Male Lower Urinary Tract Symptoms Module (ICIQ-MLUTS) Opens in new window​ 

Urodynamics

Perform a postvoid residual (PVR) assessment before surgical intervention for LUTS attributed to BPH.[17]​ This is helpful for postoperative management and assessing the success of surgical interventions. Consider PVR measurement as an optional study in the initial management of patients where medical therapy is being considered; a PVR can help to assess the ability of the bladder to empty at baseline, identify severe urinary retention, and/or indicate detrusor dysfunction.[17][18]​ 

Consider uroflowmetry (a noninvasive measure of peak urinary flow rate) in patients with moderate to severe BPH, particularly before surgical intervention for LUTS attributed to BPH.[17][30]​​ The diagnostic accuracy of uroflowmetry for detecting bladder outlet obstruction (BOO) varies considerably, and specificity improves with repeated flow rate testing. Low peak urinary flow rate may be due to bladder outlet obstruction, detrusor underactivity, or an underfilled bladder. A peak urinary flow rate of 10 mL/second has a specificity of 70% and a sensitivity of 47% for BOO, and a peak urinary flow rate of 15 mL/second has a specificity of 38% and a sensitivity of 82% for BOO.[31]

Consider pressure flow studies before surgical intervention for LUTS attributed to BPH when there is diagnostic uncertainty.[17] Pressure flow studies provide the most complete means of determining the presence of BOO but most patients can be managed and treated surgically without them. Pressure flow studies can be helpful in distinguishing BOO from detrusor underactivity and may be helpful in counseling patients about their individual risk for improvement following treatment.[32]

A synchronous pressure flow study that looks at the pressure flow relationship, with rises in pressure during filling suggesting bladder overactivity (detrusor overactivity) or elevated voiding pressures combined with a reduced flow, can be useful for patients for whom surgery may be contemplated or if symptoms are persistent following invasive procedures.[30]

Imaging

Prostate imaging is recommended to accurately assess the size and shape of the prostate before treatment with a 5-alpha-reductase inhibitor or to inform choice of surgical interventions.[17][18]​​[33]

Transrectal or abdominal ultrasound, or cystoscopy may be considered, or preexisting imaging scans can be used (including magnetic resonance imaging/computed tomography), preferably obtained within the preceding 12 months.[17] Transrectal ultrasound is more accurate than transabdominal measurement and is the most commonly used modality for imaging the prostate.​[18]​​[33]

Ultrasound is the preferred method of assessing bladder volume in PVR. A measurable PVR may be seen in bladder outflow obstruction due to BPH.[33]

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