benign%20prostatic%20hyperplasia
BENIGN PROSTATIC HYPERPLASIA
Treatment Guideline Chart
Benign prostatic hyperplasia (BPH) is a histopathological diagnosis characterized by epithelial cell & smooth muscle cell proliferation in the transition zone of the prostate leading to a non-malignant enlargement of the gland, which may result in lower urinary tract symptoms, including voiding and storage symptoms.
It is commonly called enlarged prostate.
The exact cause of BPH is still not well understood.

Benign%20prostatic%20hyperplasia Diagnosis

History

  • Beginning and frequency of symptoms
  • History of recurrent urinary tract infections (UTIs), hematuria, erectile dysfunction, hypotension and fainting
  • How much liquid the patient typically drinks each day
  • Frequency of caffeine and alcohol use
  • General medical history, including past illnesses or surgeries and intake of medications such as decongestants, antihistamines, antidepressants and diuretics

International Prostate Symptom Score (IPSS)

  • Scoring system used to screen and diagnose BPH as well as to monitor and guide decisions in managing the disease
  • Contains 8 questions [7 regarding symptoms and 1 for patient’s quality of life (QoL)]
  • According to the scoring system, the scores are categorized as follows:
    • Mild if the score is ≤7
    • Moderate if the score is 8 to 19
    • Severe if the score is 20 to 35
  • For questions on the QoL, a score of 6 means that the patient perceives a “terrible” QoL while a score of 0 indicates that the patient is “delighted” with his QoL

Physical Examination

  • Check for:
    • Any signs of distended bladder when examining the abdomen 
    • Back and flank pain from urinary retention 
    • Discharges from the urethra
    • Swelling or tenderness of the scrotum
  • Perform digital rectal exam (DRE) for the examination of the prostate
    • Simplest method to assess the volume of the prostate but there is poor correlation to actual prostate volume 
    • Identify any palpable enlargement of the prostate
    • Detection of hard, firm or nodular areas in the prostate raises suspicion of prostate cancer
  • Focused neurological examination to evaluate for neurologic diseases that might produce LUTS

Laboratory Tests

Diagnostic Tests

Urinalysis 

  • Urine sample is tested for signs of infections and microscopic hematuria

Frequency Volume Chart

  • Provides useful information including frequency, total voided volume, functional capacity, fluid intake habits and demonstrates nocturnal polyuria

Prostate-specific Antigen (PSA)

  • Performed to detect or rule out prostate cancer
  • Strong predictor of prostate growth and has good predictive value for assessing prostate volume

Optional Tests

  • May be used to screen men >40 years old with LUTS or other comorbidities 

Urodynamic Tests 

  • These procedures check how well the sphincter and urethra and the bladder store and release urine
  • Mostly focus on the ability of the bladder to hold the urine, as well as to empty steadily and completely
  • May include uroflowmetry which measures how rapid the bladder releases urine and postvoid residual (PVR) measurement  which evaluates how much urine has remained in the bladder
    • An increasing PVR may indicate medication failure and the need for surgical intervention or the need for further urodynamic testing
    • A large PVR (>300 mL) must be monitored

Pressure Flow Studies

  • Bladder pressure measured during urination helps differentiate between obstructive symptoms and those resulting from bladder muscle or nerve problem 
  • May be done before surgical intervention when diagnosis is uncertain

Cystoscopy

  • Used to look inside the urethra and bladder to check for blockage and stones in the lower urinary tract
  • Used to find the cause of urinary tract problems such as frequent UTIs, hematuria, urinary frequency, urinary urgency, urinary retention, urinary incontinence, pain or burning sensation before, during or after urination, trouble in starting urination, completing urination or both, abnormal cells such as cancer cells found in the urine sample
  • Can be used to treat problems such as bleeding and blockage in the urethra, to remove stones and to remove or treat abnormal tissue

Cystometrogram 

  • Measures pressure, compliance and storage capacity of the urinary bladder; a uroflowmetry test may be included

Imaging

  • Perform prostate imaging when surgical treatment is considered
  • Must provide sagittal and cross-sectional views with sufficient resolution in order to assess presence or absence of an intravesical lobe or a median lobe configuration (a lobe of hyperplastic tissue which protrudes into the lumen of the bladder causing mechanical obstruction by occluding the bladder neck each time the bladder contracts during voiding) and to calculate prostate volume

Ultrasound

  • Abdominal or transrectal ultrasound (TRUS) may be performed to assess prostate size and shape prior to surgical intervention
    • Assessment of prostate size (volume) is important for the choice of interventional treatment ie enucleation techniques, open prostatectomy, transurethral incision of the prostate, transurethral resection or minimally invasive surgical therapies (MIST)
      • Prostate gland is considered enlarged if size is >40 cm3 
    • Presence of median/middle or intravesical lobe will guide the treatment of choice in patients planned for minimally invasive therapy

Computed Tomography (CT) or Magnetic Resonance Imaging (MRI)

  • May be done prior to surgical intervention to assess prostate size and shape
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