BPH Investigations

Cheatsheet Content

### Introduction to BPH Investigations Benign Prostatic Hyperplasia (BPH) is a common condition in aging men, characterized by non-malignant prostatic enlargement that can lead to Lower Urinary Tract Symptoms (LUTS). Investigations aim to confirm diagnosis, assess symptom severity, rule out other conditions, and guide management. ### Symptom Assessment & History - **International Prostate Symptom Score (IPSS):** - 7 questions on LUTS severity (storage & voiding) + 1 on quality of life (QoL). - Score 0-35 (0-7 mild, 8-19 moderate, 20-35 severe). - Essential for baseline and monitoring treatment efficacy. - **Voiding Diary:** - Records fluid intake, voided volume, frequency, urgency, incontinence episodes over 24-72 hours. - Useful for assessing nocturnal polyuria, bladder capacity, and frequency. - **Medical History:** - Review comorbidities (e.g., diabetes, neurological conditions), medications (e.g., diuretics, anticholinergics, decongestants, opioids), prior surgeries. - Ask about hematuria, dysuria, pain, recurrent UTIs, and sexual function. ### Physical Examination - **Digital Rectal Exam (DRE):** - Assess prostate size, consistency, symmetry, and presence of nodules. - BPH typically feels smooth, elastic, and enlarged. - Crucial for ruling out prostate cancer (hard, nodular areas). - **Abdominal Examination:** - Palpate for distended bladder (suggests urinary retention). - **Focused Neurological Exam:** - Assess lower extremity sensation and reflexes if neurogenic bladder is suspected. ### Urinalysis & Blood Tests - **Urinalysis:** - Rule out infection (pyuria, bacteriuria), hematuria, glucosuria, proteinuria. - Microscopic hematuria warrants further investigation (e.g., cystoscopy, imaging). - **Serum Creatinine:** - Assess renal function, especially if obstructive uropathy is suspected. - **Prostate-Specific Antigen (PSA):** - **Purpose:** Used in conjunction with DRE to screen for prostate cancer, especially before surgical intervention for BPH. - **Interpretation:** - PSA levels can be elevated in BPH, prostate cancer, prostatitis, and after prostatic manipulation. - Age-specific PSA ranges and PSA velocity/density can aid interpretation. - Discussion of risks/benefits of PSA testing is crucial with the patient. ### Urodynamic Studies - **Uroflowmetry:** - Measures urine flow rate (peak flow rate, average flow rate) and voided volume. - **Normal:** Peak flow rate > 15 mL/s for voided volume > 150 mL. - **Interpretation:** Decreased flow rate suggests outflow obstruction or detrusor underactivity. - **Post-Void Residual (PVR) Volume:** - Measured by bladder scan or catheterization after voiding. - **Normal:** 100-200 mL) suggests incomplete bladder emptying, risk of UTIs, and potential for renal impairment. - **Pressure-Flow Studies (PFS):** - Considered the gold standard for diagnosing bladder outlet obstruction (BOO). - Measures detrusor pressure and flow rate simultaneously during voiding. - Differentiates BOO from detrusor underactivity. - **Indications:** Atypical symptoms, prior failed BPH surgery, neurological conditions, large PVR, young patients, or when non-invasive tests are inconclusive. ### Imaging Studies - **Renal and Bladder Ultrasound:** - Assess kidney size, hydronephrosis (indicates upper tract obstruction). - Evaluate bladder wall thickness, diverticula, stones. - Measure prostate volume (transabdominal ultrasound). - **Transrectal Ultrasound (TRUS) of the Prostate:** - Provides accurate prostate volume measurement. - Used mainly for prostate biopsy guidance, not routinely for BPH diagnosis. - **Cystoscopy:** - Endoscopic visualization of the urethra, prostate, and bladder. - **Indications:** Hematuria, prior urethral/prostate surgery, stricture suspected, bladder stones, or to assess prostate configuration before surgery. - Not routinely recommended for uncomplicated BPH. ### Differential Diagnosis It is crucial to differentiate BPH from other conditions causing LUTS: - **Prostate Cancer:** Often asymptomatic, but can cause LUTS. Ruled out by DRE and PSA. - **Prostatitis:** Inflammatory condition, often with pain, fever, dysuria. - **Urethral Stricture:** Obstructive symptoms, often with history of instrumentation or trauma. - **Bladder Stones:** Can cause hematuria, pain, intermittent flow. - **Neurogenic Bladder:** Due to neurological conditions (e.g., Parkinson's, MS, stroke, spinal cord injury). - **Overactive Bladder (OAB):** Primarily storage symptoms (urgency, frequency, nocturia) without obstruction. - **Urinary Tract Infection (UTI):** Dysuria, frequency, urgency, often with fever/chills. - **Medication Side Effects:** Certain drugs (e.g., decongestants, anticholinergics) can worsen LUTS. ### Management Overview Investigations guide the choice of BPH management, which can include: - **Watchful Waiting:** For mild symptoms. - **Lifestyle Modifications:** Fluid management, avoiding irritants. - **Pharmacotherapy:** - **Alpha-blockers:** (e.g., Tamsulosin, Alfuzosin) Relax smooth muscle in prostate and bladder neck. - **5-alpha reductase inhibitors (5-ARIs):** (e.g., Finasteride, Dutasteride) Reduce prostate size. - **Combination therapy:** Alpha-blocker + 5-ARI. - **PDE5 inhibitors:** (e.g., Tadalafil) For LUTS with or without erectile dysfunction. - **Minimally Invasive Therapies:** (e.g., UroLift, Rezum, Aquablation) - **Surgical Intervention:** (e.g., TURP - Transurethral Resection of the Prostate, simple prostatectomy) For severe symptoms, complications (refractory retention, recurrent UTIs, bladder stones, renal impairment).