Enlarged prostate (bph) symptoms diagnosis

December 5, 2009 by Prostate Dr.

DRE & Enlarged prostate

If bph symptoms occur, a physical examination- DRE (Digital Rectal Exam)- is performed followed by a neurologic examination. The size and consistency of the prostate gland are noted. BPH is usually felt like a smooth, firm, elastic enlargement of the prostate. If Induration is detected during the DRE, the physician should realize the possibility of cancer and request further evaluation (prostate-specific antigen test [PSA], transrectal ultrasound, biopsy).

Symptoms assessment

The self-administered questionnaire developed by the American Urological Association (AUA) is a perfect start when first symptoms of prostate enlargement are felt, as well as during the subsequent monitoring phases. It is a reliable source of information and is very important in identifying the need to treat patients and in monitoring their response to therapy. The AUA Symptom Score questionnaire (see following table) is perhaps the single most important tool used in the evaluation of patients with BPH symptoms and is recommended for all patients before the initiation of therapy.

This assessment focuses on 7 items that ask patients to quantify the severity of their obstructive or irritative symptoms on a scale of 0-5. Thus the score can range from 0 to 35.

According to McConnell et al, 1994, the relative distribution of scores for patients with BPH symptoms and for control subjects is:

20% and 83% in patients with mild scores
57% and 15% in those with moderate scores
23% and 2% in those with severe scores

This is what the questionnaire looks like:

International Prostate Symptom Score (I-PSS)

SYMPTOM	SCORE
SYMPTOM	Not at all	Less than 1 time in 5	Less than half the time	About half the time	More than half the time	Almost always	Total score
Incomplete emptying: Over the past month, how often have you had asensation of not emptying yourbladder completely after youfinished urinating?	0	1	2	3	4	5
Frequency: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?	0	1	2	3	4	5
Intermittency: Over the past month, how often have you found you stopped and started again several times when you urinated?	0	1	2	3	4	5
Urgency: Over the past month, how often have you found it difficult to postpone urination?	0	1	2	3	4	5
Weak stream: Over the past month, how often have you had a weak urinary stream?	0	1	2	3	4	5
Straining: Over the past month, how often have you had to push or strain to begin urination?	0	1	2	3	4	5
	NONE	1 TIME	2 TIMES	3 TIMES	4 TIMES	5 OR MORE TIMES
Nocturia: Over the past month, how many times did you most typicallyget up to urinate from the time youwent to bed at night until the timeyou got up in the morning?	0	1	2	3	4	5
Total I-PSS score = ...

Laboratory tests to assess prostate enlargement/BPH

Psa score for bph

Prostate specific antigen (PSA) is a protease secreted by epithelial cells of the prostate. It was found to be elevated in 30% to 50% of patients with an enlarged prostate. Testing for PSA is used mostly to increases detection rate for prostate cancer and tends to detect cancer at an earlier stage. However, the PSA test does not discriminate well between patients with symptomatic BPH/enlarged prostate and those with prostate cancer, especially if the cancers are pathologically localized and curable. The test may also provide additional guidance concerning additional evaluation options, including ultrasound biopsy of the prostate. Recent data show that asymptomatic men with PSA levels <2 ng/ml do not need annual testing. According to the AUA policy report published in the February 2000 issue of Oncology,

PSA testing and digital rectal examination should be offered to any asymptomatic man older than 50 years of age with a life expectancy of =10 years.

PSA testing can also be done at an earlier age in those men with a higher risk of prostatic cancer (e.g., black men, or first-degree relatives with prostate cancer).

Measurement of "free" PSA is useful to assess the probability of prostate cancer in patients with normal digital rectal examination and total PSA between 4 and 10 ng/ml. In these patients the global risk of prostate cancer is 25%; however, if the free PSA is >25%, the risk of prostate cancer decreases to 8%, whereas if the free PSA is >10%, the risk of cancer increases to 56%. Free PSA is also useful to evaluate the aggressiveness of prostate cancer. A low free PSA percentage generally indicates a high-grade cancer, whereas a high free PSA percentage is generally associated with a slower growing tumor.

In order to exclude exclude infection or hematuria (if any is suspected) a urinalysis test should be performed.

BUN (Blood Urea Nitrogen) and creatinine should be performed to rule out postrenal insufficiency. A BUN test is done to estimate the function of yor kidneys. BUN level increases when the kidneys are not able to remove urea from the blood.

Imaging studies for BPH symptoms

Transrectal ultrasound may be indicated in patients with palpable nodules or significant elevation of PSA. It is also useful to estimate prostate size.
Uroflowmetry may be used to determine relative impact of obstruction on urine flow. Urethral pressure profile is useful to predict prostatic hypertrophy within the urethral lumen.
Pressure flow studies, although invasive, are particularly helpful in patients whose history and/or examination suggest primary bladder dysfunction as a cause of symptoms of prostatism.
Urethral cystoscopy is an option during later evaluation if invasive treatment is being planned.
Postvoid residual urine measurement is to be used not as much to in predicting the need for or response to treatment, but it may be useful in monitoring the course of the disease in patients who choose nonsurgical treatment.

Differential Diagnosis

Other obstructive conditions of the lower urinary tract, such as urethral stricture, bladder neck contracture, bladder stone, or CaP, must be considered when evaluating men with enlarged prostate symptoms. The patient's history involving urethral instrumentation, urethritis, or trauma should be elucidated to exclude urethral stricture or bladder neck contracture.

Urinary tract infection can mimic the irritative symptoms of BPH. It can be readily identified by urinalysis and culture; but it should be considered that a urinary tract infection can also be a complication of BPH.