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F Additional Tests
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Cystometrograms and urodynamic profiles should be reserved for patients with suspected neurologic disease or those who have failed prostate surgery Flow rates, postvoid residual urine determination, and pressure-flow studies are considered optional
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C Laboratory Findings
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Urinalysis should be performed to exclude infection or hematuria A serum PSA is considered optional, yet most clinicians will include it in the initial evaluation, particularly if life expectancy is more than 10 years PSA certainly increases the ability to detect prostate cancer over DRE alone; however, because there is much overlap between levels seen in benign prostatic hyperplasia and prostate cancer, its use remains controversial (see below in the section on screening for prostate cancer)
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Other obstructive conditions of the lower urinary tract such as urethral stricture, bladder neck contracture, bladder stone, or carcinoma of the prostate must be considered when evaluating men with presumptive benign prostatic hyperplasia A history of prior urethral instrumentation, urethritis, or trauma should be elucidated to exclude urethral stricture or bladder neck contracture Hematuria and pain are commonly associated with bladder stones Carcinoma of the prostate may be detected by abnormalities on the DRE or an elevated PSA (see below) A urinary tract infection can mimic the irritative symptoms of benign prostatic hyperplasia and can be readily identified by urinalysis and culture; however, a urinary tract infection can also be a complication of benign prostatic hyperplasia Carcinoma of the bladder, especially carcinoma in situ, may also present with irritative voiding complaints; however, urinalysis usually shows evidence of hematuria Patients with a neurogenic bladder may also have many of the same symptoms and signs as those with benign prostatic hyperplasia; however, a history of neurologic disease, stroke, diabetes mellitus, or back injury may be obtained, and diminished perineal or
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D Imaging
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Upper tract imaging (IVU, CT, or renal ultrasound) is recommended only in the presence of concomitant urinary tract disease or complications from benign prostatic hyperplasia (ie, hematuria, urinary tract infection, renal insufficiency, history of stone disease)
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E Cystoscopy
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Cystoscopy is not recommended to determine the need for treatment but may assist in determining the surgical approach in patients opting for invasive therapy
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Urologic Disorders
1 Initial evaluation History Physical examination and DRE Urinalysis Creatinine PSA (optional) 2
CMDT 2008
Presence of Refractory retention Any of the following, clearly secondary to BPH: Recurrent urinary tract infection Recurrent or persistent gross hematuria Bladder stones Renal insufficiency
3 Quantitative symptom assessment
Surgery 4 Mild 5 Moderate to severe 6 Optional diagnostic tests based on physician and patient preference 7 Offer treatment alternatives Flow rate Residual urine Pressure flow Medical therapy Yes 9 Option for urethrocystoscopy or sonography if important in planning operative approach Non-BPH problems identified and treated Compatible with obstruction No
8 Watchful waiting Surgery: TUIP, TURP, open
Figure 23 2 Benign prostatic hyperplasia decision diagram DRE, digital rectal examination; PSA, prostate-specific antigen; BPH, benign prostatic hyperplasia; TUIP, transurethral incision of the prostate; TURP, transurethral resection of the prostate
lower extremity sensation or alterations in rectal sphincter tone or the bulbocavernosus reflex might be observed on examination Simultaneous alterations in bowel function (constipation) might also suggest the possibility of a neurologic disorder
A Watchful Waiting
The risk of progression or complications is uncertain However, in men with symptomatic disease, it is clear that progression is not inevitable and that some men undergo spontaneous improvement or resolution of their symptoms Retrospective studies on the natural history of benign prostatic hyperplasia are inherently subject to bias, relating in part to patient selection and also to the type and extent of follow-up Very few prospective studies addressing the natural history have been reported One small series demonstrated that approximately 10% of symptomatic men may progress to urinary retention while 50% of patients demonstrate marked improvement or resolution of symptoms Recently, a large randomized study was reported comparing finasteride with placebo in men with moderate to severely symptomatic disease and enlarged prostates on DRE Patients in the placebo arm demonstrated a 7% risk of developing urinary retention over 4 years Men with moderate or severe symptoms can also be managed in this fashion if they so choose The optimal interval for follow-up is not defined, nor are the specific end points for intervention
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