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Diagnosis of Benign Prostatic Hyperplasia and Benign Prostatic Syndrome

• Benign prostatic hyperplasia: definitions, epidemiology and etiology
• Benign prostatic hyperplasia: signs and symptoms
• Benign prostatic hyperplasia: diagnosis
• Benign prostatic hyperplasia: medical treatment
• Benign prostatic hyperplasia: surgical treatment

Principles of Diagnostic Workup

The diagnostic challenge is to determine the cause of voiding symptoms. Neither symptoms, urinary stream, nor prostate volume alone reliably predict prostate-related bladder outlet obstruction. The following algorithm presents a guideline-based approach to the diagnosis and treatment of lower urinary tract symptoms and benign prostatic syndrome.

Algorithm for the diagnosis and treatment of benign prostatic syndrome at initial presentation: adapted from the DGU and EAU Guidelines.
(*) Despite adequate medical treatment.
(**) Urodynamics should be considered before invasive treatment, particularly in men younger than 50 years, patients older than 80 years, patients with postvoid residual urine >300 ml, maximum urinary flow >15 ml/s, suspected neurogenic lower urinary tract dysfunction, previous radical pelvic surgery, or unsuccessful invasive treatment.
(***) Not after urinary retention or prostatic bleeding.

Medical History

The medical history assesses symptom severity, course, bother, fluid intake, nocturia, hematuria, urinary tract infections, urinary retention, neurologic disorders, previous surgery, sexual function, and treatment goals. It is central to the differential diagnosis of male lower urinary tract symptoms.

Risk Factors for Urethral Stricture

Urethritis, transurethral procedures, catheterization, pelvic or perineal trauma, and previous radiation therapy.

Neurogenic Bladder Disorders

Diabetes mellitus, Parkinson disease, multiple sclerosis, stroke, spinal cord disorders, and surgery involving the spinal canal or pelvis.

Medication

Sympathomimetics, anticholinergics, tricyclic antidepressants, antipsychotics, opioids, and antihistamines may worsen lower urinary tract symptoms or cause urinary retention.

Voiding Diary

A voiding diary for at least 2–3 days can document fluid intake, voiding frequency, voided volumes, and nocturnal polyuria. It is useful for the differential diagnosis of nocturia caused by diabetes, COPD, or heart failure.

Physical Examination

Physical examination includes the abdomen, external genitalia, meatus, and phimosis; digital rectal examination to estimate prostate size and identify suspicious induration; and, where indicated, a focused neurologic examination including sphincter tone, perineal sensation, saddle anesthesia, and paresis.

International Prostate Symptom Score

The International Prostate Symptom Score quantifies subjective symptoms.

Laboratory Studies

Urine Sediment

Perform urine sediment examination; obtain a urine culture if abnormalities are present.

Creatinine

Measure creatinine to exclude obstruction with upper urinary tract damage.

PSA

PSA helps distinguish between benign prostatic hyperplasia and prostate cancer and is useful in patients with a life expectancy exceeding 10 years. Evaluate elevated PSA values according to individual risk; the indication for biopsy depends on the overall risk, digital rectal examination, PSA kinetics, PSA density, and, where appropriate, multiparametric MRI. For a detailed discussion of PSA reference values and derived parameters, see PSA.

Further Diagnostic Tests

Uroflowmetry

For meaningful uroflowmetry, voided volume should exceed 150 ml. A maximum urinary flow below 10 ml/s is typical of benign prostatic syndrome, whereas a flow above 15 ml/s raises doubt about the benefit and necessity of surgical treatment. Uroflowmetry contributes little to the differential diagnosis of bladder outlet obstruction or bladder dysfunction.

Ultrasound

Ultrasound assesses postvoid residual urine, bladder wall and detrusor thickness, prostate size, intravesical middle lobe, bladder stones, bladder diverticula, and hydronephrosis.

Ultrasound of a bladder diverticulum. With kind permission, Prof. Dr. R. Harzmann, Augsburg.

Ultrasound of a trabeculated bladder with marked bladder wall thickening (19 mm): bladder trabeculae with pseudodiverticula are readily identifiable as echogenic structures with acoustic shadowing caused by air in the bladder after long-term catheterization. With kind permission, Dr. U. Sonntag, Augsburg.

Postvoid Residual Urine

Postvoid residual urine may promote recurrent urinary tract infections, bladder stones, and urinary retention. Single measurements have limited reliability because of substantial intraindividual variation. High postvoid residual volumes can result from both benign prostatic obstruction and detrusor underactivity; clear thresholds for surgery or failure of conservative treatment are lacking.

Kidneys

Assess the kidneys to exclude hydronephrosis, particularly in patients with elevated creatinine, urinary retention, high postvoid residual urine, recurrent infections, or flank pain.

Prostate Size

Determine prostate size transabdominally or by transrectal ultrasonography; it is important for selecting medical and invasive treatment options. Image the prostate in the sagittal and transverse planes, measure length, width, and height, and calculate prostate volume.

Benign prostatic hyperplasia on transrectal ultrasonography: enlarged middle lobe and isolated small cysts; sagittal plane on the left, transverse plane of the enlarged lateral lobes in the center, and transverse plane of the intravesical middle lobe at the level of the seminal vesicles on the right.

Intravesical Prostatic Protrusion

Measure intravesical prostatic protrusion in the sagittal plane with adequate bladder filling. Measure the perpendicular distance from the bladder base to the highest point of the prostatic middle lobe protruding into the bladder lumen. A protrusion exceeding 10 mm suggests relevant obstruction.

Intravesical prostatic protrusion: sagittal transabdominal ultrasonography of the filled bladder shows prostatic protrusion of 24 mm.

Urodynamics

Uroflowmetry is part of the routine diagnostic workup; invasive urodynamics are reserved for selected uncertain cases. Consider urodynamics before invasive treatment in men younger than 50 years, men older than 80 years, patients with postvoid residual urine >300 ml, maximum urinary flow >15 ml/s, suspected neurogenic lower urinary tract dysfunction, previous radical pelvic surgery, or unsuccessful invasive treatment.

Despite adequate diagnostic assessment and patient selection, lower urinary tract symptoms persist in some patients after invasive treatment, usually because of storage symptoms, detrusor overactivity, or detrusor underactivity.

Cystoscopy

Cystoscopy is indicated for gross hematuria, suspected urethral stricture, bladder cancer, bladder stones, bladder diverticula, or before planned invasive treatment when endoscopic anatomy influences procedure selection. Cystoscopy should not be used as the sole basis for deciding on surgery. A large middle lobe, bladder bar, or kissing lateral lobes do not independently establish an indication for surgery.

Cystoscopy in BPH: kissing lateral lobes (left), bladder pseudodiverticula (center), and trabeculated bladder mucosa (right).

Radiologic Imaging

The urogram was long the standard investigation for evaluating the upper urinary tract before surgical treatment of benign prostatic syndrome. Today, ultrasound, laboratory testing, and targeted cross-sectional imaging have largely replaced it in routine diagnostics.

Urogram in BPH: enlargement of the middle lobe elevates the bladder base. The ureters enter the bladder in a fish-hook configuration; hydronephrosis is absent. With kind permission, Dr. R. Gumpinger, Kempten.

CT or MR Urography

Indicated for unexplained gross hematuria, suspected tumor, urolithiasis, complex bladder diverticula, unexplained hydronephrosis, suspected extrinsic obstruction, or inconclusive ultrasonography.

Retrograde Urethrography

Indicated if urethral stricture is suspected.

Cystography

Indicated if bladder diverticula or bladder stones are suspected.

Cystography with multiple bladder diverticula: a bladder stone is present in the large right diverticulum and is visible because of double contrast.

References

Andriole u.a. 2004 ANDRIOLE, G. L. ; ROEHRBORN, C. ; SCHULMAN, C. ; SLAWIN, K. M. ; SOMERVILLE, M. ; RITTMASTER, R. S.: Effect of dutasteride on the detection of prostate cancer in men with benign prostatic hyperplasia.
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Burnett und Wein 2006 BURNETT, A. L. ; WEIN, A. J.: Benign prostatic hyperplasia in primary care: what you need to know.
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Chapple 2004 CHAPPLE, C. R.: Pharmacological therapy of benign prostatic hyperplasia/lower urinary tract symptoms: an overview for the practising clinician.
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DGU Guideline, “S2e Leitlinie Diagnostik und Therapie des Benignen Prostatasyndroms (BPS).,” 2023. [Online]. Available: https://register.awmf.org/assets/guidelines/043-034l_S2e_Diagnostik_Therapie_benignes_Prostatasyndrom_2023-04.pdf

Donovan u.a. 2000 DONOVAN, J. L. ; PETERS, T. J. ; NEAL, D. E. ; BROOKES, S. T. ; GUJRAL, S. ; CHACKO, K. N. ; WRIGHT, M. ; KENNEDY, L. G. ; ABRAMS, P.: A randomized trial comparing transurethral resection of the prostate, laser therapy and conservative treatment of men with symptoms associated with benign prostatic enlargement: The CLasP study.
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“EAU Guideline: Non-neurogenic Male LUTS,” Available: https://uroweb.org/guidelines/treatment-of-non-neurogenic-male-luts/.

Kopp, R. P.; Freedland, S. J. & Parsons, J. K. Associations of benign prostatic hyperplasia with prostate cancer: the debate continues.
Eur Urol, 2011, 60, 699-700; discussion 701-2.

Ørsted, D. D.; Bojesen, S. E.; Nielsen, S. F. & Nordestgaard, B. G. Association of clinical benign prostate hyperplasia with prostate cancer incidence and mortality revisited: a nationwide cohort study of 3,009,258 men.
Eur Urol, 2011, 60, 691-698.

Parsons, J. Kellogg; Messer, Karen; White, Martha; Barrett-Connor, Elizabeth; Bauer, Douglas C; Marshall, Lynn M; in Men (MrOS) Research Group, Osteoporotic Fractures & the Urologic Diseases in America Project Obesity increases and physical activity decreases lower urinary tract symptom risk in older men: the Osteoporotic Fractures in Men study.
Eur Urol, 2011, 60, 1173-1180.

Reich u.a. 2006 REICH, O. ; GRATZKE, C. ; STIEF, C. G.: Techniques and long-term results of surgical procedures for BPH.
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Uygur u.a. 1998 UYGUR, M. C. ; GUR, E. ; ARIK, A. I. ; ALTUG, U. ; EROL, D.: Erectile dysfunction following treatments of benign prostatic hyperplasia: a prospective study.
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  Deutsche Version: Diagnostik der benignen Prostatahyperplasie

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