Download BPH - Patient Evaluation and Diagnosis

Benign Prostatic Hyperplasia (BPH)
Patient Evaluation and Diagnosis
BPH Diagnosis and Treatment Algorithm
Initial Evaluation
• History
• DRE & Focused PE
• Urinalysis
• PSA
Presence of
• Refractory retention or any of the
following clearly related to BPH
•Persistent gross hematuria
•Bladder stones
•Recurrent UTIs
•Renal insufficiency
AUA/IPSS Symptom Index
Assessment of Patient Bother
Moderate/Severe Symptoms
(AUA/IPSS 8)
Mild Symptoms
(AUA/IPSS 7) or No
Bothersome Symptoms
Surgery
Optional Diagnostic Tests
• Uroflow
• PVR
Discussion of Treatment Options
Patient Chooses
Noninvasive Therapy
Watchful Waiting
AUA Guideline 2003/updated 2006.
Patient Chooses
Invasive Therapy
Optional Diagnostic Tests
• Pressure flow
• Urethrocystoscopy
• Prostate ultrasound
Medical Therapy
Minimally Invasive Therapies
Surgery
Initial Evaluation
•
•
•
•
•
Detailed medical history
DRE and focused physical exam
Urinalysis
PSA in selected patients*
Symptom assessment
– AUA/IPSS Symptom Index
– Assessment of patient bother
DRE - digital rectal exam
PSA - prostate-specific antigen
*Per physician’s clinical judgment
AUA Guideline 2003/updated 2006.
Further Evaluation Warranted?
• Abnormal DRE
• History of diabetes
• Abnormal PSA
• History of pelvic
surgery/ trauma
• Prior therapy for
LUTS/BPH
• Non-response to
medical therapy
• Neurologic symptoms/
disease
• Renal insufficiency
• <50 years of age
AUA Guideline 2003/updated 2006.
Questions to Ask Relative
to History
• Oral intake
– Timing
– Caffeine
– Alcohol
• Medications
affecting volume
– Diuretics
– Stool-bulking agents
• Medications affecting
voiding
– Antihistamines
– Decongestants
• Diseases
– Diabetes
– Congestive heart failure
– Neurologic
AUA Guideline 2003/updated 2006.
Optional Diagnostic Tests
Following initial evaluation
• Uroflow
– Urinary flow-rate recording (Qmax)
• PVR
If patient chooses invasive therapy
• Pressure flow
• Urethrocystoscopy
• Prostate ultrasound
AUA Guideline 2003/updated 2006.
Standard Questionnaires for Patient’s
Perception of BPH Symptoms
• AUA Symptom Score
• International Prostate Symptom Score (IPSS)
• BPH Impact Index (Bother Score)
AUA Symptom Score Index
• Seven-item questionnaire related to BPH
symptoms
• Validated and reproducible
• Determines disease severity
• Documents response to therapy
• Allows standardized comparisons of symptom
relief when evaluating treatments
AUA Guideline 2003/updated 2006.
AUA Symptom Score
AUA Guideline 2003/updated 2006.
Classification of AUA Symptom Scores
The possible total runs from 0-35 points with higher
scores indicating more severe symptoms. Scores
lower than 7 are considered mild and generally do
not warrant treatment.
Classification ranges
• Mild (0-7)
• Moderate (8-19)
• Severe (20-35)
• Without bother or bothersome
AUA Guideline 2003/updated 2006.
Initial Management and Discussion
Using AUA Symptom Score
Patients with mild symptoms (AUA symptom score ≤ 7)
and
Patients with moderate or severe symptoms (AUA
symptom score ≥ 8) who are not bothered by their
symptoms
– Offer watchful waiting
– Reassure patient
– Reassess periodically
Initial Management and Discussion
Using AUA Symptom Score
Patients with bothersome, moderate to severe
symptoms (AUA Symptom Score ≥ 8)
– Watchful waiting
– Discuss BPH treatment options, including benefits
and risks
– Provide patient education materials
International Prostate Symptom
Score (IPSS)
AUA Symptom Score Index plus additional question on
QOL as a function of urinary symptoms:
“If you were to spend the rest of your life with
your urinary condition just the way it is now, how
would you feel about that?”
– Scale of 0 to 6 (delighted to terrible)
– Note: While symptoms may be prevalent, they may not be
troublesome
O’Leary MP. Urology. 2000.
BPH Impact Index (Bother Score)
None
Only a little
Some
A lot
Not at all
bothersome
Bothers
me a little
Bothers
me some
Bothers
me a lot
A little of
the time
Some of
the time
Most of
the time
All of
the time
1. Over the past month, how much physical
discomfort did any urinary problems cause you?
2. Over the past month, how much did you worry
about your health because of any urinary
problems?
3. Overall, how bothersome has any trouble
with urination been during the past month?
None of
the time
4. Over the past month, how much of the time
has any urinary problem kept you from doing
the kinds of things you would usually do?
AUA Guideline 2003/updated 2006.
References
• American Urological Association Education and Research, Inc. AUA
Guideline 2003/Updated 2006.
• Barry MJ, Fowler FJ, O’Leary MP et al. “The American Urological
Association Symptom Index for benign prostatic hyperplasia”, J Urol.
1992;148:1549-1557.
• O’Leary MP. LUTS, ED, QOL: alphabet soup or real concerns to
aging men? Urology, 2000;56(suppl 5A):7-11.
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