REVIEW CME CREDIT ' Benign prostatic hyperplasia: an approach for the internist CRAIG D. ZIPPE, MD IAGNOSING and treat- In benign prostatic hyperplasia, urodynamic testing ing benign prostatic and the many available drugs and surgical procedures have hyperplasia (BPH) complicated the issue of what to do for whom. Although the have become increas- Dingly complicated. Although uro- severity of a patient's symptoms and his informed preferences should be the driving forces, specialized tests can help tailor dynamic tests can reveal much treatment to the individual patient. about the pathophysiology of BPH and new drugs and surgical l'ikd The American Urological Association symptom in- procedures provide more treat- dex, which is derived from a short questionnaire, should be ment options, these advances the primary determinant of treatment. Patients with mild paradoxically leave less certainty symptoms need reassurance and yearly follow-up, but no medi- about what to do for the individ- cal or surgical treatment. I recommend baseline urodynamic ual patient. Additionally, since testing for patients with moderate symptoms. Those with no internists are assuming greater signs of bladder decompensation can receive medical therapy; primary care of patients with BPH if there are signs of bladder decompensation, surgery is offered. (because new drug therapies are The first-line medical therapy most commonly used is an al- available), there is less certainty pha adrenergic blocking agent (either terazosin or doxazosin) about when to refer a patient to a in titrated doses. Surgery is offered if the symptoms do not urologist. abate with maximal medical therapy. Patients with severe Our strategy in some ways di- symptoms usually need one of the more aggressive surgical pro- verges from the recommendations cedures. of the Agency for Health Care Policy and Research (AHCPR).1 INDEX TERMS: PROSTATIC HYPERTROPHY Although the severity of a pa- CLEVE CLIN ] MED 1996; 63:22^236 tient's symptoms and his informed preferences should be the driving From the Department of Urology, The Cleveland Clinic Foundation. Address reprint requests to C.D.Z., Department of Urology, A100, The forces in choosing what treatment Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195. to give, I advocate greater use of specialized studies to tailor BPH treatment to the individual pa- tient. We are gathering data ob- tained from such studies before therapy to develop a large, stand- ardized database to scientifically 226 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 63 • NUMBER 4 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. BENIGN PROSTATIC HYPERPLASIA • ZIPPE evaluate and compare the outcomes of different tion (to assess renal function).1 In addition, I recom- therapies. Ultimately, this effort may help to distin- mend measuring the prostate-specific antigen guish between patients who will benefit from medi- (PSA) level, both to screen for prostate cancer and cal therapy and those who require surgery. to establish a baseline value, as some of the drugs used to treat BPH can decrease the PSA concentra- DIAGNOSTIC DILEMMAS tion considerably (see below). BPH is a syndrome that can cause multiple symp- Symptom assessment and diagnostic tests toms in any one patient. Traditionally, symptoms of A variety of tests are available to assess the pa- BPH have been classified as irritative (frequency, tient with symptoms of BPH. nocturia, urgency) and obstructive (hesitancy, diffi- American Urological Association symptom in- cult voiding, weak stream, sensation of incomplete dex. The most important aspect of the initial evalu- emptying). ation is the American Urological Association symp- For a long time it was believed that the symptoms tom index, derived from a questionnaire in which of BPH resulted entirely from obstruction of the patients rate how often they experience each of bladder outlet. We now know that BPH may be seven symptoms on a scale of 0 (least often) to 5 obstructive or nonobstructive; further, neither "irri- (most often). These numbers are totalled to classify tative" or "obstructive" symptoms correlate with the symptoms as mild (0 to 7), moderate (8 to 19), outlet obstruction, and no single sign or symptom or severe (20 to 35) (Table I ).4 The symptom index indicates obstruction.' should be the primary determinant of treatment (see Complicating this dilemma for the clinician, the below). It should also be used to follow disease pro- behavior of the bladder varies regardless of whether gression and response to treatment. outlet obstruction is present or absent. An ob- Voiding flow rate. This test consists of voiding structed detrusor muscle may be normally contrac- into a cylinder that contains transducers connected tile or weak; conversely, an unobstructed detrusor to a personal computer to measure the flow rate can vary in compliance and contractility.' throughout the voiding cycle. For this test to be A trabeculated bladder (one that contains multi- accurate, the patient should void at least 125 mL. ple small diverticuli—referred to as cellules—that Patients with normal flow rates (> 15 mL/second result from increased detrusor compliance) has long mean) are less likely to benefit from therapy. been considered the hallmark of an obstructed blad- Pressure-volume studies. By measuring the pres- der outlet. But an obstructed bladder is not always sure inside the bladder while the patient voids, this trabeculated, whereas the unstable unobstructed invasive test can detect problems with bladder con- bladder is often trabeculated. Thus, the permuta- traction due to either neurologic disease or detrusor tions are multiple and confusing. decompensation. Measurement of residual urine after voiding, by DIAGNOSTIC EVALUATION either catheterization or ultrasonography, may be useful in monitoring the course of BPH. Patients Given the wide range of presentations of BPH with large residual urine volumes are at increased and the subjective nature of its symptoms, clinicians risk of bladder infections and stones. must obtain as much information as possible about Cystoscopy reveals information about the pros- the patient's symptoms and the interaction between tate size and shape that may be useful in deciding the bladder and prostate. which surgical procedure to perform. Men of middle age or older who experience symp- toms of BPH should undergo a complete history and MANAGEMENT BASED ON SYMPTOMS physical examination. This should include a digital rectal examination to estimate the size of the pros- Patients seek treatment for BPH because of tate and to look for prostate cancer. It should also bothersome symptoms that affect the quality of include a focused neurologic examination.1 their lives. To the patient, relief of symptoms is the Laboratory tests should include a urinalysis (to single most important outcome—not flow rate, de- rule out urinary tract infection and hematuria) and trusor pressure, or residual urine volume after void- a measurement of the serum creatinine concentra- ing. Therefore, my management strategy is based JULY • AUGUST 1996 CLEVELAND CLINIC JOURNAL OF MEDICINE 227 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. BENIGN PROSTATIC HYPERPLASIA • ZIPPE TABLE 1 AMERICAN UROLOGIC ASSOCIATION SYMPTOM INDEX FOR BENIGN PROSTATIC HYPERPLASIA* Questions (Circle one answer for each question) Not at Less Less About More Almost all than 1 than half half than half always time in 5 the time the time the time 1. During the last month or so, how often have you 0 1 2 3 4 5 had a sensation of not emptying your bladder completely after you finished urinating? 2. During the last month or so, how often have you 0 1 2 3 4 5 had to urinate again less than 2 hours after you finished urinating? 3. During the last month or so, how often have you 0 1 2 3 4 5 found you stopped and started again several times when you urinated? 4. During the last month or so, how often have you 0 1 2 3 4 5 found it difficult to postpone urination? 5. During the last month or so, how often have you 0 1 2 3 4 5 had a weak urinary stream? 6. During the last month or so, how often have you 0 1 2 3 4 5 had to push or strain to begin urination? Question None One TWo Three Four Five time times times times times 7. During the last month, how many times did you 0 1 2 3 4 5 most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? *From Barry et al, reference 4, used with permission from the American Urological Association primarily on the symptom index, and only secon- swers to these questions will come when our workup darily on the other tests listed above. However, I do for BPH is systematically performed and our treat- believe the other tests should be used more often. ments are longitudinally quantitated. Specifically, I recommend measuring the voiding flow rate, performing pressure-volume studies, and Mild symptoms (score 0 to 7) measuring the residual urine volume after voiding Generally, patients with mild symptoms do not in all patients with moderate or severe symptoms, need additional testing or treatment and can begin and performing cystoscopy in all candidates for sur- a program of observation or "watchful waiting," gery (Figure l). with yearly follow-up. Patients with mild symptoms Although this approach may seem excessive to can be followed up on a yearly basis. Many patients some, I believe it is necessary if we are to scientifi- actually have improvement in their symptoms cally evaluate and compare the outcomes of the without treatment. However, if symptoms worsen, different medical and surgical therapies. Only a the voiding flow rate should be measured and treat- large standardized database will allow us to opti- ment considered.