U Assessment

HISTORY. Generally, men with suspected BPH have a history of frequent urination, nocturia, straining to urinate, weak stream, and an incomplete emptying of the bladder. Distinguish between these obstructive symptoms and irritative symptoms such as dysuria, frequency, and urgency, which may indicate an infection or inflammatory process. A "voiding diary" can also be obtained to determine the frequency and nature of the complaints. The International Prostate Symptom Score (IPSS) has been adopted worldwide and provides information regarding symptoms and response to treatment (Box 1). Each question allows the patient to choose 1 of 6 answers on a scale of 0 to 5 indicating the increasing degree of symptoms; the total score ranges from 0 (mildly symptomatic) to 35 (severely symptomatic). The eighth question, known as the Bother score, refers to quality of life.

PHYSICAL EXAMINATION. Inspect and palpate the bladder for distension. A digital rectal exam (DRE) reveals a rubbery enlargement of the prostate, but the degree of enlargement does not consistently correlate with the degree of urinary obstruction. Some men have enlarged prostates that extend out into soft tissue without compressing the urethra. Determine the amount of pain and discomfort that is associated with the DRE.

• BOX 1 The International Prostate Symptom Score

1. Incomplete emptying: Over the past month, how often have you had the sensation of not emptying your bladder completely after you have finished urinating? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)

2. Frequency: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)

3. Intermittency: Over the past month, how often have you stopped and started again several times when urinating? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)

4. Urgency: Over the past month, how often have you found it difficult to postpone urination? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)

5. Weak stream: Over the past month, how often have you had a weak urinary stream? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)

6. Straining: Over the past month, how often have you had to push or strain to begin urination? (Never = 0, once = 1, twice = 2, thrice = 3, 4 times or more = 4, 5 times or more = 5)

7. Nocturia: Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)

8. How would you feel if you were to spend the rest of your life with your urinary condition just the way it is now? (Delighted = 0, pleased = 1, mostly satisfied = 2, mixed = 3, mostly dissatisfied = 4, unhappy = 5, terrible = 6)

Adapted from International Scientific Committee: The evaluation and treatment of lower urinary tract symptoms (LUTS) in older men. Proceedings of the 5th International Consultation on BPH; Paris, France, 2000; pp. 519-32.

124 Benign Prostatic Hyperplasia (Hypertrophy)

PSYCHOSOCIAL. The patient who is experiencing BPH may voice concerns related to sexual functioning after treatment. The patient's degree of anxiety, as well as his ability to cope with the potential alterations in sexual function (a possible cessation of intercourse for several weeks, possibility of sterility or retrograde ejaculation) should also be determined to provide appropriate follow-up care.

Diagnostic Highlights

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