The presence of Lower Urinary Tract Symptoms (LUTS) although not specific or exclusive of BPH are characteristic of this disease. LUTS can be typically divided into those associated with obstruction (voiding symptoms) and those associated with bladder irritation (storage symptoms) (see table below).
Over time, the enlarging prostate can cause complications as a result of progressive bladder outlet obstruction (BOO). These complications include acute or chronic urinary retention, renal failure, recurrent or chronic urinary tract infection, recurrent or chronic haematuria, overflow incontinence, hydronephrosis, and bladder stone formation.
Lower urinary tract symptoms observed in men with BPH
| Symptom type | Symptom |
| Obstructive (voiding) | Weak urinary stream Prolonged voiding Abdominal straining Hesitancy Intermittency Incomplete bladder emptying Terminal and post-voiding dribbling |
| Irritative (storage) | Frequency Nocturia Urgency Incontinence |
| Associated symptoms | Dysuria Haematuria Haematospermia |
If BPH is a progressive disease, complications of BPH are the end points of that progression. The most common end point of BPH progression is symptom deterioration to the point that activities of daily living are markedly affected. The most dramatic and life altering complications are AUR and BPH bleeding. The problems of urinary infection and bladder stones lie between these extremes. While renal decompensation due to BPH was a common problem in an earlier era, it is now rare.1
AUR is the complication of BPH disease progression that impacts men most severely and dramatically. It always requires emergency medical attention, often with hospitalization and eventual operation. AUR may be precipitated by some event, such as an unrelated surgical procedure or medication, or it may be spontaneous. Many cases of precipitated AUR resolve when the precipitating factor is removed, while most cases of spontaneous AUR due to BPH require invasive treatment. Most men with AUR ultimately require invasive therapy because the risk of recurrent AUR is high. Definitive treatment for AUR generally involves major anesthesia, prostatectomy, a hospital stay of at least several days and a time to full recovery of weeks or months.1
The progressive appearance of complications of BPH disease, eg bleeding, infection, stones and AUR, is more important than symptoms and flow from a medical standpoint. As a discrete event that is uniformly recorded and coded, AUR serves as an index of BPH disease severity and numerous studies have focused on this serious event in regard to the progression issue. Barry et al found that the incidence of AUR was 2.5% yearly in symptomatic men undergoing watchful waiting in urology practices in the United States. In the Health Professionals Follow-Up Study the annual incidence of AUR was 0.5%, which increased sharply when patient age and BPH diagnosis were added factors.1
In community based studies of randomly selected older men Jacobsen et al found that the incidence of AUR was 13.7% in the average 60-year-old man in the next 10 years of life.10 The incidence of AUR in this population exceeded that of stroke, heart attack and hip fracture in similar men (fig. 2). Men in the Olmsted County Study were not patients. Rather, they were randomly sampled men living in the community of Olmsted County, Minnesota. Thus, AUR is not purely a symptom driven event because these men were not included based on symptoms. Although age and advanced symptoms are important risk factors, even men with few antecedent symptoms have AUR. This fact has important implications for prophylactic treatment for BPH in men with few symptoms but a large prostat.1
AUR is one of the most common complications, and is experienced as a sudden, painful inability to urinate. Catheterisation is required to relieve AUR, and this may involve a hospital stay. An average 60-year-old man has a 23% risk of developing AUR if he lives to 80 years.6 Once AUR occurs, the risk of a subsequent episode increases significantly. Furthermore, AUR results in prostatectomy in 24-42% of men7 and observational studies have shown that this is associated with increased morbidity and an increased risk of death - both during and after surgery - compared with elective prostatectomy for symptoms alone.8
Many patients admitted to the hospital for AUR require surgery. In a UK audit of AUR, 52.3% of the men admitted to hospital for AUR underwent prostatectomy during their initial stay (1). Forty five percent of the remaining patients were sent home with a catheter before a planned prostatectomy. In a four-year study of finasteride (PLESS) in the US, about 75% of placebo-treated BPH patients with AUR required surgery (2).
Medical history, physical examination - including digital rectal examination(DRE) - evaluation of LUTS severity, and the measurement of serum PSA levels provide the basis for BPH diagnosis.9 In patients with prostate cancer or BPH, PSA 'leaks' into the bloodstream and serum levels rise dramatically. This is also discussed in Predictors of Progression. The severity of LUTS associated with BPH is most commonly evaluated with a questionnaire, such as the International Prostate Symptom Score (IPSS) - a self-administered questionnaire that is probably the most widely used (see table below).10,11
The International Prostate Symptom Score (IPSS) questionnaire (the American Urological Association Symptom Index Score(AUA-SI) is equivalent to IPSS questions 1-7)
| Urinary symptoms |
Not at
all |
Less than
one time in five |
Less than
half the time |
About
half the time |
More than
half the time |
Almost
always |
|
| 1. | Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? |
0
|
1
|
2
|
3
|
4
|
5
|
| 2. | Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? |
0
|
1
|
2
|
3
|
4
|
5
|
| 3. | Over the past month, how often have you found you stopped and started again several times while urinating? |
0
|
1
|
2
|
3
|
4
|
5
|
| 4. | Over the past month, how often have you found it difficult to postpone urination? |
0
|
1
|
2
|
3
|
4
|
5
|
| 5. | Over the past month, how often have you had a weak urinary stream? |
0
|
1
|
2
|
3
|
4
|
5
|
| 6. | Over the past month, how often have you had to push or strain to begin urination? |
0
|
1
|
2
|
3
|
4
|
5
|
| 7. | Over the past month, how many times did you typically get up to urinate from time you went to bed until the time you got up in the morning? |
0
|
1
|
2
|
3
|
4
|
5
|
|
Total for urinary symptoms:
|
|||||||
| Quality of life owing to urinary symptoms |
Delighted
|
Pleased
|
Mostly
satisfied |
Mixed
|
Mostly
dissatisfied |
Unhappy
|
Terrible
|
|
| 8. | 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? |
0
|
1
|
2
|
3
|
4
|
5
|
6
|
| Total for quality of life: | ||||||||
| TOTAL: | ||||||||
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The questionnaire was initially developed as the American Urological Association Symptom Index (AUA-SI); however, following the addition of a general quality of life question, it was adopted at two international consultations sponsored by the World Health Organization (WHO), and was renamed the IPSS. The total IPSS score indicates urinary symptom severity and provides a useful guide to disease management (see tables above and below).9
Degree of LUTS
| IPSS score |
Symptom severity
|
Symptom description |
| 0-7 |
Mild
|
Little bother, reasonable urine flow and low residual volume |
| 8-19 |
Moderate
|
Bothersome, reduced urine flow and higher residual volume but no evidence of complications |
| 20 |
Severe
|
Complications of obstruction |
The impact of BPH on a patient's quality of life can be evaluated using the BPH Impact Index (BII) questionnaire12. This brief four-element questionnaire assesses the degree of bother caused by symptomatic BPH in terms of physical discomfort, urinary symptoms, worry and lifestyle changes to accommodate urinary difficulties (see table below).
The BPH Impact Index (BII) questionnaire. The minimum BII score is 0, and the maximum 13. A high score indicates a great impact
| BPH impact |
Response
|
Points
|
|
| 1 | Over the past month, how much physical discomfort did any urinary problems cause you? |
None
Only a little Some A lot |
0
1 2 3 |
| 2 | Over the past month, how much None did you worry about your health because of any urinary problems? |
None
Only a little Some A lot |
0
1 2 3 |
| 3 | Overall, how bothersome has any trouble with urination been during the past month? |
Not at all bothersome
Bothers me a little Bothers me some Bothers me a lot |
0
1 2 3 |
| 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? |
None of the time
A little of the time Some of the time Most of the time All of the time |
0
1 2 3 4 |
| TOTAL: | |||
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Additional Reference:
1. Marks et al Journal of Urology Vol. 176, 1299-1306, October 2006