Managing the Multiple Symptoms of Benign Prostatic Hyperplasia
Introduction
BPH is commonly experienced in men as they age. Lower urinary tract symptoms (LUTS) associated with BPH often begin in the fourth decade of life and affect nearly 3 in 4 men by the seventh decade of life.1,2 Lower urinary tract symptoms that prompt men to seek medical care typically include nocturia, frequency, incomplete emptying, and urgency.3,4 Men typically wait almost 2 years before seeking medical care for their urinary symptoms. Among men who do not seek medical care for LUTS, the most common reason is the belief that urinary symptoms are an inevitable part of aging. Many men who do not seek treatment indicate that they would rather accept their urinary symptoms than discuss them with a physician.4
In addition to urinary symptoms, BPH has been associated with symptoms of sexual dysfunction independent of the effects of aging and other comorbidities (eg, diabetes) and lifestyle factors.5-8 Erectile dysfunction and ejaculatory dysfunction are the most common symptoms of sexual dysfunction in men with BPH.9-11 Symptoms of sexual dysfunction may also be caused by some pharmacologic agents used for the treatment of BPH.6,9,10
,Evaluation
Although BPH and the symptoms associated with it are not often life-threatening, ruling out other causes such as prostate cancer, diabetes mellitus, or Parkinson disease is an important diagnostic goal.
Screening
Because many men are slow to seek medical care and reluctant to speak with a physician about their symptoms, it is important that family physicians routinely inquire about urinary function in men over the age of 50 years. Beyond simply asking whether there have been changes in urinary function, posing the last question on the International Prostate Symptom Score (IPSS) questionnaire may be helpful: “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?”12 This question may be followed with, “Are you bothered enough by your symptoms that you would accept taking a medication?” Inquiries such as these, coupled with education to help the patient to understand that LUTS are not simply due to aging and that effective treatments are available, may motivate patients to share their concerns regarding urinary function. In addition, helping patients to understand that BPH is not a risk factor for prostate cancer, but that there are other causes of LUTS, which are best detected early, may be helpful.
Assessment
A history and focused urologic examination are crucial for the diagnosis of BPH. The medical history should identify a patient’s LUTS and their severity. To do this, a questionnaire such as the IPSS or the American Urological Association BPH Symptom Score Index Questionnaire can be administered [www.adultpediatricuro.com/apuauass.pdf]. As noted earlier, the eighth question on the IPSS questionnaire is useful for assessing the degree to which a patient is bothered by LUTS, with a higher score suggesting a greater willingness of the patient to be treated.13 Lower urinary tract symptoms are generally categorized into storage or bladder-emptying symptoms, with the latter subclassified as voiding or postmicturition symptoms.14 Storage problems are generally of greater concern to patients. Possible sexual dysfunction should also be assessed. A thorough medication history must be taken to identify AEs possibly related to the use of diuretics, anticholinergics, opioids, or decongestants.
The digital rectal examination (DRE) and prostate specific antigen (PSA) test are helpful to rule out a diagnosis of prostate cancer.15,16 The DRE is used for assessing the size, shape, symmetry, nodularity, and consistency of the prostate. The suprapubic area and genitals should be examined as well.17 The PSA test is also useful in the diagnosis and treatment of BPH because the PSA level rises as the prostate increases in size.13,14 A PSA level of 1.5 ng/mL roughly correlates with a prostate size of 30 mL.18 A urinalysis is needed to screen for urinary tract infections, bladder cancer, and kidney stones. Other laboratory analyses such as a fasting plasma glucose test may be needed based on the patient’s history and other findings.17
RI returns 3 weeks later for further evaluation. History confirms nocturia 3 or 4 times per night, as well as occasional erectile dysfunction and sometimes an inability to ejaculate. His IPSS questionnaire reveals a score of 9 (moderate symptoms), with occasional urinary frequency and straining. His LUTS are more bothersome than his occasional erectile dysfunction. It is decided that he will discontinue treatment with the thiazide diuretic because it may be contributing to his LUTS. An alternative antihypertensive agent will be initiated based on the results of the evaluation. The DRE reveals a boggy, slightly enlarged but normally shaped prostate with no nodules. The remainder of the urologic examination is normal. His PSA level is 0.8 ng/mL, and the urinalysis is normal. Further evaluation rules out prostate cancer and other causes of his symptoms.
A diagnosis of BPH is confirmed, with evidence of storage (ie, nocturia) and voiding (ie, urinary intermittency and straining) problems, as well as erectile dysfunction and occasional ejaculatory dysfunction.
