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Elterman et al

therapeutic agents, must be reviewed. A focused physical – Urodynamics
examination, including a digital rectal exam (DRE), is also – Radiological evaluation of upper urinary tract
mandatory. Urinalysis is required to rule out diagnoses – Prostate ultrasound
other than BPH that may cause LUTS and may require – Prostate biopsy
additional diagnostic tests. 1-3,5-7 An algorithm summarizing the appropriate diagnostic
steps in the workup of a typical patient with MLUTS/BPH
1.2. Recommended is summarized in Figure 1.

Symptom inventory (should include bother assessment) 1.5. Further diagnostic considerations for surgery
A formal symptom inventory (e.g., International Prostate
Symptom Score [IPSS] or AUA Symptom Index [AUA-SI]) is Indications for surgery
1-3
recommended for an objective assessment of symptoms at Indications for MLUTS/BPH surgery include 1) recurrent or
initial consultation, for followup of symptom evolution for refractory urinary retention; 2) recurrent urinary tract infec-
those on watchful waiting, and for evaluation of response tions (UTIs); 3) bladder stones; 4) recurrent hematuria; 5)
to treatment. 8-11 renal dysfunction secondary to BPH; 6) symptom deteri-
oration despite medical therapy; and 7) patient preference.
Prostate-specific antigen The presence of a bladder diverticulum is not an absolute
Testing of prostate-specific antigen (PSA) should be offered to indication for surgery unless associated with recurrent UTI
patients who have at least a 10-year life expectancy and for or progressive bladder dysfunction.
whom knowledge of the presence of prostate cancer would
change management, as well as those for whom PSA measure- Preoperative testing
ment may change the management of their voiding symptoms Determination of prostate size and extent of median lobe
(i.e., estimate for prostate volume that may lead to more pre- are related to procedure-specific indications (see section on
cise measurements). Among patients without prostate cancer, Surgical Treatment). For patients in whom surgery is being
serum PSA may also be a useful surrogate marker of prostate considered, cystoscopy should be performed to evaluate
size and may also predict risk of BPH progression. 12,13 prostate size, as well as presence or absence of significant
middle/median lobe and/or bladder calculi. Ultrasound (US)
1.3. Optional (either by transrectal ultrasound [TRUS] or transabdominal
US) is recommended to determine the volume of the prostate
In cases where the physician feels diagnostic uncertainty and the extent of median lobe presence in order to select
exists, it is reasonable to proceed with one or more of the appropriate modality of surgical therapy. This information
following:
- Serum creatinine
- Urine cytology Typical man presenting with LUTS
- Uroflowmetry Mandatory assessment
- Postvoid residual (PVR) History
- Voiding diary (recommend frequency volume chart Focused PE
for men with suspected nocturnal polyuria) UA
- Obstructive sleep apnea (OSA) screening for men
Recommended
with nocturia over the age of 50 (STOP BANG ques- Symptom inventory
tionnaire) PSA (selected) Indications for surgery
- Sexual function questionnaire
Mild symptoms Moderate/severe Other diagnostic tests
1.4. Not recommended No bother symptoms as necessary
(cystoscopy, urodynamics,
possible volume)
The following diagnostic modalities are not recommended in Optional
Creatinine
the routine initial evaluation of a typical patient with BPH- Urine cytology
associated LUTS. These investigations may be required in Urolflow
patients with another indication, such as hematuria, diagnos- PVR
tic uncertainty, DRE abnormalities, poor response to medical Sexual function questionnaire
therapy, or for surgical planning: Figure 1. Algorithm of appropriate diagnostic steps in the workup of a typical
– Cytology patient with male lower urinary tract symptoms/benign prostatic hyperplasia
– Cystoscopy (LUTS/BPH). PE: physical exam; PSA: prostate-specific antigen; PVR: postvoid
residual; U/A: urinalysis.

246 CUAJ • August 2022 • Volume 16, Issue 8