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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
       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
         -   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
             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
       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
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