Initial Evaluation And Selection Of Therapy

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The Agency for Healthcare Policy and Research clinical guidelines for the diagnosis and treatment of BPH provide an approach to the evaluation and therapy for this disease (15). On initial evaluation, taking a medical history and performing a physical examination, including a digital rectal exam, are recommended. Laboratory evaluation includes a urinalysis, creatinine measurement, and optional prostate-specific antigen test.

Surgical intervention should be considered primary therapy for those patients with refractory retention, recurrent urinary tract infection, recurrent or persistent gross hematuria, bladder stones, or renal insufficiency secondary to bladder outlet obstruction. For the remaining patients, quantitative symptom assessment with instruments such as the International Prostate Symptom Score (I-PSS) provide a standardized measurement of symptoms (16). The I-PSS includes a quality of life scale to determine the degree of bother experienced by the patient. The symptom score may be used to monitor response to therapy as well.

Patients with mild symptoms may be offered watchful waiting, medical management, or more invasive therapy. Those with moderate-to-severe symptoms should be considered for more thorough evaluation, including measurement of urinary flow rate and residual urine and pressure/flow studies. If those studies are consistent with bladder outlet obstruction, surgical and medical therapy may be offered along with watchful waiting. Patients with symptoms not caused by BPH should be treated according to the established diagnosis.

Cystoscopy and prostate ultrasonography are optional by the Agency for Healthcare Policy and Research BPH guidelines if they are impor tant in planning the operative approach. Certainly cystoscopy is useful in evaluating patients with hematuria and those with risk factors for transitional cell carcinoma.

Voiding diaries are invaluable in evaluating symptoms and correlate well with symptom scores and quality of life assessments (17). Measurement of volume and voiding frequency will determine bladder functional capacity and may elucidate urine volume abnormalities such as polyuria and nocturnal diuresis. Poorly controlled diabetes mellitus, diabetes insipidus, peripheral edema, or diuretic therapy may produce urine volume abnormalities with complaints similar to those caused by BPH. These symptoms will not likely respond to therapy directed at BPH and should be addressed by treatment of the underlying cause. Voiding diaries may identify problems that may be corrected with lifestyle changes, such as the reduction of caffeine, alcohol, and excess fluid consumption.

In summary, medical therapy of BPH-associated male LUTS is appropriate in patients with mild, moderate, and severe symptoms. Patients desiring medical management do not require invasive testing before initiating therapy. The a-antagonists are an appropriate choice for most patients who desire medical management of LUTS. Those patients with higher prostate-specific antigen levels and larger prostates are those most likely to respond favorably to 5 a-reductase inhibitors (18).

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