© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
16
Rosenberg ET AL.
Basic work up: evaluating LUTS
The evaluation starts with the identification of
symptoms. Although screening tools exist, they may
not always be practical in the office of the busy PCP.
Regardless of whether one is used by the physician,
being familiar with the questions is helpful. The
International Prostate SymptomScore (IPSS) is themost
universal option. It has been validated, and includes
an additional impact question concerning ‘quality-of-
life’,
9
Table 1. Although helpful in obtaining a thorough
history, it is not specific to BPH, as other conditions
can produce similar symptoms.
10
By whatever means
the PCP queries about the symptoms it is essential
to differentiate between obstructive (prostate) and
irritative (bladder), as well as to assess bother,
11
Table 2.
Given that patients may suffer both obstructive and
irritative symptoms, the provider should evaluate
which, if either, cause the predominant issue.
Basic work up: history, physical, labs and
role of other tests
Once BPH-LUTS is identified, whatever the cause,
the next step is to proceed with a focused history
and physical, as well as a few laboratory tests. The
process is to screen for other factors that may cause
or contribute to BPH-LUTS symptoms, including
reversible issues or comorbidities that may complicate
treatment or represent significant underlying disease.
Table 3 lists the possible causes of LUTS.
11
The PCP
should also be mindful of the “red flags” or reasons for
referral.
12-14
Table 4 lists common reasons for referral.
11
A distinct advantage for the PCP is having a prior
medical knowledge of the patient, therebymaking some
of the needed information more readily available. The
PCP should be mindful of the temporal relationship
of the symptoms that the patient is describing to any
change in their life or daily habits. Certain behaviors
can be a major cause of the bothersome symptoms of
BPH. “Urinary hygiene” is a term that has been used to
describe voiding habits.
15
Good habits include relaxing
the pelvic musculature and taking the time to void to
TABLE 2.
Male lower urinary tract symptoms
BPH (obstructive)
OAB (irritative)
Hesitancy
Urgency
Poor flow/weak stream Frequency
Intermittency
Nocturia
Straining to void
Urge incontinence
Terminal dribble
Stress incontinence
Prolonged urination
Mixed incontinence
Urinary retention
Overflow incontinence
BPH=benignprostatic hyperplasia; OAB=overactive bladder
TABLE 3.
Lower urinary tract symptoms: differential diagnosis and other causes
Differential diagnosis
Medications
Other risk factors
Consider:
May cause or
Consider:
exacerbate LUTS:
Prostate cancer
Trycyclic antidepressants
Obesity
Prostatitis
Anticholinergic agents
Cigarette smoking
Bladder stones
Diuretics
Regular alcohol consumption
Interstitial cystitis
Narcotics
Elevated blood pressure
Radiation cystitis
1
st
generation antihistamines
Urinary tract infection
Decongestants
Diabetes mellitus
Parkinson’s disease
Primary bladder neck hypertrophy
Congestive heart failure
Lumbosacral disc disease
Multiple sclerosis
LUTS = lower urinary tract symptoms
