Diagnosis

Benign Prostate Hyperplasia

Diagnosis of benign prostatic hyperplasia

The diagnosis of benign prostatic hyperplasia is complex because of the interrelationship of the prostate with adjacent organs and the unspecificity of the symptoms. It is essential to ascertain the origin of the problems and to rule out, above all, bladder tumor. Secondly, it will be necessary to understand the extent of prostate problems, their severity and possible complications in order to establish the best possible diagnosis and attack it with the most appropriate treatment.

Generally, we establish three levels of diagnosis:

• Initial diagnosis, which we perform in all men with symptoms suggestive of prostate problems. It is usually done with a renovesicoprostatic ultrasound and a PSA blood test.
• Diagnosis in case we want to rule out other causes of prostate symptoms that have not been made clear by the above tests. We can perform a urinary cytology or cystoscopy to rule out bladder tumor. For urethral stricture, urethroscopy or voiding and retrograde cysturethrography is very useful. If the ultrasound suggests the existence of bladder lithiasis, we can perform a CT scan and cystoscopy.
• Some patients with urinary symptoms due to prostate hyperplasia need to undergo complementary tests. These can be: prostate biopsy in case we need to rule out prostate cancer; cystoscopy if we want to appreciate the anatomy of the prostate internally; transrectal prostate ultrasound to determine more precisely the size of the prostate, usually in view of an operation; and, in selected cases, urodynamics to learn more about prostate obstruction and its impact on voiding dynamics.

Thus, the diagnosis begins with an assessment of your medical history and the performance of a series of questions and tests:

• Measurement of symptoms through a questionnaire. The most commonly used is the IPSS (Prostate Symptom Scale).
• Physical examination by rectal examination to assess the size, shape and consistency of the prostate.
• Urinalysis to rule out infection or other conditions that may cause similar symptoms.
• Blood tests to rule out kidney problems and measure levels of a substance produced in the prostate called prostate-specific antigen (PSA). Levels of this substance increase in cases of prostate enlargement, although elevated levels may be due to recent procedures, infection, surgery or prostate cancer.
• Urine flow test (urine flowmetry) -- urinating into a container connected to a machine that measures the force and amount of urine flow. The results help to see how the condition is progressing and determine whether it is getting better or worse over time.
• Ultrasound of the bladder to determine if urine remains after emptying the bladder.

To rule out the presence of a bladder tumor, urethral stricture, urinary tract infection, bladder lithiasis or overactive bladder, tests such as renovesicoprostatic ultrasound and urinary cytology will be performed. In this sense, urethrocystoscopy can be useful if there is suspicion of urethral stricture or the presence of a bladder tumor -by ultrasound or after an abnormal cytology-.

Once the above is ruled out, it will be determined whether benign prostatic hyperplasia may be producing complications secondary to obstruction, such as bladder lithiasis, repeated urinary tract infections, chronic urinary retention, hydronephrosis or the presence of chronic renal insufficiency. For this purpose, we rely on ultrasound and the performance of a blood test in which we determine renal function.

In addition, the risk of prostate disease progression will be calculated using PSA and prostate volume (by ultrasound). Men with a prostate larger than 40cc and PSA >1.5 have a higher risk of symptom progression at five years and will require more intensive treatment. In those with smaller prostates or lower PSA, especially if they have fewer symptoms, we can be more conservative with treatment.

Finally, tests are performed to help detect bladder obstruction. The simplest of these is urinary flowmetry, which allows the volume of urine per unit of time to be measured.

In cases where more diagnostic power is needed, urodynamics can be performed. This is a more invasive test performed by inserting a small bladder and rectal catheter to measure bladder and abdominal pressures.