Benign Prostatic Hyperplasia: Symptoms, Symptom Scores, and Outcome Measures

The approach to a patient with benign prostatic hyperplasia and lower urinary tract symptoms (LUTS) begins with a detailed history. The goal is to clearly identify the patient’s urinary complaints, including frequency of micturition, urgency, urge incontinence, weak stream, the need to push or strain, hesitancy, intermittency, dysuria, and hematuria. Bladder diaries and symptom questionnaires are useful as adjuncts to information that is acquired in the history. The voiding diary is an essential part of the workup. The voiding diary differs from a simple frequency-volume chart in that it incorporates not only the frequency, voided volume, urge episodes, pad usage, and fluid intake but also the data related to patient activities. It allows patients to have a more thorough self-evaluation of their LUTS.

The approach to a patient with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) begins with a detailed history. The goal is to clearly identify the patient’s urinary complaints, including frequency of micturition, urgency, urge incontinence, weak stream, the need to push or strain, hesitancy, intermittency, dysuria, and hematuria. Causes of these symptoms gleaned from the history include urinary tract infection, prostatic obstruction, BPH, bladder cancer, prostate cancer, urolithiasis, urethral stricture disease, and neurologic causes (eg, Parkinson disease, cerebrovascular accident). In patients experiencing urinary frequency or polyuria, the symptoms may be caused by nonurologic conditions, such as polydipsia, diabetes mellitus, and diabetes insipidus. Similarly, nocturia may be associated with factors other than prostatic obstruction or BPH, including detrusor overactivity, sensory urgency, abnormal drinking patterns, congestive heart failure, venous insufficiency, or polydipsia. The use of prescription drugs and over-the-counter medications should be discussed because some medications affect detrusor contractility (eg, anticholinergics) or increase bladder outflow resistance (eg, alpha agonists). Bladder diaries and symptom questionnaires are useful as adjuncts to information acquired in the history.

Questionnaires are especially useful in evaluating patients in that they afford the patient and physician an opportunity to efficiently record the nature, frequency of occurrence, severity, and degree of bother of the patient’s LUTS. However, questionnaires are not an end unto themselves; rather, they serve as a useful adjunct to history taking. Merely reading the questionnaire makes the patients think more intently about their symptoms, but not all patients are compliant. Some do not answer the questions at all; others answer them without even thinking; and some do not understand the questions and answer them incorrectly. It is important, therefore, that the patients be specifically queried for the accuracy of their answers. The purpose, function, and characteristics of each of the more common LUTS questionnaires can be seen in Table 1 . The International Prostate Symptom Score (IPSS), also known as the American Urological Association Symptom Index, has been recommended for the assessment of severity of patients’ LUTS. However, the IPSS cannot differentiate between patients with BPH and those with other causes of voiding dysfunction; therefore, its utility is mostly as a general guide to symptom severity. The Overactive Bladder Symptom Score, the Urgency Perception Score, and the Urgency Perception Scale are the 3 questionnaires that focus on urgency-associated symptoms, and these are useful in determining patient response to treatment. In addition, the Patient Global Impression of Improvement questionnaire is a simplistic assessment of how the patient feels after treatment, and it does not evaluate LUTS specifically. The King’s Health Questionnaire, which is not a symptom score, focuses on the bother owing to LUTS and incontinence and on overall quality of life, including personal, social, and emotional perspectives. The Pittsburgh Sleep Quality Index is an instrument used to assess patient sleep patterns and interruptions that can be associated with LUTS, but it does not evaluate specific voiding symptoms in patients. Some questionnaires double as outcome instruments in assessing response to treatment. For example, the LUTS Outcome Score is used in patients receiving treatment for LUTS, and it combines subjective and objective parameters. This score may easily be ciphered with the data derived from the IPSS, uroflow, postvoid residual volume, voiding diary, and a single question regarding whether treatment administered resulted in cure, improvement, or same or worse status. Subanalysis of components of these questionnaires allows for the determination of what drives patients to seek treatment and what in fact gets better (or not) in response to such therapy. The International Consultation on Incontinence Modular Questionnaire contains several modules designed to evaluate LUTS (including subsets of incontinence, overactive bladder, nocturia, and neurogenic and pediatric conditions) and vaginal and bowel symptoms.

Table 1

Instruments used in the evaluation of men with BPH and LUTS

Instrument	Origination	Function	Number of Questions	Other Features or Disadvantages
International Prostate Symptom Score	1992	Primarily used in the clinical management of men with LUTS. Also used in research studies investigating the medical/surgical management of patients with voiding dysfunction in treatment response	7	Instrument is nonspecific in that it is not able to differentiate between patients with BPH and those with other forms of voiding dysfunction. It is weighted toward voiding as opposed to storage symptoms
Overactive Bladder Symptom Score	8/2007	Quantitates all aspects of overactive bladder symptoms (OAB) Total possible score is 28	7	Questions are in graded response format Contains urgency subscale Assigns severity score (28 being the worst) May be useful as an OAB outcome instrument
Urgency Perception Score	1/2007	Objectively quantifies severity/degree of OAB/urgency	1	When used as outcome instrument, improvement based on decrease in grade of usual reason for voiding or decrease in number of urgency voids. Sometimes used in combination with urgency severity score
Patient Global Impression of Improvement (PGII)		Used to evaluate patient condition pre- and postsurgery.	Single item-graded response	Treatment failure based on PGII ≥4
King’s Health Questionnaire Assessment		Quality of life assessment Used for evaluation of clinical response in BPH patients	7 domains	Most useful when used in patients with OAB Also used as an assessment tool for urinary incontinence
The Pittsburgh Sleep Quality Index	5/1998	Assesses sleep quality and disturbances over a 1-mo period Quantitates patient’s level of sleep disturbance associated with nocturia	19 items (7 component scores)	Standardized version of areas routinely assessed in patients with sleep disturbance Used in patients with sleep/wake complaints
LUTS Outcome Score	2004	Outcome instrument used in patients receiving treatment for LUTS	8 items (assigned score of 0–2)	Unlike the International Prostate Symptom Score, it combines subjective, semisubjective, and objective parameters
Urgency Perception Scale	2005	Used to assess perceived urinary urgency; specifically used to evaluate patient response to antimuscarinic treatment	1	Used as outcome instrument In comparison to Urgency Perception Score, similar function when evaluating patient response to treatment; however, fewer response options make it less specific