• Symptom scores such as American Urological Association (AUA). It consists of 7 questions, each of which is scored on a scale of 0 (not present) to 5 (almost always present). Symptoms are classified as mild (total score 0–7), moderate (total score 8–19), and severe (total score 20–35):
  • Frequency
  • Nocturia
  • Weak urinary stream
  • Hesitancy
  • Intermittence
  • Incomplete emptying
  • Urgency
• Gross hematuria
• History of type 2 diabetes, which can cause nocturia and is a risk factor for BPH
• Symptoms of neurologic disease that would suggest a neurogenic bladder
• Sexual dysfunction, which is correlated with LUTS
• History of urethral trauma, urethritis, or urethral instrumentation that could lead to urethral stricture
• Family history of BPH and prostate cancer
• Treatment with drugs that can impair bladder function (anticholinergic drugs) or increase outflow resistance (sympathomimetic drugs)

• Digital rectal exam finding of enlarged prostate, but size does not always correlate with symptoms
• Percussion to detect distended bladder, particularly if post-void
• Signs of renal failure due to obstructive uropathy (edema, pallor, pruritus, ecchymoses, nutritional deficiencies)

LabInitial Labs

• PSA may be elevated, but usually <10 ng/mL (10 μg/L). Acute urinary retention, prostatitis, urinary tract instrumentation, or prostatic infarction may elevate PSA.
• Urinalysis: Pyuria if stones or infection present, pH changes due to chronic residual urine
• Urine culture positive (sometimes due to chronic residual urine)
• BUN and creatinine (if concerns for uremia)

Follow-Up and Special Considerations

• Uroflow: Volume voided per unit time (peak flow <10 mL/sec is abnormal)
• Post-void residual: Either with catheterization or bladder ultrasound (>100 mL demonstrates incomplete emptying)

ImagingInitial Imaging Approach Postvoid residual in order to detect obstruction/distended bladder

Follow-Up and Special Considerations

• Transrectal ultrasound: Assessment of gland size; not necessary in the routine evaluation
• Abdominal ultrasound: Can demonstrate increased postvoid residual or hydronephrosis; not necessary in the routine evaluation

ALERT
Geriatric Considerations
Drugs to be avoided include anticholinergics, antihistamines, sympathomimetics, tricyclic antidepressants, narcotics, and skeletal muscle relaxants when possible.

Diagnostic Procedures/Other

• Pressure-flow studies (urine flow vs. voiding pressures):
  • Best test to determine etiology of voiding symptoms
  • Obstructive pattern shows high voiding pressures with low flow rate
• Cystoscopy:
  • Demonstrates presence, configuration, cause (stricture, stone), and site of obstructive tissue
  • May help determine best minimally invasive therapeutic option
  • Not recommended in initial evaluation unless other factors such as hematuria are present

Pathological Findings Confirmation obtained by biopsy, resection, or surgical removal

• Obstructive:
  • Prostate cancer
  • Urethral stricture or valves
  • Bladder neck contracture (usually secondary to prostate surgery)
  • Prostatitis
  • Inability of bladder neck or external sphincter to relax appropriately during voiding
• Neurologic:
  • Spinal cord injury
  • Stroke
  • Parkinsonism
  • Multiple sclerosis
• Medical:
  • Poorly controlled diabetes mellitus
  • Congestive heart failure (CHF)
• Pharmacologic:
  • Diuretics
  • Sympathomimetics (e.g., cold medications)
  • Anticholinergics
• Other:
  • Bladder carcinoma
  • Overactive bladder
  • Bladder calculi
  • UTI