Benign Prostate Hyperplasia – diagnosis
Particular attention should be given to start in time but also in the potential deterioration of LUTS; the presence or absence of hematuria or dysuria; any potential acute or chronic urinary tract infection; the presence of concomitant disease [eg, diabetes, heart failure , nervous system diseases (stroke, Alzheimer Parkinson)]; previous surgeries in the urinary tract or in the pelvis generally in sexually transmitted diseases during puberty (cause urethral stricture) as well as the use of drugs which can affect the lower genitourinary (diuretics, anticholinergics, sympathomimetics, antidepressants).
The digital rectal examination of the prostate (DEP) must be done to every man with LUTS because it gives us useful information about the size of the gland, which is absolutely essential for making treatment decisions, but they may in some cases be likely discovered prostate cancer.
It is now accepted that the symptoms of lower urinary tract (LUTS) not only leads the patient to the physician but also represents the cornerstone for the diagnosis of cystical impediment. In recent years there was an attempt by the urological community “clustering” and “classification” of LUTS using questionnaires. The latter are used for, not only as far as possible accurate diagnosis of BPH, but as valuable tools for the monitoring of disease progression and the effectiveness of the applied treatment. Against this background, the American Urological Association (AUA) published in 1992 a questionnaire, the International Grading of Prostatic Symptoms (IPSS), which constitutes today «international standard».
Measurement of prostate antigen (PSA)
PSA is a glycoprotein with a molecular weight (M.W.) 34.000 Daltons, which is produced by the tubular epithelial cells of prostate cells and resources. An integral part in the diagnosis of BPH after the price leads us to a large extent, exclusion or other non-prostate disease. Two additional factors must be taken into account in the assessment of prostatic antigen: the age and the race of the patient.
The test of choice is ultrasound kidney-bladder-prostate before and after urination, which is painless, cheap and provides adequate information during examination, which especially before surgery gives us useful information on the type of surgery you choose, regarding: the size of the prostate; the presence or non intravesical; the thickness of the bladder wall; the presence or non trabeculation bladder as stones or diverticula thereof.
Computed (CT) and magnetic resonance imaging (MRI) have no place in LUTS patients’ control patients.
The diary is a simple and objective way of recording and urinate can give us useful information when used to diagnose patients with voiding disorders and to monitor them after treatment. The remaining question is what is the ideal time recording urination: it has shown that the 24-hour recording is enough and gives us the necessary information. According to the above, the voiding diary is a valuable tool for the assessment and for monitoring patients with symptoms of lower urinary tract.
Urine residue is the amount of urine remaining in the bladder immediately after urination. If found significant void residual urine (> 300 ml), we must consider that may exist some degree of dysfunction of the bladder muscle, which can be responsible and non-response to therapy.
Uroflowmetry is the method by which the relationship between the pressure within the bladder and urinary flow rate is measured, expressed in cubic millimeters per second (ml / sec). Uroflowmetry is a basic non-invasive urodynamic examination in the investigation of patients with symptoms of lower urinary tract, which is considered mandatory before performing surgery for BPH. This test basically reflects the interaction between extruding capacity of the bladder muscle (for urine) and resistance projected from the urethra. This results in recording the whole process of the disorder without voiding can clarify whether a fault or detrusor impediment.
Urodynamic examination, in accordance with the guidelines of the American Urological Association (AUA) and based on the conclusions reached by the 5th international conference on prostatic hyperplasia, is an optional test to diagnose patients with BPH. Via urodynamic exam, we receive reports of intravesical and intra-abdominal pressure, pressure of the bladder muscle, capacity and bladder sensation, appearance of potential involuntary detrusor contractions and the detrusor pressure during the phase of maximum flow rate.
Cystoscopy is the endoscopic method of choice for the investigation of the lower urinary tract.
For several years, it is known that the degree of obstruction is not always proportional to the size of the prostate gland. The smaller the size of the gland is, the more intense the symptoms are. At the same time, larger glands do not cause any disturbance.
During cystoscopy, there are several points which may indicate obstruction such as prostate hyperplasia (lateral and / or middle lobe), bladder trabeculation, stones therein presence and urinary retention. Bladder trabeculation is a phenomenon observed in older men and is associated with the presence of symptoms from the lower urinary tract. Cystoscopy should be done selectively in patients with possible accompanying diseases of the lower urinary or as an integral part of the transurethral surgical technique.
In conclusion, according to the guidelines of the European Association of Urology (EAU), the diagnostic investigation in patients with BPH should include:
1. Using IPSS
2. Serum creatinine and urinalysis.
3. Digital rectal examination of the prostate.
4. Imaging of the upper urinary tract in the following cases:
– History or current urinary tract infection
– History calculi
– Surgery history
– History of transitional cell cancer
– Urinary retention
5. Bladder ultrasound, though not recommended, it may help the diagnosis of diverticulum and bladder stones.
6. Measurement of prostate before surgery and before treatment
7. Endoscopy only during surgery.
8. Urodynamic testing in the following cases:
– in young men (eg <50 years)
– in the elderly (> 80 years)
– in urine residue> 300 ml
– in Qmax> 15ml/sec
– when there is a suspected neurological bladder disorder
– after pelvic surgery and
– when prior surgical method has failed.