Simple Tests for Diagnosis of Benign Prostatic Hyperplasia
Effective treatment of benign prostatic hyperplasia (BPH) improves lower urinary tract symptoms (LUTS) and patient quality of life, and reduces the risk of complications arising from disease progression. However, treatment can only be initiated when men with BPH are identified by accurate diagnostic tests. Current evidence suggests that diagnostic procedures employed by primary care physicians vary widely across Europe. The expected increases in BPH prevalence accompanying the gradual aging of the population, coupled with greater use of medical therapy, mean that general practitioners (GPs) are likely to have an increasingly important role in managing the condition. The GP/primary care clinic is therefore an attractive target location for strategies designed to improve the accuracy of BPH diagnosis. The Diagnosis Improvement in Primary Care Trial (D-IMPACT) is a prospective, multicentre, epidemiological study that aims to identify the optimal subset of simple tests applied by GPs in the primary care setting to diagnose BPH in men who spontaneously report obstructive (voiding) and/or irritative (storage) LUTS. These tests comprise medical history, symptom assessment with the International Prostate Symptom Score questionnaire, urinalysis, measurement of serum levels of prostate-specific antigen and subjective GP diagnosis after completing all tests including digital rectal examination. GP diagnoses and all other tests will be compared with gold-standard diagnoses provided by specialist urologists following completion of additional diagnostic tests. D-IMPACT will establish the diagnostic performance using a non-subjective and reproducible algorithm. An adjusted and multivariate analysis of the results of D-IMPACT will allow identification of the most efficient combination of tests that facilitate accurate BPH diagnosis in the primary care setting. In addition, D-IMPACT will estimate the prevalence of BPH in patients who present spontaneously to GPs with LUTS.
The quality of life of many older men is considerably impaired by the presence of benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS). According to strict histopathological definitions, BPH is a condition characterised by hyperplastic changes in prostatic tissue and benign enlargement of the prostate gland. However, clinicians have generally adopted BPH to describe a clinical syndrome comprising three components: LUTS, benign prostatic enlargement (BPE) and bladder outlet obstruction (BOO). A fourth term, benign prostatic obstruction (BPO), describes the concurrent occurrence of BOO and BPH.
BPH is common in older men and the prevalence of this condition has been shown to increase with age. For example, the proportion of men aged 31-40 years with histological evidence of BPH is approximately 8%; this increases sharply to 50% in men aged 51-60 years, 70% in men aged 61-70 years and 90% in men aged 81-90 years. In the Baltimore Longitudinal Study of Aging, clinical BPH was reported in 60% of men by the age of 60 years, while one retrospective review calculated that a symptom-free man aged 46 years has a 45% risk of developing BPH and/or LUTS within the next 30 years of life. In Europe, the percentage of the total population who are aged over 65 years is expected to increase from 15% in 2000 to more than 25% by 2050. Therefore, the overall prevalence of BPH is also expected to increase. The negative impact of LUTS on the quality of life of patients with BPH is well established, and recent evidence shows that BPH also represents a significant economic burden across Europe.
Longitudinal population-based studies and long-term randomised clinical trials have shown that BPH is a progressive disease. Progression of BPH is characterised by worsening LUTS and, in some patients, by serious complications including acute urinary retention (AUR), prostate surgery, haematuria and recurrent urinary tract infections. Patients at increased risk of progression can be identified by analysis of risk factors including age, serum levels of prostate-specific antigen (PSA) and prostate volume.
Men with LUTS may be reluctant to discuss these symptoms with their physician, perhaps because of embarrassment, a belief that such symptoms are a normal part of aging, or even a fear of the possible treatments such as surgery. For example, a study of 448 men presenting to their primary care physician for a routine visit identified 129 men with moderate-to-severe LUTS and an enlarged prostate or a PSA ≥ 1.5 ng/ml; among these 129 men, only 33% (n = 42) intended to discuss their symptoms with their physician. This reluctance suggests that physicians need to take a more proactive approach to identifying men with LUTS. This is reflected in some local guidelines for the management of LUTS related to BPH; for example, Italian recommendations advocate that all men aged ≥ 50 years should be asked about LUTS and informed about their meaning and available therapeutic options.
Men who do present with LUTS should be assessed to rule out causes other than BPH. The European Association of Urology (EAU) recommends the following investigations for initial evaluation of men with LUTS: complete medical history; physical examination including digital rectal examination (DRE); symptom assessment with the International Prostate Symptom Score (IPSS) questionnaire; PSA measurement; creatinine measurement; urinalysis; uroflowmetry; and measurement of postvoid residual volume via transabdominal ultrasonography. However, it is worth noting that local guidelines for evaluating LUTS are not fully aligned with the EAU recommendations. For example, the strength of recommendation for some of these assessments may be different in guidelines such as those from Italy, France and the UK, compared with the EAU guidelines. In addition, local guidelines regard some of these tests as optional or only recommended in a restricted subset of patients. These differences reflect, in part, the fact that some of the EAU-recommended assessments may not be available or practical in the primary care setting. Once a diagnosis of BPH is confirmed, the aims of therapy are to improve LUTS and quality of life, and to reduce the risk of complications arising from disease progression.
Abstract and Introduction
Abstract
Effective treatment of benign prostatic hyperplasia (BPH) improves lower urinary tract symptoms (LUTS) and patient quality of life, and reduces the risk of complications arising from disease progression. However, treatment can only be initiated when men with BPH are identified by accurate diagnostic tests. Current evidence suggests that diagnostic procedures employed by primary care physicians vary widely across Europe. The expected increases in BPH prevalence accompanying the gradual aging of the population, coupled with greater use of medical therapy, mean that general practitioners (GPs) are likely to have an increasingly important role in managing the condition. The GP/primary care clinic is therefore an attractive target location for strategies designed to improve the accuracy of BPH diagnosis. The Diagnosis Improvement in Primary Care Trial (D-IMPACT) is a prospective, multicentre, epidemiological study that aims to identify the optimal subset of simple tests applied by GPs in the primary care setting to diagnose BPH in men who spontaneously report obstructive (voiding) and/or irritative (storage) LUTS. These tests comprise medical history, symptom assessment with the International Prostate Symptom Score questionnaire, urinalysis, measurement of serum levels of prostate-specific antigen and subjective GP diagnosis after completing all tests including digital rectal examination. GP diagnoses and all other tests will be compared with gold-standard diagnoses provided by specialist urologists following completion of additional diagnostic tests. D-IMPACT will establish the diagnostic performance using a non-subjective and reproducible algorithm. An adjusted and multivariate analysis of the results of D-IMPACT will allow identification of the most efficient combination of tests that facilitate accurate BPH diagnosis in the primary care setting. In addition, D-IMPACT will estimate the prevalence of BPH in patients who present spontaneously to GPs with LUTS.
Introduction
The quality of life of many older men is considerably impaired by the presence of benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS). According to strict histopathological definitions, BPH is a condition characterised by hyperplastic changes in prostatic tissue and benign enlargement of the prostate gland. However, clinicians have generally adopted BPH to describe a clinical syndrome comprising three components: LUTS, benign prostatic enlargement (BPE) and bladder outlet obstruction (BOO). A fourth term, benign prostatic obstruction (BPO), describes the concurrent occurrence of BOO and BPH.
BPH is common in older men and the prevalence of this condition has been shown to increase with age. For example, the proportion of men aged 31-40 years with histological evidence of BPH is approximately 8%; this increases sharply to 50% in men aged 51-60 years, 70% in men aged 61-70 years and 90% in men aged 81-90 years. In the Baltimore Longitudinal Study of Aging, clinical BPH was reported in 60% of men by the age of 60 years, while one retrospective review calculated that a symptom-free man aged 46 years has a 45% risk of developing BPH and/or LUTS within the next 30 years of life. In Europe, the percentage of the total population who are aged over 65 years is expected to increase from 15% in 2000 to more than 25% by 2050. Therefore, the overall prevalence of BPH is also expected to increase. The negative impact of LUTS on the quality of life of patients with BPH is well established, and recent evidence shows that BPH also represents a significant economic burden across Europe.
Longitudinal population-based studies and long-term randomised clinical trials have shown that BPH is a progressive disease. Progression of BPH is characterised by worsening LUTS and, in some patients, by serious complications including acute urinary retention (AUR), prostate surgery, haematuria and recurrent urinary tract infections. Patients at increased risk of progression can be identified by analysis of risk factors including age, serum levels of prostate-specific antigen (PSA) and prostate volume.
Men with LUTS may be reluctant to discuss these symptoms with their physician, perhaps because of embarrassment, a belief that such symptoms are a normal part of aging, or even a fear of the possible treatments such as surgery. For example, a study of 448 men presenting to their primary care physician for a routine visit identified 129 men with moderate-to-severe LUTS and an enlarged prostate or a PSA ≥ 1.5 ng/ml; among these 129 men, only 33% (n = 42) intended to discuss their symptoms with their physician. This reluctance suggests that physicians need to take a more proactive approach to identifying men with LUTS. This is reflected in some local guidelines for the management of LUTS related to BPH; for example, Italian recommendations advocate that all men aged ≥ 50 years should be asked about LUTS and informed about their meaning and available therapeutic options.
Men who do present with LUTS should be assessed to rule out causes other than BPH. The European Association of Urology (EAU) recommends the following investigations for initial evaluation of men with LUTS: complete medical history; physical examination including digital rectal examination (DRE); symptom assessment with the International Prostate Symptom Score (IPSS) questionnaire; PSA measurement; creatinine measurement; urinalysis; uroflowmetry; and measurement of postvoid residual volume via transabdominal ultrasonography. However, it is worth noting that local guidelines for evaluating LUTS are not fully aligned with the EAU recommendations. For example, the strength of recommendation for some of these assessments may be different in guidelines such as those from Italy, France and the UK, compared with the EAU guidelines. In addition, local guidelines regard some of these tests as optional or only recommended in a restricted subset of patients. These differences reflect, in part, the fact that some of the EAU-recommended assessments may not be available or practical in the primary care setting. Once a diagnosis of BPH is confirmed, the aims of therapy are to improve LUTS and quality of life, and to reduce the risk of complications arising from disease progression.
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