Tradition has divided symptoms of “prostatism” into those of obstruction (hesitancy, poor flow, intermittency, abdominal straining, feeling of not fully emptying bladder, dribbling, and double voiding) and those of irritation (dysuria, nocturia, urgency or urge incontinence, and frequency). A seven-question symptom index was developed by the American Urological Association (AUA) to evaluate the response to therapies for BPH (Table 68-1). The index is used in some settings for making clinical decisions (Barry & O’Leary, 1995).

More recent research has cast doubt on the relation between “prostatism” and the prostate gland. Urodynamic studies and transrectal ultrasound (TRUS) have demonstrated that the AUA symptoms are neither sensitive nor specific for prostatic obstruction. The AUA symptom index is not even statistically related to a number of anatomic and physiologic variables, such as the peak urinary flow rate or the postvoid residual, which are thought to be associated with urinary obstruction. A study of unselected adults age 55 to 79 found no significant differences between AUA symptom scores in men and women (Lepor & Machi, 1993). It would probably be more appropriate to consider these as symptoms of lower urinary tract dysfunction rather than prostate disease. The differential diagnosis for such dysfunction includes cystitis, bladder cancer, ureteral stricture, bladder diverticulae, neurogenic bladder, bladder neck dyssynergia, ureteral stricture, and bladder calculi.

Symptoms of prostatism also need to be evaluated with a sense of how bothersome they are for the patient. Many men find their voiding symptoms tolerable and would prefer not to undergo treatment that has important potential morbidities.

Prostate cancer is often asymptomatic until well advanced. It can cause erectile dysfunction or symptoms of obstruction. More commonly, it presents with metastatic disease. Bony pain is typical in metastatic disease; the pain location depends on the area of tumor spread. Frank spinal cord compression or other neurologic compromise also can occur (Palmer & Chodak, 1996).

Prostatitis presents with a broad array of symptoms. These may include the classic symptoms of prostatism or symptoms of dyspareunia (painful ejaculation). The patient with bacterial prostatitis
may present with fever and septic shock. Prostatodynia refers to a poorly understood symptom complex of pain that can be experienced in the perineal or rectal area or lower back. The prostate gland itself may not be the cause of prostatodynia.

Hematospermia (bloody ejaculate) generally reflects disease of either the prostate or seminal vesicles. Hematuria may suggest prostatic disease but can arise from anywhere in the genitourinary tract. Incontinence is not generally a result of purely prostatic disease.

Prostatic massage is done to evaluate patients with symptoms of chronic prostatitis. Prostatic massage is not done in acute prostatitis for fear of precipitating bacteremia. Prostatic massage is done either alone or as part of a three-glass test (also known as the four-glass test). This test is described below. Expressed prostatic secretions (EPS) should be cultured for bacteria and mycobacteria. Additional cultures for gonococci and parasites may be appropriate in certain settings.

Prostatic massage is best accomplished by rolling rather than pushing the finger, as this is gentler on the rectum. The basic motion is that of massaging toward the midline of the prostate and down. An occasional patient will have no secretions at the tip of his penis after massage; these patients can be instructed to milk the penis. If no secretions are obtained at this point, the patient should void a few drops of urine, which will contain liquid from the prostate.

Normal prostatic secretions contain lecithin bodies and epithelial cells. The presence of many white cells is diagnostic for prostatitis. Experts disagree on the exact number, but 10 white cells per high-power field is generally accepted as evidence of prostatitis. The presence of fat-laden macrophages is specific for prostatic inflammation (Tanagho & McAninch, 1995).

In patients with prostatic obstruction, it is important to evaluate for possible urinary retention, either acute or chronic. Patients with chronic retention can have massively enlarged bladders and still be relatively or entirely asymptomatic.

Approximately 400 cc of urine must be present in the bladder before it can be palpated suprapubically. A more sensitive method is percussion.

If there is doubt concerning the size of the bladder, a postvoid residual can be obtained with a Foley catheter or by using ultrasound. Ultrasound is obviously less traumatic for the patient but may not be available in all clinics. In general, postvoid values of more than 50 to 100 cc of urine are considered evidence of retention.

A basic urinalysis and urine culture should be performed in all patients with prostatic symptoms. EPS are generally cultured as part of the three- or four-glass test (Doble, 1994). Patients collect two urine samples before prostatic massage but should not fully empty the bladder at this time. The first two samples are labeled voided bladder 1 (VB1, the first 10 cc of urine voided) and VB2 (a midstream sample). After prostatic massage, an additional two samples are collected: the EPS and VB3 (the first 10 cc of urine voided after the EPS). VB1 is considered a urethral sample, VB2 is a sample of bladder contents, and VB3 is a 1:100 dilution of prostatic secretions. Figure 68-1 describes this test and its significance.

Three general patterns emerge in the three-glass test:

The serum creatinine is used to evaluate kidney function. Acid and alkaline phosphatase played important roles historically in the management of prostate cancer, but these tests have been supplanted by PSA in current practice.

PSA is a protease that functions to liquefy the ejaculate. It is produced throughout the prostate gland and, for practical purposes, is found nowhere else in the body. As the prostate
hypertrophies with age, more PSA is produced. PSA levels tend to increase with age, so the normal range increases as men grow older. Levels also increase in prostatitis and when the prostate is manipulated surgically or by cystoscopy.

Difficulty arises in distinguishing PSA elevations from BPH and those from prostate cancer. This generally occurs with PSA levels in the range of 4 to 10 ng/mL.

Four approaches have been proposed for discriminating borderline PSA values (4 to 10 ng/mL) in BPH versus prostate cancer, but none has gained complete acceptance. The approaches are:

Urodynamics includes a variety of techniques, ranging from the simple to the sophisticated. Uroflowmetry is a simple test commonly used for evaluating symptoms of urinary obstruction. It is the urologic equivalent of the pulmonary flow-volume curve. The patient urinates into a special measuring device that produces a curve of flow versus time. The curve permits normal outflow to be distinguished from the decreased pattern characteristic of prostatic obstruction and the plateau characteristic of bladder neck obstruction. Unfortunately, there are limitations to uroflowmetry. Decreased flow can be caused by a lazy detrusor without prostatic obstruction. Normal flow can occur despite obstruction if the detrusor is hypertrophied. Maximum rates of less than 10 mL/second are highly suggestive of obstruction, whereas rates greater than 15 mL/second pretty much rule it out.

TRUS and transrectal biopsy are the current standards for evaluation of a suspicious finding on DRE or PSA. Some experts advocate TRUS as a screening test for prostate cancer. Cancers are usually hypoechoic on TRUS. However, most hypoechoic areas are not cancerous, so all abnormal areas must be biopsied. When no suspicious areas are found, some urologists perform multiple blind biopsies; others prefer to follow serial PSA levels. Bleeding is the main complication of prostatic biopsy.

Despite the frequency of BPH and the quantity of resources invested in BPH treatment, the epidemiology of the condition remains poorly studied (Guess, 1995). The main risk factors are age and the presence of androgens.

How common BPH is depends on how it is defined: histologically, anatomically, urodynamically, or clinically. Natural history studies have been flawed but have reported that symptoms improve or stabilize in 42% to 86% of untreated patients (Oesterling, 1993). It has been estimated that 31% to 55% of men with BPH will have improvement of symptoms with watchful waiting (Benign Prostatic Hyperplasia Guideline Panel, 1994).

Whether volunteered by the patient or elicited by the primary care provider, voiding symptoms usually initiate the workup for BPH. Occasionally, the provider will notice an enlarged bladder that is entirely asymptomatic; this is known as silent
prostatism. The AUA symptom index presented in Table 68-1 may be useful at this point to establish a baseline of symptoms against which to judge the effects of therapy.

The size of the prostate on physical exam is of little use diagnostically. Obstruction can occur with small prostates; conversely, large prostates do not necessarily obstruct. Evaluation of bladder size is diagnostically useful. When there is concern about bladder size, postvoid residual should be measured.

The minimum initial evaluation should include a urinalysis and creatinine measurement. These are done primarily to exclude other conditions, including infection or renal damage, rather than to confirm the diagnosis. Whether urodynamics and a PSA are necessary at this stage is controversial. Some providers order these tests routinely, but others do not.

Patients who do not meet the criteria for urologic referral can be managed in one of several ways. The choice is largely dictated by patient preference.