How Do You Know If You Have BPH?

(This information is from Dr. Patrick Walsh's Guide to Surviving Prostate Cancer)

Some men go right to a specialist, a urologist, for help with their urinary problems, but most men start out with a generalist—their family doctor or internist. Most likely, all of these doctors will approach your symptoms the same way: there should be a digital rectal examination and a PSA blood test. (These and other diagnostic tests are discussed in chapter 5.) You should be referred to a urologist if your doctor suspects BPH (or, for that matter, prostatitis or prostate cancer).

Because other conditions can mimic BPH, your doctor will probably begin by taking a detailed medical history and performing a physical exam. It is very important for your doctor to know your entire medical history, even if you have what appears to be a classic case of BPH. For example, an injury to the urethra (from having a catheter inserted into the bladder during a surgical procedure, perhaps) can create a urethral stricture—scar tissue that narrows the urethra —that has nothing to do with the prostate but does a great impersonation of BPH. Blood in the urine or pain in the bladder or penis could point to a bladder tumor or mean that a stone has developed in the bladder, prostate, or kidney. If you have a history of urologic trouble—recurrent urinary tract infections, for example, or prostatitis—it could be that an old problem has returned, but in disguise. BPH symptoms can also be produced by bladder cancer, prostate cancer, and neurogenic bladder (trouble with bladder function caused by a neurological problem, such as Parkinson's disease).

You will also be asked to score the severity of your symptoms and how much they bother you on a questionnaire called the International Prostate Symptom Score (IPSS). This is a series of seven questions that can be answered on a scale from 1 to 5. (Briefly, symptoms are considered mild if the score total is 0 to 7, moderate if it's 8 to 19, and severe if it's 20 to 35.) The last question is the most important of all: How much do the symptoms bother you? This is critical, because BPH is not life-threatening. All of its treatments are directed at relieving symptoms—which means this symptom score will be the main basis for selecting therapy. (Thus, it is essential that you be brutally honest—rather than stoic and long-suffering or overly optimistic that this problem will go away by itself—in answering these questions.) The big question your doctor needs answered—and the one only you can decide—is whether you could live the rest of your life this way. Are you changing your life to accommodate BPH—giving up seats to a basketball game, for instance, so you won’t have to tough it out in the long lines at the men's room? Are you planning your day around trips to the bathroom? If not—if you can put up with it for now—then you may choose to delay treatment. But if this problem is driving you crazy and disrupting your life, then it may be time to seek treatment.

The physical examination is discussed in detail in chapter 5. With BPH—because the disease affects only the innermost core of the prostate—your doctor may not be able to feel anything out of the ordinary. It's important to keep in mind that the size of the prostate may have nothing to do with the degree of symptoms. Some men with major prostate enlargement have no urinary tract trouble, while other men with seemingly minor enlargement or even a small prostate can suffer terrible problems from obstruction. Again, it all depends on where the trouble is (see above for a discussion of the types of BPH).

You may also need other tests, including:

Uroflowmetry

This test measures the speed of your urinary stream and the amount of urine you pass, and is done as you urinate (while you're alone in a testing room) into an electronic machine. (It's a urological version of the radar gun used to measure professional baseball pitchers’ throws.) To ensure an accurate result, it's important that you urinate at least 5 or 6 ounces. This test can identify men whose maximum flow rate is not noticeably diminished and who may not benefit from treatment. (The normal peak urinary flow rate is 15 cubic centiliters or more per second.)

Ultrasound

This is a painless imaging technique. It creates a picture by bouncing high-frequency sound waves off an object, like sonar on a submarine. It can be performed from the outside, through the abdomen, or transrectally, using a wand inserted in the rectum. Though not recommended for most men with BPH, ultrasound may be helpful in diagnosing such problems as obstruction of the kidney, stones, or a hidden tumor in the upper urinary tract; in estimating how well the bladder is emptying; and in determining the size of the prostate.

Residual Urine Measurement

If you're not emptying your bladder completely, this important test will find out. Further, it will show how much urine you're leaving behind. This can be done indirectly by an ultrasound examination of the lower abdomen immediately after you urinate or directly by inserting a small catheter into the bladder (like a dipstick) and measuring what's there. These measurements can be a helpful means of following the course of BPH and showing any change for the worse. If it turns out that you have large amounts of residual urine, your doctor will probably suggest that you seek treatment to avoid chronic urinary tract infection or damage to your kidneys.

Urodynamic studies

Your urologist may want to do these studies if there is evidence that the primary problem is with the bladder, not the prostate. Cystometry is a way to measure bladder pressure and function. It's performed by threading a tiny catheter into the penis, through the urethra, and into the bladder to monitor pressure changes as the bladder is filled with water. Pressure-flow studies, using a small catheter, check bladder pressure as you urinate. (Note: Any time a catheter is inserted into the urethra, there is a slight risk of a urinary tract infection developing a few days later. Be sure to tell your doctor if you experience any subsequent fever or discomfort.) In these tests, pressures within the bladder are compared with the rate at which urine is flowing. This can determine whether men with high peak urinary flow rates have obstruction. Imagine squeezing water out of a balloon with a small opening. If you can squeeze hard enough, you can make the water flow, not just trickle. Similarly, some men with significant obstruction can produce reasonable urinary flow rates because they can generate high bladder pressure. These men will have relief of symptoms if their obstruction is treated. However, in some men, low urinary flow rates are caused by diseased bladders that can't produce much pressure. Relieving the obstruction in the prostate won’t help these men, because the true problem is the bladder.

Cystoscopy

This test, usually performed in an outpatient setting, is uncomfortable but not painful; it is often used to assess the situation before an invasive procedure. A cystoscope is a slender, lighted tube (often flexible) that works like a periscope. It is inserted into the tip of the anesthetized penis and threaded through the urethra into the bladder. This allows the urologist to see the bladder, prostate, and urethra and spot anything abnormal—such as a stone, stricture, or enlargement. With cystoscopy, your doctor may also be able to see thickened muscle bands in the bladder. Like rings in a tree trunk, these tell a story—that a condition of bladder obstruction has probably evolved over months or even years. (Note: As with insertion of a catheter into the urethra, this test carries a small risk of urinary tract infection. Some men also experience blood in the urine or a temporary inability to urinate. Be sure to tell your doctor if you develop a fever or feel any discomfort.) Cystoscopy can also be used to rule out other conditions, such as the presence of a bladder stone or bladder tumor.