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How is BPH Diagnosed?

BPH is diagnosed based on lower urinary tract symptoms and the symptoms impact on the patients quality of life. The first part of the evaluation should include a review of lower urinary tract symptoms.

The American Urological Association (AUA) developed a BPH Symptom Score Index. The AUA-SI and the International Prostate Symptom Score (I-PSS) are nearly identical, validated short, self-administered questionnaires, used to assess the severity of three storage symptoms (frequency, nocturia, urgency) and four voiding symptoms (feeling of incomplete emptying, intermittency, straining, and a weak stream). The I-PSS also has a question assessing the severity of bother associated with the urinary symptoms.

The AUA-SI and I-PSS should be utilized at the initial evaluation and during the different phases of treatment in order to document therapeutic response to therapy

Insert AUA SI and I-PSS

A three-point improvement in the AUA-SI is considered meaningful.

Initial patient evaluation

AUA and UroGPO Guidelines were reviewed and the initial evaluation may include:  There is not absolute agreement upon the use of all of these

Medical history

Assessment of symptoms. AUA-SI or I-PSS should be administered.

History should include a description of onset, duration, severity and bother of the urinary symptoms.

Past medical and surgical history to identify other causes of voiding dysfunction and comorbidities the may complicate treatment.  Assessment of sleep apnea, diabetes and neurologic conditions including diabetes or neurologic conditions along with previous urologic evaluation, instrumentation, catheterization.  

Evaluation of prescription and over-the-counter drugs. There are some medications which affect bladder function and urinary symptoms.

Assessment of smoking history, alcohol consumption, caffeine intake, overall fluid intake.

Physical examination (AUA and UroGPO guidelines)

The physical examination should include a focused neurologic examination and digital rectal examination (DRE).  A DRE can give your provider an idea of your prostate size and help to evaluate the risk of prostate cancer. Neurologic diseases can result in lower urinary tract symptoms (LUTS)


A urinalysis is useful to evaluate for the presence of infection, hematuria (blood in the urine, or glucosuria (diabetes).

Post void residual urine (PVR) (UroGPO Guidelines)

A PVR measures the volume of urine that is left in the bladder after urinating.

Limitations and Variability

Prostate specific antigen testing (PSA test) (AUA Guidelines)

PSA testing is used in patients who meet the guidelines for PSA screening.  PSA values should be obtained in patients with at least a 10 year life expectancy and in whom the presence of prostate cancer would change management and in whom the PSA may change the management of the patient’s voiding symptoms.

Voiding log (frequency-volume charts) (AUA Guidelines)

Frequency volume charts should be used when nocturia (nighttime urination) is the dominant symptom.

Optional tests

  • Urine cytology
  • Uroflow
  • Serum creatinine
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