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Then we would rule out other problems of the lower urinary tract which can give rise to the same symptoms as BPH and some relevant tests, if necessary. This is the voiding diary we just talked about and this is the symptom score. These are mainly in the form of seven questions which the patient would circle 1, 2, 3, 4, 5. We then go down the list and calculate the total score. The maximum you can score is 35 which is the worst. So depending upon what symptoms the patient has, then we’ll score.

As an addendum to that symptom score, at the bottom there is a quality of life grading. They would grade their satisfaction to their lifestyle at present, 1, 2, 3, 4, 5 and again the 5 is worst. I also usually look at the this score at the same time as the symptom score itself because that will then give me an idea if the patient has circled 3, he is not happy, he is dissatisfied, 4 would be he is unhappy and 5 is very unhappy with his quality of life. Then we do the grading of the symptom score. If the total score is less than 7, the patient has mild symptoms. If it is between 8 to 19, he’s got moderate symptoms of his BPH and severe would be anywhere above 20.

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Differential diagnosis. The patient can have other problems. All these problems along with the benign enlargement of the prostate can give the same symptoms similar to somebody who has a urinary tract infection. They would also have the same symptoms of frequency, urgency, nocturia or difficulty in emptying. Or they may have just prostatitis (inflammation of the prostate gland) or prostate cancer. When it is enlarged it’s because of the cancer. Or some bladder abnormalities like, for example, a neurogenic type of bladder from nerve damage, the spinal cord injury patients, multiple sclerosis patients or patients who just have bladder stones or even bladder cancers. They can also have exactly the same symptoms.

If you have a stricture of the urethra, usually they are younger patients when you have a stricture in your urethra either from chronic inflammation – urethritis – or from trauma or some sexually transmitted diseases. Gonorrhea is the one which usually gives rise to strictures. Some medical diseases like diabetes can affect the bladder because of the autonomic nerve damage. Basically, the patient gets autonomic neuropathy which causes the bladder dysfunction.

Congestive heart failure. What happens is they have fluid overload. During the day, they are walking around, they are doing other things. But at night, when they lie supine, they mobilize all that fluid which gets dumped on to the kidney and then goes to the bladder and they pee a lot. So they get up a few times at night. So one really has to take these things into consideration when you are evaluating this patient who claims of nocturia, frequency and urgency type of symptoms.

As a person becomes older, they are over 60 years of age, more than half of the people would have some evidence of benign prostatic enlargement, whether histologically or clinically. When you reach the age of 85 years, almost 90% of people in this country would have benign prostatic enlargement, again, histologically. You can even find evidence histologically of enlargement of this gland in at least 10% of people in the younger age group between 25-30 years.

The histologic evidence of benign prostatic enlargement, even at the age of 30 years. Then it keeps on enlarging and it can become symptomatic, mainly after the age of 50. Similarly, this is also just the prevalence of this gland this slide shows in a graphic fashion in over 1000 autopsies. This is the age range in years here and the number of autopsies done in this particular age group. Again, this is where it just jumps up. What symptoms does benign enlargement of the prostate give you? There are two different types of symptoms. One is the obstructive type of symptoms and the second would the irritative type of symptoms.

More classically, the symptoms from a BPH would be an obstructive type. The patient would complain of incomplete emptying of his bladder, intermittent or very poor stream or that he has to strain to empty his bladder. The other classic symptom which is not listed here is also hesitancy. It would take him a long time when he stands in the toilet before the stream comes out. That would be called hesitancy. That’s also a classic symptom of benign enlargement of the prostate.

The second part would the irritative symptoms which would be frequency (that he is going more often to the toilet), urgency and nocturia. Most of the time that people come to the clinic saying, “Well, I started getting up at night now, two, three or maybe five times at night.” And they would probably think, “Well, I’ve got an enlarged prostate.” But as I said, these are mainly the irritative symptoms which usually are as a result of obstruction caused by the prostate. So the first symptom they would have is the obstructive symptoms followed by the irritative symptoms.

How do we evaluate these patients when they come in with these symptoms? We have what we call a symptom score sheet that we usually hand to the patient as soon as he walks in the clinic. He will fill out a questionnaire which was actually finalized by the Medical Urological Association. They are also called an International Prostate Symptom Score which has been accepted all over the world as a standard scoring system. We also have patients we give voiding diaries to that they usually take home. They fill out a frequency volume chart, also how much are they drinking, at what time and then how much are they voiding and at what time. So they will record their intake and output for at least for 48 hours…to be continued.