Current assessment and proposed staging of patients with benign prostatic hyperplasia

With better understanding of the natural history of benign prostatic hyperplasia (BPH), and recent advances in ultrasound and the many new modalities of treatment, the assessment of BPH has undergone rapid changes in the past few years. A system of staging of patients with BPH, to assist in the tailoring of treatment to the severity of the disease is proposed. The initial assessment consists of the International Prostatic Symptoms Score (IPSS) and the Quality of Life Index, digital rectal examination (DRE), urinalysis, prostate specific antigen (PSA) estimation, and subsequently, assessment with ultrasound of the urinary system and estimation of residual urine and uroflow done at the same sitting. Patients with no bothersome symptoms and no significant obstruction are classified as stage one, and they can generally be watched. Stage 2 patients are those with bothersome symptoms but no significant obstruction and they can be treated with pharmacotherapy in the first instance, failing which other less invasive therapies such as thermotherapy are advised before considering transurethral resection of the prostate (TURP). Stage 3 patients are those with significant obstruction and defined as patients with significant residual urine of more than 100 ml, generally with a maximum flow rate of less than 10 ml. This group of patients would be advised TURP first, then thermotherapy, or pharmacotherapy in descending order, taking into account the age of the patients, their co-morbidity and preferences. Stage 4 patients are those with complications resulting from significant obstruction by BPH such as retention of urine, bladder stone and recurrent urinary infection; they would be strongly advised to have TURP. With proper assessment and staging, it is hoped that patients with BPH will not be over or undertreated, and treatment outcome will be improved.