Health and Prostate

An indexing tool called the International Prostate Symptoms Score (IPSS) II can help evaluate key lower urinary tract symptoms. The patient’s score on this test gives a highly accurate assessment of the effect of lower urinary tract symptoms on the quality of a man’s life, and it is a reasonable basis from which the patient and clinician can discuss treatment options. The index is also often used to gauge treatment outcomes and may be a better indicator of success than objective tests, such as the measurement of the prostate gland or the rate of urine flow. The higher the IPSS, the more likely would be the severity of symptoms. It should be noted that the IPSS is useful only as a gauge of symptom severity. Other conditions can produce similar scores, so the test is not often used as a diagnostic tool for benign prostatic hyperplasia (BPH). Furthermore, the index does not include other urinary symptoms that are important for determining quality of life, such as dribbling and incontinence. It also does not reflect regional or ethnic differences that can vary the responses to these symptoms. Other indexing systems, such as Symptom Problem Index (SPI) and the BPH Impact Index (BII), which gauge different quality-of-life and disease issues, are being used in addition to the IPSS to help evaluate patients.

The clinician will usually press on and manipulate (palpate) the abdomen and flanks to detect signs of kidney or bladder abnormalities. The clinician will also check for signs of anemia or swelling in the legs and arms. Certain procedures that test reflexes, sensations, and motor response may be performed in the lower extremities to rule out possible neurologic causes of bladder dysfunction.

To determine whether the bladder is obstructed, a uroflowmeter is employed to determine the speed of urine flow. This device does not determine the cause of obstruction but only that obstruction exists. Since numerous factors can affect urine flow (including straining or holding back because of self-consciousness) this test should be conducted more than once to ensure accuracy and reliability. The rate of urine flow is calculated as milliliters of urine passed per second. The flow of urine normally decreases as men get older, ranging from more than 25 mL/second in young men to less than 10 mL/second in elderly men. Men with peak flow rates less than 12 mL/second are more likely to suffer from urinary retention.

Urinalysis is utilized to detect signs of bleeding, infection, or bladder cancer. Urinary infections are more common in older men, particularly those with benign prostatic hyperplasia. A Pre and Post Massage Test (PPMT) of the prostate is about 90% accurate in ruling out prostatitis.

A PSA (prostate specific antigen) test is the standard screening device for detecting prostate cancer but is often used in men with suspected BPH. It is recommended annually for all men over 50 years old and for men over 40 who are at high risk for prostate cancer. The value of the test in a man over 70 with benign prostatic hyperplasia is questionable, since BPH itself can raise PSA levels. The test measures the amount of prostate specific antigen in the blood. A PSA of 4 ng/mL or lower is considered normal whereas a level of 5 to 10 ng/mL is considered to be slightly elevated. A prostate specific antigen reading above 10 ng/mL is considered to be moderately to highly elevated. It should be noted that most men with slightly elevated PSA levels do not have prostate cancer, but that a normal prostate specific antigen level does not rule out the presence of cancer. Therefore, a biopsy is often performed to rule out prostate cancer. Prostate specific antigen levels tend to increase with age. A PSA level of 2.5 ng/mL is considered to be normal in men age 40 to 49, whereas a level of 3.5 ng/mL is considered to be normal in men age 50 to 59. It is not uncommon to routinely see prostate specific antigen levels of 6.5 ng/mL or higher in men age 70 and older. A more recent test identifies free PSA, which is found in lower levels when prostate cancer is present and in higher levels with benign prostate hyperplasia. Certain treatments for BPH, including finasteride or transurethral resection of the prostate (TURP), may reduce prostate specific antigen levels and possibly mask existing cancer.

A postvoid residual urine (PVR) test measures the amount of urine left in the bladder after urination. A PVR reading of less than 50 mL generally indicates adequate bladder emptying. Excessive residual urine (100 to 200 mL or higher) may indicate the presence of a neurologic disease that is impairing bladder function.

Ultrasound of the prostate is a noninvasive approach toward an accurate account of the size and shape of the prostate. Ultrasound tests can be administered via a rectal probe (transrectal ultrasonography) or abdominal sensor (transabdominal ultrasonography). Transabdominal ultrasonography offers a more accurate measure of postvoiding and residual urine, and is less invasive and expensive than transrectal ultrasonography. However, transrectal ultrasonography is significantly more accurate in determining prostate volume and can detect cancer.

Filling cystometry is useful in patients who cannot urinate and in whom nerve damage or injury of the bladder is suspected. The test is used to determine the absence or presence of uninhibited detrusor contractions (UDC), which often occur in men with storage urinary tract symptoms. During this procedure, sterile water is instilled into the bladder and the pressure in the bladder is continuously measured until the patient feels the need to void. Then a fluid-inflatable balloon is inserted into the rectum for a second measurement that reflects abdominal pressure, which is calculated together with the measurements of bladder pressure to provide an accurate assessment of detrusor contractions.

Urethrocystoscopy is particularly useful in men with suspected urinary tract complications, as noted from blood in the urine, infection, bladder cancer, or prior surgery or injury. This procedure can confirm the diagnosis of benign prostatic hyperplasia. Possible complications associated with this procedure include hypersensitivity reactions to the local anesthetic, urinary tract infection, bleeding, and urine retention. An intravenous pyelogram (IVP), which utilizes an injected dye to detect urine flow on roentgenogram, is also useful for determining urinary tract infections or complications.