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40: Benign Prostatic Hyperplasia & Prostate Cancer

Serena Chao, MD, MSc; Ryan Chippendale, MD

Disease processes involving the prostate gland are common in older men and can have a significant impact on their quality of life. The diagnostic evaluation and treatment plan of such conditions can be challenging for the primary care clinician, who must align the patients’ goals of care with the risks and benefits of the available testing and treatment options. This chapter discusses 2 common prostate issues that frequently occur in older adults: benign prostatic hyperplasia (BPH) and prostate cancer.

Benign Prostatic Hyperplasia

Essentials of Diagnosis

  • Symptoms of obstruction and irritation on voiding.

  • An elevated American Urologic Association score.

  • Possible enlargement of prostate on exam.

  • Absence of other diagnoses that might cause symptoms (such as prostatitis or urinary tract infection [UTI]).

General Principles in Older Adults

BPH remains a common condition in older men that can lead to diminished quality of life. Based on autopsy data, the prevalence of BPH approaches 50% by the sixth decade of life and is close to 90% in men age 80 years and older. However, older men who are symptomatic from BPH underreport their symptoms to their clinicians and, therefore, are less likely to receive medical or surgical treatment for bothersome complaints.

Clinical Findings

Symptoms & Signs

When patients develop clinically significant BPH, they complain to clinicians of lower urinary tract symptoms (LUTS) such as increased urinary frequency, nocturia, urinary hesitancy, urine stream weakness, postvoid dribbling, and incomplete bladder emptying. Dysuria and hematuria are not commonly associated with BPH and may be an indication that another disease process is present.

The American Urological Association Symptom Index (AUA-SI) is a 7-item tool that health care providers can use to screen for symptomatic BPH as well as to assess a patient’s LUTS severity. Individual item scores are 0 for “not at all” to 5 for “almost always,” with a total maximum score of 35 (Table 40–1).

Table 40–1.The American Urological Association Symptom Index for BPH.
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Table 40–1. The American Urological Association Symptom Index for BPH.
...
Patient Name:_____________________________ DOB:____________________ ID:____________________ Date of assessment:___________________ Initial Assessment () Monitor during:_____________________ Therapy () after:___________________ Therapy/surgery ()____________________ AUA BPH Symptom Score
Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always
1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0 1 2 3 4 5
2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0 1 2 3 4 5
3. Over the past month how often have you found you stopped and started again several times when you urinated? 0

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