Prostatic symptomsBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7300.1468 (Published 16 June 2001) Cite this as: BMJ 2001;322:1468
- Andrew Farmer, honorary senior lecturer in general practice ()
This is part of a series of occasional articles on common problems in primary care
A 68 year old man has been urinating two or three times a night for the past six months and is worried because two friends have similar symptoms, and one has been told he has cancer and the other is due to have an operation, “though it isn't cancer”.
Determining the international prostate symptom score (IPSS)
Ask the patient seven questions (below) about his urinary symptoms. Answers are given on a scale of 0-5, depending on severity of the problem. For the first six questions the choice of answers is: not at all (score 0); less than one time in five (1); less than half the time (2); about half the time (3); more than half the time (4); almost always (5). For the final question, the choices are: never (0); once (1); twice (2); three times (3); four times (4); five or more times (5).
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
Over the past month, how often have you had the urge to urinate again less than two hours after you finished urinating?
Over the past month, how often have you found you stopped and started again several times when you urinated?
Over the past month, how often have you found it difficult to postpone urination?
Over the past month, how often have you had a weak urinary stream? (Please compare with your stream size at age 30)
Over the past month, how often have you had to push or strain to begin urination?
Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?
Add the scores together to give the total score and thus the severity category for symptoms (mild, <8; moderate, 8-19; severe, 20-35).
What issues you should cover
Discuss the cause of his symptoms. Show him a picture of where the prostate is and how it causes problems. He may be worried about cancer, so explain that usually the prostate simply enlarges but that in a small minority the symptoms are due to cancer. About 1 in 14 men will develop prostate cancer at some point in their life.
Discuss plans for initial investigation, including the prostate specific antigen test. Tell him that if the test result is high then further tests will be needed, although cancer is not the only reason for an abnormal result.
Explain the three main options if the test results are normal: (a) try to reduce symptoms by managing fluid intake and avoiding caffeine; (b) use medication, which often helps but sometimes has side effects (most people start by using an α blocker, which is likely to improve symptoms such as frequency, urgency, and poor stream—it works quickly, but there is no evidence that it reduces long term complications—but finasteride is an alternative drug that takes up to six months to work); (c) consider surgery, which is usually very effective but occasionally leads to complications (surgery is usually reserved for those with severe symptoms and for those in whom medication has not worked).
McConnell JD, Barry MJ, Bruskewitz RC, Bueschen AJ, Denton SE, Holtgrewe HL, et al. Benign prostatic hyperplasia: diagnosis and treatment. Rockville, MD: Agency for Health Care Policy and Research. (Publication No 94-0582)
Benign prostatic hyperplasia. Effective Health Care 1995;2(2).
Royal College of Surgeons of England. Guidelines on the management of men with lower urinary tract symptoms suggesting bladder outflow obstruction. London: RCSE, 1997
What you should do
Ask about urinary stream, urgency, and hesitancy. The international prostate symptom score (IPSS) is a useful way to quantify symptoms and monitor response to treatment (see box).
Explore the impact of the symptoms on daily living. Are his activities constantly interrupted, for example, by “having to nip to the loo”? Would he consider treatment successful if he could return to normal activity?
Ask about any worries he might have. As well as cancer, possible incontinence or impotence after prostate surgery are other common concerns.
Examine him. Look particularly for signs of uraemia, enlargement of the bladder, kidneys, prostate, and palpable nodes.
Arrange investigations: a midstream urine test to exclude urinary tract infection; serum creatinine test to rule out renal failure; and the prostate specific antigen test.
Most men decide to try taking tablets, in anticipation that the test results will be normal.
Check blood pressure. Avoid using α blockers in people prone to postural hypotension.
Warn that common side effects of the drugs include dizziness. Unusual side effects are drowsiness, weakness, and dry mouth. Choose from alfuzosin, doxazosin, indoramin, prazosin, tamsulosin, and terazosin.
To avoid hypotension, start some of these drugs at a low dose and increase at weekly intervals. Some drugs are available in starter packs.
Follow up at one month to discuss results and treatment.
The series is edited by Ann McPherson and Deborah Waller
The BMJ welcomes contributions from general practitioners to the series