How can I differentiate between BPH and other potential causes of lower urinary tract symptoms in men?

To differentiate between benign prostatic hyperplasia (BPH) and other potential causes of lower urinary tract symptoms (LUTS) in men, a structured assessment is undertaken, focusing on excluding serious underlying conditions ¹.

• Initial Assessment (General Practice):
  • A comprehensive general medical history is taken to identify possible causes of LUTS and any associated comorbidities ².
  • Current medications, including herbal and over-the-counter remedies, are reviewed as they may contribute to LUTS ².
  • A physical examination is performed, including examination of the abdomen, external genitalia, and a digital rectal examination (DRE) ².
  • Men with bothersome LUTS are asked to complete a urinary frequency volume chart ².
  • A urine dipstick test is offered to detect blood, glucose, protein, leucocytes, and nitrites, which can indicate infection or other issues ².
  • Prostate-specific antigen (PSA) testing is offered if LUTS suggest bladder outlet obstruction secondary to BPH, if the prostate feels abnormal on DRE, or if the man is concerned about prostate cancer ². Suspected prostate cancer is managed according to NICE guidelines ².
  • A serum creatinine test (with eGFR calculation) is only offered if renal impairment is suspected, for example, with a palpable bladder, nocturnal enuresis, recurrent urinary tract infections, or a history of renal stones ².
  • Routine cystoscopy, upper urinary tract imaging, flow-rate measurement, or post-void residual volume measurement are generally not offered at initial assessment for uncomplicated LUTS ².
• Referral for Specialist Assessment:
  • Men are referred for specialist assessment if their bothersome LUTS have not responded to conservative management or drug treatment ².
  • Referral is also necessary if LUTS are complicated by recurrent or persistent urinary tract infection, retention, suspected renal impairment caused by lower urinary tract dysfunction, or suspected urological cancer ².
• Specialist Assessment:
  • At specialist assessment, a general medical history, medication review, and physical examination (including DRE) are repeated ².
  • A urinary frequency volume chart is completed ².
  • PSA testing is offered under the same criteria as initial assessment ².
  • Measurement of flow rate and post-void residual volume are offered ².
  • Cystoscopy is only performed when clinically indicated, such as with a history of recurrent infection, sterile pyuria, haematuria, profound symptoms, or pain ².
  • For men with chronic urinary retention (residual volume greater than 1 litre or a palpable bladder), a serum creatinine test and imaging of the upper urinary tract are carried out ².