How can I differentiate between benign prostatic hyperplasia (BPH) and other causes of LUTS in men during a consultation?

To differentiate benign prostatic hyperplasia (BPH) from other causes of lower urinary tract symptoms (LUTS) in men during a consultation, start with a thorough clinical assessment including:

• Medical history: Identify LUTS characteristics, associated comorbidities, and review current medications that may contribute to symptoms.
• Physical examination: Perform an abdominal and external genitalia exam plus a digital rectal examination (DRE) to assess prostate size and detect abnormalities.
• Symptom assessment: Use a validated symptom score such as the International Prostate Symptom Score (IPSS) to quantify symptom severity and impact on quality of life.
• Urine dipstick test: Check for blood, glucose, protein, leucocytes, and nitrites to exclude infection or other pathology.
• Consider PSA testing: Offer prostate-specific antigen (PSA) testing if LUTS suggest bladder outlet obstruction due to BPH, if the prostate feels abnormal on DRE, or if there is concern about prostate cancer.

Initial investigations such as flow-rate measurement, post-void residual volume, and imaging of the upper urinary tract are not routinely recommended at first assessment unless complications or serious pathology are suspected.

Referral for specialist assessment is indicated if LUTS are complicated by recurrent urinary tract infections, retention, renal impairment, or suspected urological cancer, or if symptoms do not respond to conservative or drug treatment.

This approach helps distinguish BPH-related LUTS from other causes such as bladder dysfunction, infection, or malignancy by combining clinical evaluation, symptom scoring, and targeted investigations.

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