Can benign prostatic hyperplasia be identified in the primary care setting using only simple tests? Results of the Diagnosis IMprovement in PrimAry Care Trial

Abstract

Summary Aims: Diagnosis IMprovement in PrimAry Care Trial (D‐IMPACT) was a prospective, multicentre epidemiological study in three European countries to identify the optimal subset of simple tests applied in primary care to diagnose benign prostatic hyperplasia (BPH) in men who spontaneously present with lower urinary tract symptoms (LUTS). Methods: Consecutive male patients aged ≥ 50 years who spontaneously attended their regular general practitioner (GP) office with LUTS were eligible for inclusion if they had not previously undergone BPH diagnostic tests or received treatment for BPH. Patients were assessed on three occasions, twice by their regular GP (visits 1 and 2) and once by a urologist (visit 3). The diagnostic accuracy of each variable was determined using the urologists’ final BPH diagnosis (at visit 3) as gold‐standard. Independent variables analysed were as follows: age; BPH diagnosis performed by GP in visit 1 (yes/no); probability of BPH diagnosis assessed by GP in visit 1; urinalysis (normal/abnormal); prostate‐specific antigen (PSA); International Prostate Symptom Score (IPSS); diagnosis of BPH performed by GP in visit 2 (yes/no); and probability of BPH diagnosis assessed by GP in visit 2. Statistically significant variables (p < 0.1) were included in a logistic regression model to identify the best algorithm and describe each test contribution. Results: The most frequent spontaneously reported LUTS were nocturia and weak urinary stream. BPH study prevalence was 66.0% (95%CI: 62.3–69.5) and 32% of patients were at risk of BPH progression (PSA > 1.5 ng/ml and prostate volume ≥ 30 cm3). Among the independent variables analysed, only age, IPSS and PSA showed a statistically significant relationship with BPH diagnosis. In a logistic regression model including age, IPSS, PSA and probability of BPH (based on physical examination and symptoms), positive predictive value (PPV) was 77.1%. Exclusion of BPH probability resulted in a PPV of 75.7%. Conclusions: A diagnostic algorithm including only objective variables (age, IPSS and PSA), easily implemented in any GP office, allows GPs to accurately diagnose BPH in approximately three‐quarters of patients spontaneously reporting LUTS.

Management of male lower urinary tract symptoms suggestive of benign prostatic hyperplasia by general practitioners in Jakarta

“…Our BPH management guidelines in Indonesia also recommend performing the IPSS questionnaire, DRE, frequency-volume chart, PSA level measurement, renal function assessment, and urinalysis to diagnose LUTS suggestive of BPH [12]. The D-IMPACT study showed that age, IPSS, and PSA level measurement were accurate for diagnosis with a positive predictive value of 75% and were easily implemented in any GP office [7]. One reason for the low use of the IPSS questionnaire was probably because it was considered to be impractical and too time consuming, especially in a busy primary care setting [16,17].…”

“…Orthostatic hypotension is one of the main side effects of α-adrenergic antagonists because it increases the risk of falls [6]. The cardiovascular effect of α-adrenergic antagonists prescribed for male LUTS suggestive of BPH should also raise caution because there is an association between LUTS and metabolic syndrome and vascular risk factors [7,8,20]. …”

“…Impairment of QoL is mostly caused by nocturia and a weak urinary stream [6]. The validity of simple diagnostic tools such as medical history, International Prostate Symptom Score (IPSS), digital rectal examination (DRE), and measurement of the serum prostate-specific antigen (PSA) level has been proven in studies such as the diagnosis improvement in primary care trial (D-IMPACT) study [7]. However, in a study performed by Fourcade et al [8], only less than half of men who presented with LUTS suggestive of BPH were diagnosed by use of a standardized assesment by GPs.…”

Collagen content in the bladder of men with LUTS undergoing open prostatectomy: A pilot study

“…Benign prostatic enlargement (BPE) is a highly prevalent condition in the male population and may cause LUTS due to bladder outlet obstruction (BOO). Prevalence of BPE/LUTS in men aged over 50 years and seeking medical care is estimated at 66% . Nevertheless, LUTS in men with prostatic diseases may be related not only to BOO, but also to changes in bladder function.…”

Medical Management of Lower Urinary Tract Symptoms in Men with Benign Prostatic Enlargement

“…Indeed, 48-60% of men >60 years of age seen by general practitioners have a clinically enlarged prostate and approximately one third have both moderate-to-severe LUTS and an enlarged prostate [3,8]. Larger prostate volume has been correlated with more severe LUTS and a higher risk of progression of symptoms and complications [9].…”