Benign prostatic hyperplasia or BPH is the benign or non-cancerous enlargement of the prostate gland as men age. For most men, the prostate continues growing throughout life and can eventually display bothersome urinary symptoms. A BPH symptom score system for determining BPH symptom severity as presented by lower urinary tract symptoms (LUTS), has been devised and is called the International Prostate Symptom Score or IPSS. The American Urological Association (AUA) calls this system the AUA Symptom Index (SI) to quantify BPH symptom severity.

As the prostate continues to enlarge, many men will begin noticing the ramifications of their prostate gland encroaching on their urethra and/or up into their bladder. Both day and nighttime bathroom trips may increase in frequency and some key BPH symptoms such as not being able to empty completely, having a weaker urine stream, dribbling, stopping and starting, hesitancy, straining, urgency, and other urinary symptoms will begin presenting themselves. PSA levels may increase as well since a bigger prostate produces more PSA. A man can have benign prostatic hyperplasia with a normal PSA number, but it is typically milder. When PSA numbers increase above normal for a man’s age, and BPH has been diagnosed, symptoms typically increase as well.

The International Prostate Symptom Score or BPH Score is a 7-question scoring system that evaluates the severity of LUTS brought on by benign prostatic hyperplasia once the disease is diagnosed by a physician. It can be utilized to define both BPH severity and a person’s response to treatment. The point values from the seven questions are tallied up to determine the severity of LUTS. A score of 0 to 7 points indicates mild LUTS; 8 to 19 points: Moderate LUTS, and 20 to 35 points: Severe LUTS.

International Prostate Symptom Score (IPSS) Calculator

The following benign prostatic hyperplasia or BPH symptom score calculator utilizes the IPSS platform. The way to interpret the IPSS score is to add up the points from each of the seven categories to form a grand total. This total determines how severe lower urinary tract symptoms are or how well therapy is proceeding.

BPH Severity Classification

Prostate adenoma (clinical BPH) is the most commonly occurring benign tumor that develops in older men. It develops from the transitional zone of the prostate and can involve various prostatic zones depending on how large it grows. It can cause lower urinary tract symptoms and bladder obstruction, which if not addressed, could result in organ dysfunction or damage.^1,2

The severity of benign prostatic hyperplasia or BPH can be defined according to the obstruction and symptoms. The symptoms can be quantified with the IPSS, and the quality-of-life index (QOL). However, since there is a poor correlation between IPSS and obstruction, the symptoms score should not be used as the sole parameter in the decision-making regarding further treatment. Also, the IPSS is not related to QOL, which depends upon a patient’s lifestyle and occupation. For example, a retiree with nocturia (having to urinate at night) 4 times each night may not be bothered while a young executive experiencing nocturia 2 times, may be bothered. Therefore, QOL is more important than IPSS in the assessment of symptoms.^1,2

Prostate adenoma (PA) can cause varying degrees of obstruction. When organ dysfunction is involved, obstruction is deemed as being significant. The two main functions of the bladder are storage and emptying. When the emptying function is affected, patients develop consistently high residual urine. When the storage function is affected, the maximum voided urinary volume would be low, and thus can easily be measured. Significant obstruction can then be defined as when there is a persistent residual of more than 100 ml and/or maximum voided volume of less than 100 ml. With these cut-offs and definitions, the severity of BPH can be classified accordingly:^1,2

1. Stage I: would be a patient with no significant obstruction or bothersome symptoms;
2. Stage II: would be a patient with bothersome symptoms but no significant obstruction;
3. Stage III: would be a patient with significant obstruction, irrespective of symptoms;
4. Stage IV: would be a patient with complications of BPH such as retention of urine, recurrent gross hematuria, urinary infection, and bladder stone formation.

Generally, there is good concordance between the grade and stage of benign prostatic hyperplasia. Stage I patients can be treated conservatively and advised on proper fluid intake and living a healthy lifestyle. Stage I Grade 1 can be reassured and discharged from follow-up, while stage I grade 2 or 3 patients need to be followed up at 6 months to a 1-year interval as it is predicted they are more likely to progress with their BPH symptoms. ^1,2

Stage II patients can be treated with medication, while Stage III grade 3 patients would be advised to seek more aggressive treatment with surgery as an option for their benign prostatic hyperplasia. Stage IV patients would generally require surgical treatment.^1,2

Staging of BPH

Significant obstruction: PVR >100 MLS, or max voided volume <100 MLS

Bothersome symptoms: QOL >3

The benign prostatic hyperplasia or BPH symptom score, also known as the International Prostate Symptom Score (IPSS) or American Urological Association (AUA) Symptom Index (SI), is a BPH symptom severity scorecard that calculates the frequency of lower urinary tract symptoms so BPH risk can be assessed. This IPSS score is used by physicians and patients to identify if BPH is present and to what degree. By utilizing the IPSS and other urologic investigative measurements, a diagnosis of BPH can be determined by a patient in conjunction with their doctor.

References

1. Foo KT. Current assessment and proposed staging of patients with benign prostatic hyperplasia. Ann Acad Med Singapore 1995;24:648-51.
 
2. Wang D, Foo KT. Staging of benign prostate hyperplasia is helpful in patients with lower urinary tract symptoms suggestive of benign prostate hyperplasia. Ann Acad Med Singapore 2010;39:798-802.