**6.1 Symptom assessment by standardized questionnaires**

BPH Impact Index (BII) is a questionnaire that assesses the effect of symptoms on everyday life and their interference with daily activities, and thus aimes to capture the impact of the condition. This questionnaire can be administered in conjunction with the IPSS and provides useful additional information (AUA 2010).

Symptom quantification is useful for diagnosis, determination of disease severity and monitoring of BPH. IPSS has become the international standard. It is derived from the American Urological Association Symptom Index (AUA-7 or AUA SI) described by Barry and colleagues in 1992 (Barry, Fowler et al. 1992; Barry, Fowler et al. 1992).

A recent multivariate analysis conducted by Hong *et* al., found associations of individual symptoms from the IPSS questionnaire and CKD status – obstruction-related symptoms, e.g. weak stream and hesitancy were significantly associated with CKD in age and comorbidityadjusted analyses (Hong, Oh et al. 2010). Irritative symptoms, on the other hand, had no positive correlation with CKD. According to a subsample from the Olmsted County Study, moderate to severe LUTS (IPSS > 7) were positively correlated with CKD (Rule, Lieber et al. 2005). Kidney failure risks were 2.60 (CI 95%, 1.47-4.58) and 4.08 (CI 95%, 1.74-9.53) times higher for men with moderate and severe LUTS compared with men with no or mild LUTS, respectively (p<0,001) (Hallan, Kwong et al. 2010). However, after adjusting for age and

overdistention of the bladder (overflow incontinence) or to detrusor instability. It is estimated to affect up to one half or more of all obstructed patients (urge incontinence)

Gross hematuria with clots with no other identifiable cause is common among BPH patients. Faubert *et* al, showed more than 30% of patients with microscopic or gross hematuria (Faubert 1998). Evidence suggests that in the patients predisposed to hematuria the microvessel density in prostate is higher than in controls (Wein 2007), suggesting that vascular

Although nowadays it is increasingly rare to find a patient with chronic renal failure from chronic urinary retention due to BPH, about 13,6% (range from 0,3 to 30%) of men with BPH may present with CKD defined by a baseline serum creatinine of more than 133 mmol/L (1,5 mg/dL). This is particularly true in older patients with cognitive deterioration and autonomy impairment. In order to diagnose and monitor the impact of a bladder outlet obstruction due to BPH in the upper urinary tract, some laboratory and imaging tests should be considered: standardized questionnaires, serum creatinine levels or estimated glomerular filtration rate (eGFR), urinalysis, serum prostatic specific antigen (PSA) levels, uroflowmetry with peak flow rate determination, renal ultrasonography, bladder ultrasonography with detrusor thickness evaluation, transrectal prostate ultrasonography, pre and post-void residual urinary volume, cystometry, other urodynamic studies and

BPH Impact Index (BII) is a questionnaire that assesses the effect of symptoms on everyday life and their interference with daily activities, and thus aimes to capture the impact of the condition. This questionnaire can be administered in conjunction with the IPSS and provides

Symptom quantification is useful for diagnosis, determination of disease severity and monitoring of BPH. IPSS has become the international standard. It is derived from the American Urological Association Symptom Index (AUA-7 or AUA SI) described by Barry

A recent multivariate analysis conducted by Hong *et* al., found associations of individual symptoms from the IPSS questionnaire and CKD status – obstruction-related symptoms, e.g. weak stream and hesitancy were significantly associated with CKD in age and comorbidityadjusted analyses (Hong, Oh et al. 2010). Irritative symptoms, on the other hand, had no positive correlation with CKD. According to a subsample from the Olmsted County Study, moderate to severe LUTS (IPSS > 7) were positively correlated with CKD (Rule, Lieber et al. 2005). Kidney failure risks were 2.60 (CI 95%, 1.47-4.58) and 4.08 (CI 95%, 1.74-9.53) times higher for men with moderate and severe LUTS compared with men with no or mild LUTS, respectively (p<0,001) (Hallan, Kwong et al. 2010). However, after adjusting for age and

and colleagues in 1992 (Barry, Fowler et al. 1992; Barry, Fowler et al. 1992).

(McConnell, Barry et al. 1994; McConnell, Bruskewitz et al. 1998; Wein 2007).

**6.1 Symptom assessment by standardized questionnaires** 

useful additional information (AUA 2010).

**5.1.5 Hematuria** 

**6. Diagnostic tests** 

urethrocystoscopy.

lesions can be the cause of hematuria.


Table 1. International Prostate Symptom Score (IPSS).

Benign Prostate Hyperplasia and Chronic Kidney Disease 361

sixfold) than those with normal renal function (Holtgrewe and Valk 1962; Melchior, Valk et al. 1974; Mebust, Holtgrewe et al. 2002). Most studies have found that the incidence of azotaemia in men with BPH varies from 15-30% (Mukamel, Nissenkorn et al. 1979). The Agency for Health Care Policy and Research (AHCPR) and the Fourth International Consultation on BPH highly recommends serum creatinine evaluation (McConnell, Barry et al. 1994). MTOPS data suggest that creatinine measurement is not necessary if voiding is normal. Estimated glomerular filtration rate (eGFR) is a more reliable measure to define CKD and is preferred

Urinalysis is a simple and inexpensive test that is recommended for the primary evaluation of a patient with suspected BPH. It is used to rule out urinary tract infection and hematuria. On the other hand, the finding of proteinuria/microalbuminuria may be indicative of renal

Total PSA should be offered to patients with more than 10 years of life expectancy and in whom the PSA measurement may change the management of the symptoms (AUA 2010). In conjunction with digital rectal examination (DRE), total PSA measurement is the cornerstone of prostatic basic screening. PSA and prostatic volume can be used to evaluate

Uroflowmetry is a simple and noninvasive urodynamic test that allows an objective evaluation of the patient micturition. Even though uroflowmetry is an unspecific evaluation, the micturition graphic may show some recognizable patterns (e.g. meatal stenosis, urethral stricture, BPH) and represent a reproducible way to quantify the strength of the urinary stream. It is a useful preoperative test. Peak urinary flow rate (PFR), or Qmax, appears to predict surgical outcome – patients with a preoperative Qmax > 15 mL/s have poorer outcomes than patients with preoperative Qmax < 15 mL/s do. PFR is an independent predictor for CKD rather than reported LUTS by standardized questionnaires (Hong, Lee et al. 2010). A study conducted by Rule *et* al. in community-dwelling men showed that men with CKD were more likely to have a slow urinary stream (Qmax < 15 mL/s) considering CKD as serum creatinine > 133 μmol/L or as eGFR < 60 mL/min/1,73 m2. (Rule, Jacobson et al. 2005).

the risks of either needing surgery or developing acute urinary retention.

over simple creatinine measurement (Roehrborn 2008).

**6.5 Uroflowmetry / Peak urinary flow rate** 

Fig. 1. Uroflowmetry. A) Normal patient; B) BPH patient.

**6.3 Urinalysis** 

**6.4 Total PSA** 

failure.

#### Additional Question:


Table 2. Additional Question evaluating quality of life.

#### **Total score:**

0-7 Mildly symptomatic 8-19 Moderately symptomatic 20-35 Severely symptomatic

therefore in isolation, IPSS is not a basis for kidney failure screening (Hallan, Kwong et al. 2010). Kidney function decreases with age and age significantly correlates with LUTS. Ponholzer A. *et* al also concluded that LUTS was not associated with increased loss of kidney function (Ponholzer, Temml et al. 2006).

Even though symptom score assessment do not directly correlates with CKD or can't be used to establish the diagnosis of BPH, it may serve as a basis for symptom severity and management approach to patients with LUTS. Further testing should be considered in patients with an IPSS score ≥ 8.

### **6.2 Serum creatinine**

For decades, medical textbooks have stated that patients with BPH should have serum creatinine measured (Humes 2000; Goldman 2008). Clinical practice guidelines disagree on serum creatinine screening among men being evaluated for LUTS. The routine measurement of serum creatinine levels is not indicated in the initial evaluation according to the AUA Guideline Management of BPH (AUA 2010). This recommendation is based on the conclusion that baseline renal insufficiency appears to be no more common in men with BPH than in men of the same age group in the general population. On the other hand, the EAU Guidelines on BPH (2004) and the nephrology-focused NICE (National Institute for Health and Clinical Excellence) guidelines for the United Kingdom advocate that it is probably cost effective to measure serum creatinine levels in all patients. This is based on the fact that bladder outlet obstruction due to BPH might cause hydronephrosis and renal failure (Sacks, Aparicio et al. 1989).

Patients with BPH and renal insufficiency have much higher postoperative complications (25% complication rate compared with 17% for patients without the condition) and mortality (up to sixfold) than those with normal renal function (Holtgrewe and Valk 1962; Melchior, Valk et al. 1974; Mebust, Holtgrewe et al. 2002). Most studies have found that the incidence of azotaemia in men with BPH varies from 15-30% (Mukamel, Nissenkorn et al. 1979). The Agency for Health Care Policy and Research (AHCPR) and the Fourth International Consultation on BPH highly recommends serum creatinine evaluation (McConnell, Barry et al. 1994). MTOPS data suggest that creatinine measurement is not necessary if voiding is normal. Estimated glomerular filtration rate (eGFR) is a more reliable measure to define CKD and is preferred over simple creatinine measurement (Roehrborn 2008).

### **6.3 Urinalysis**

360 Chronic Kidney Disease

therefore in isolation, IPSS is not a basis for kidney failure screening (Hallan, Kwong et al. 2010). Kidney function decreases with age and age significantly correlates with LUTS. Ponholzer A. *et* al also concluded that LUTS was not associated with increased loss of

Even though symptom score assessment do not directly correlates with CKD or can't be used to establish the diagnosis of BPH, it may serve as a basis for symptom severity and management approach to patients with LUTS. Further testing should be considered in

For decades, medical textbooks have stated that patients with BPH should have serum creatinine measured (Humes 2000; Goldman 2008). Clinical practice guidelines disagree on serum creatinine screening among men being evaluated for LUTS. The routine measurement of serum creatinine levels is not indicated in the initial evaluation according to the AUA Guideline Management of BPH (AUA 2010). This recommendation is based on the conclusion that baseline renal insufficiency appears to be no more common in men with BPH than in men of the same age group in the general population. On the other hand, the EAU Guidelines on BPH (2004) and the nephrology-focused NICE (National Institute for Health and Clinical Excellence) guidelines for the United Kingdom advocate that it is probably cost effective to measure serum creatinine levels in all patients. This is based on the fact that bladder outlet obstruction due to BPH might cause hydronephrosis and renal

Patients with BPH and renal insufficiency have much higher postoperative complications (25% complication rate compared with 17% for patients without the condition) and mortality (up to

Delighted

Pleased

Mostly satisfied

About equally satisfied

and dissatisfied

0 1 2 3 4 5 6

Mostly dissatisfied

Unhappy

Terrible

Additional Question:

**Quality of life due to urinary symptoms**  If you were to spend the rest of your life with your urinary condition the way it is now, how

Table 2. Additional Question evaluating quality of life.

kidney function (Ponholzer, Temml et al. 2006).

would you feel about that?

0-7 Mildly symptomatic 8-19 Moderately symptomatic 20-35 Severely symptomatic

patients with an IPSS score ≥ 8.

failure (Sacks, Aparicio et al. 1989).

**6.2 Serum creatinine** 

**Total score:** 

Urinalysis is a simple and inexpensive test that is recommended for the primary evaluation of a patient with suspected BPH. It is used to rule out urinary tract infection and hematuria. On the other hand, the finding of proteinuria/microalbuminuria may be indicative of renal failure.
