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Using the IPSS to Evaluate BPH Symptoms
Quynh-Chi Dang • May 28, 2021 • 52 hits
The International Prostate Symptom Score (IPSS) is a universal, primary assessment endorsed by the American Urological Association (AUA). The IPSS questionnaire consists of 7 questions and evaluates benign prostate hyperplasia (BPH) patients from a score of 0 to 35. Patients with higher IPSS scores have more severe BPH symptoms, while those with lower to moderate IPSS scores can be treated via lifestyle modifications. In addition to the IPSS questionnaire, urologists must also consider a patient’s quality of life before deciding on a BPH treatment option.
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The BackTable Urology Brief
• Urologists should utilize the IPSS questionnaire in their primary assessment of BPH patients because the IPSS is useful, universal, and endorsed by AUA guidelines for BPH.
• BPH patients with an IPSS of 0 to 7 are considered asymptomatic or mildly symptomatic. An IPSS of 8 to 19 is considered moderately symptomatic. Patients with an IPSS greater than 19 are considered severely symptomatic.
• The IPSS should be used in conjunction with the urologist’s assessment of the BPH patient’s quality of life. Special attention should be given to a patient’s career type, lifestyle, and expectations.
• A low or moderate IPSS can indicate the possibility of using lifestyle modifications to resolve BPH symptoms. Some examples of BPH lifestyle modifications include: timing the intake of fluids, avoiding diuretics, and using the double-voiding technique.
Table of Contents
(1) What is the International Prostate Symptom Score (IPSS)?
(2) Integrating Quality of Life into the IPSS Questionnaire
(3) Lifestyle Modifications for Moderately Symptomatic BPH
What is the International Prostate Symptom Score (IPSS)?
The IPSS is an initial tool to evaluate the severity of BPH/LUTS symptoms. A higher IPSS indicates a higher severity of BPH symptoms. The IPSS questionnaire contains 7 questions and assigns patients a score of 0 to 35, ranging from asymptomatic to severely symptomatic.
(1) Incomplete Emptying
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?
Over the past month, how often have you had to urinate again less than two hours after you finished urinating?
Over the past month, how often have you found you stopped and started again several times when you urinated?
Over the last month, how difficult have you found it to postpone urination?
(5) Weak stream
Over the past month, how often have you had a weak urinary stream?
Over the past month, how often have you had to push or strain to begin urination?
Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?
[Dr. Aditya Bagrodia]
...So, we'll start out with evaluation. So, tell us, Claus, a patient coming in for BPH symptoms, what kind of standard questionnaires, intakes are you using on a routine basis?
[Dr. Claus Roehrborn]
Aditya, the way we should refer to it is really lower urinary tract symptoms. As you know, there has been a long standing debate and BPH is just really a histological diagnosis. And nowadays, the folks who are engaged in BPH management, they refer to it as lower urinary tract symptoms suggestive of BPH. So, men do come in with either storage symptoms or voiding symptoms or a mixture of both. So, they would typically say, "Doc, it bothers me, I get up at night to urinate two or three times, I urinate during the day frequently. If I go to an event, a sports event, or take a trip, I have to stop frequently." Those would be the storage or irritative symptoms. And then some men say, "It's just hard to get the stream started, it's hard to empty my bladder. I feel like I have to strain a lot," and those would be the voiding or obstructive symptoms.
So, for most men, it's a mixture of those symptoms, and they are wonderfully put together in the so-called International Prostate Symptom Score (IPSS) or the AUA symptom score, because it was really developed under the guidance of the AUA in the 1990s. This is a seven-question questionnaire. It ranges from 0 to 35 points, and anybody who would score 7 or less on that score is considered asymptomatic or mildly symptomatic. If you score 8 to 19, you're considered moderately symptomatic, and above that, it's severely symptomatic. This is the A&O, the Alpha and Omega, this is the end and the beginning of all the questionnaires, and it really has set the standard in the assessment of these patients. It's translated and validated in many languages, and that's the score that everybody should use.
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Integrating Quality of Life into the IPSS Questionnaire
The IPSS Questionnaire ends by asking “If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?” Dr. Roehrborn emphasizes the importance of evaluating patients beyond the IPSS Questionnaire -- namely, incorporating the “quality of life question” into BPH clinical evaluation. Although some patients score in the moderate to high range of the IPSS, he believes it is important to ask them about their’ lifestyles, careers, and expectations before embarking on medical management of BPH.
[Dr. Aditya Bagrodia]
...So, everybody's coming in and they're getting an AUA symptom score. So, we've got that bit of information. What other tests are you using at the point of care in the clinic to start your evaluation?
[Dr. Claus Roehrborn]
So, let's just say a man comes in and is bothered by some of these symptoms, my first question would be, what does he score? So, let's just say he scores in the moderate range, 17 points, 18 points, or even more, 20, 22 points. So, I take a look at the score and I initially determine, this is mostly storage symptoms like overactive bladder type symptomatology, frequency, urgency, and nocturia, or is it mostly voiding symptoms? That's my first glance at it.
And then I ask the patient a quality of life question--I asked him, "Just imagine you have these symptoms and you would have to live with those symptoms and there would be nothing that could be done to make them go away, how would you feel about that? Terrible or would you be okay with it, or how would you feel about it?" This single quality of life question sort of sets the stage, because many patients, when they are retired and they score in the lower ranges, they say, "I can live with it, I can make adjustments. I just don't take long trips, or I sit at an aisle seat in a movie theater so I don't bother anybody getting up. I'll adjust to it, I'll adjust my lifestyle." If that's the case, oftentimes I say, "Maybe we don't do anything. Maybe we just monitor it and follow up." Now, other patients will say, "No, this really bothers me. I work. I'm an attorney, I have meetings, I have clients, it's embarrassing. I want something done about it."
So, this single quality of life question is also ingrained into the assessment, and every guideline, the AUA guideline and the EAU guideline have that single quality of life question as part of the initial assessment. And it's really a decision-making split in the algorithm, whether the patient will go for treatment or whether he will go in the direction of active surveillance or watchful waiting. And a lot of people go and just watch and monitor their symptoms because they don't bother enough to actually have a treatment.
Lifestyle Modifications for Moderately Symptomatic BPH
Following the “quality of life question”, it is possible for some patients to circumvent medical treatment through adopting lifestyle modifications. If a patient scores in the moderate range of the IPSS, Dr. Roehrborn recommends timing the intake of their fluids, avoiding diuretics, and using the double-voiding technique.
[Dr. Claus Roehrborn]
...So, let's just say the patient scores 15 points, so it's in a moderate range, and he says, "I can live with this, I can make some adjustments." I say, "Good. Okay, let's talk about that." So, lifestyle modifications take a little time on the part of the physicians, and actually, I'm happy to say that with a new E&M coding system being in place, actually, that's higher valued now, as you know. So, I'll take my time and explain to the patient what he can do. And it's surprising that laypeople often don't have a good understanding of how the urinary tract works, right? They drink water or iced tea, and then they're surprised they have to urinate.
So, you'd have to really start at the beginning and have to say, "Okay, look, now, whatever you drink, 80% of that comes out in the form of urine, some comes out through the skin, some comes out with a bowel movement, but most of it turns into urine an hour or two later...So, if you get up at night a lot, you want to cut down your fluid intake before you go to bed, maybe it's 6:00, maybe at dinner time, cut it in half." So, those are things that people can do easily.
Secondly, many people don't know that coffee and tea are diuretics, as well as just plain fluid. So, I always tell patients, "Look, when you drink coffee, or tea, or alcohol, it's not just the fluid that that represents--there's a little bit of extra fluid coming out that act as a diuretic, and it makes you urinate faster, so watch out for that."
Then if it's an older man and his bladder may be not quite as good, there is this double voiding technique, and it's really quite effective…. I say, "Think of your bladder as a sprinter muscle. When you void, that muscle expends all of its energy, you have to give it five minutes to rebuild the energy in that muscle and then try to void again. I'll bet you can do more." And that's called double voiding. And double voiding is very effective and gets every bit of urine out. And if you get a lot of urine out and you don't retain, you don't have to urinate as frequently. So, an empty bladder takes a longer time to fill back up and that reduces the frequency of urination both daytime and nighttime.
Dr. Claus Roehrborn
Dr. Claus Roehrborn is a urologist with UT Southwestern in Dallas, Texas.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2021, April 22). Ep. 5 – Contemporary Medical Management of BPH [Audio podcast]. Retrieved from https://www.backtable.com
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