## Investigation of Choice for BPH Severity Assessment **Key Point:** Uroflowmetry with post-void residual (PVR) measurement is the gold standard non-invasive investigation to objectively assess the degree of bladder outlet obstruction (BOO) and lower urinary tract dysfunction in suspected BPH. ### Why Uroflowmetry? **High-Yield:** Uroflowmetry measures: - Maximum flow rate (Qmax) — reduced in BOO (typically <15 mL/s in significant obstruction) - Flow pattern — plateau vs. interrupted pattern - Post-void residual urine — elevated (>100 mL suggests significant obstruction) **Clinical Pearl:** A normal Qmax (>15 mL/s) with low PVR essentially excludes clinically significant BOO, even in men with LUTS and enlarged prostate on DRE. ### Diagnostic Approach in BPH | Investigation | Purpose | When Used | |---|---|---| | **Uroflowmetry + PVR** | Objective assessment of BOO | First-line for all men with LUTS | | **TRUS** | Measure prostate volume | If considering surgical intervention (TURP, laser) | | **Cystoscopy** | Visualize bladder/urethra | Only if hematuria, recurrent UTI, or failed TURP | | **Urodynamics** | Pressure-flow study | Equivocal cases, neurogenic bladder suspected | **Warning:** Clinical diagnosis of BPH is based on symptoms + DRE findings. Prostate size on DRE does NOT correlate with degree of obstruction — objective flow studies are essential. ### Key Findings in This Case - Smooth, rubbery prostate on DRE → consistent with BPH - Normal PSA (2.8 ng/mL) → excludes malignancy - LUTS present → need objective assessment of obstruction - **Next step:** Uroflowmetry + PVR to confirm BOO and guide management (medical vs. surgical) [cite:Harrison 21e Ch 297]
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