Introduction: When Should You Seek Testing?

If you’re a man over the age of 50, it’s important to know that changes in urination patterns are common but shouldn’t be ignored. You should consider seeking diagnostic testing for benign prostatic hyperplasia (which means a non-cancerous enlargement of the prostate gland) if you notice certain warning signs. These include difficulty starting urination, a weak or interrupted stream of urine, feeling like your bladder isn’t completely empty after you’ve finished using the bathroom, or needing to urinate frequently throughout the day and especially at night.^[1][2]

You should also seek medical attention if you experience more urgent symptoms, such as a sudden inability to urinate at all, which is called acute urinary retention. This is a painful emergency situation where your bladder fills with urine but you cannot release it. Other concerning signs include blood in your urine, pain during or after urination, or changes in the color or smell of your urine. These symptoms could indicate complications that need immediate evaluation.^[2][9]

Even if you don’t have bothersome symptoms, men between the ages of 55 and 69 should discuss prostate screening with their healthcare provider. This is especially important if you’re at higher risk, such as if you’re Black or have a family history of prostate problems. Men in these higher-risk groups should start screening conversations at age 40. While BPH itself doesn’t increase your risk of prostate cancer, both conditions can have similar symptoms, so proper testing helps your doctor tell them apart.^[2][9]

Diagnostic Methods for Identifying BPH

Initial Consultation and Symptom Assessment

When you visit your doctor with concerns about urination problems, the first step in diagnosis typically involves a detailed conversation about your symptoms. Your healthcare provider will likely ask you to complete a questionnaire called the International Prostate Symptom Score, or IPSS. This scoring tool asks specific questions about your urinary habits, such as how often you feel your bladder isn’t fully empty, how frequently you need to urinate again within two hours, or how many times you wake up at night to use the bathroom. The IPSS helps your doctor understand how much these symptoms are affecting your daily life and guides decisions about whether you need treatment.^[7]

This questionnaire isn’t just used once. Your doctor may ask you to complete it periodically to track whether your symptoms are getting better, worse, or staying the same over time. The score you receive reflects the level of impact on your quality of life, which helps determine whether watchful waiting, lifestyle changes, medications, or more aggressive treatments might be appropriate.^[5]

Physical Examination

After discussing your symptoms, your doctor will perform a physical examination. The most important part of this exam is called a digital rectal exam, or DRE. During this exam, your doctor inserts a gloved, lubricated finger into your rectum to feel your prostate gland. Because the prostate sits just in front of the rectum, your doctor can assess its size, shape, and texture this way.^[5][8]

If you have BPH, your prostate will typically feel enlarged and smooth to your doctor. However, it’s important to understand that the digital rectal exam has limitations. It cannot accurately measure the exact size of your prostate, and the size you can feel from outside doesn’t always match how much the enlarged gland is blocking urine flow. Some men have significantly enlarged prostates but experience only minor symptoms, while others have smaller enlargements that cause major problems. Additionally, if your doctor feels a hard lump or irregular area during the exam, this could suggest prostate cancer rather than BPH, which would require different testing.^[5]

Urine Tests

Your doctor will likely order a urine test, also called urinalysis. This simple lab test examines a sample of your urine to look for signs of infection, blood, or other abnormalities. A urinalysis can help rule out conditions that cause symptoms similar to BPH, such as urinary tract infections or bladder stones. It can also check for blood in your urine that you might not be able to see with the naked eye, which could indicate other problems that need attention.^[8]

Blood Tests

Blood tests play several roles in diagnosing and managing BPH. First, your doctor may order blood work to check your kidney function. This is important because if an enlarged prostate severely blocks urine flow over time, it can cause urine to back up into the kidneys, potentially causing damage. Blood tests that measure substances called creatinine and blood urea nitrogen (BUN) can show how well your kidneys are working.^[8]

Another blood test that might be ordered is the prostate-specific antigen test, or PSA test. PSA is a protein produced by prostate cells, and levels increase when the prostate is enlarged. However, it’s important to understand that the PSA test is not specifically used to diagnose BPH in routine evaluations. Elevated PSA levels can occur with BPH, but they can also indicate prostate cancer, recent procedures, or even just a recent digital rectal exam. Your doctor should discuss the pros and cons of PSA testing with you, using what’s called shared decision-making, because the test has limitations and can sometimes lead to unnecessary worry or additional procedures.^[7][8]

Urinary Flow Test

A uroflowmetry test measures how fast and how much urine flows when you urinate. For this test, you’ll urinate into a special device that looks like a funnel or toilet but is connected to measuring equipment. The machine records the volume of urine you pass and how quickly it comes out. This test helps your doctor understand whether your urinary stream is weak or if there are interruptions in flow, which are common signs of bladder outlet obstruction from an enlarged prostate.^[5][8]

The urinary flow test is particularly useful for tracking whether your condition is improving or worsening over time. If you start treatment, repeating this test can show whether medications or other interventions are helping improve your urine flow.

Post-Void Residual Volume Test

After you urinate during the uroflowmetry test, your doctor will want to know if your bladder emptied completely. The post-void residual volume test measures how much urine remains in your bladder after you’ve finished urinating. There are two ways to perform this test. One method uses ultrasound, where a device is placed on your lower abdomen to create an image of your bladder and measure the remaining urine. The other method involves inserting a thin tube called a catheter through your urethra into your bladder to drain and measure any leftover urine.^[8]

If significant amounts of urine remain in your bladder after urinating, this indicates that your bladder isn’t emptying properly. Over time, this can lead to complications such as bladder infections, bladder stones, or kidney damage because bacteria have more opportunity to grow in stagnant urine, and the constant pressure can affect your kidneys.^[2]

Ultrasound Imaging

When your doctor needs to verify the exact size of your prostate, transrectal ultrasonography is the preferred method. During this test, a small ultrasound probe is inserted into your rectum. This probe uses sound waves to create detailed images of your prostate, allowing your doctor to measure it precisely. Knowing the exact size is particularly important when deciding whether certain medications called 5-alpha reductase inhibitors would be helpful, as these medications work best when the prostate volume is 30 milliliters or larger. Prostate size information is also important if you’re considering surgical treatment options.^[7][8]

Sometimes doctors use a different type of ultrasound called abdominal ultrasound, where the probe is placed on the outside of your lower abdomen. This approach is less invasive and can measure the post-void residual volume in your bladder, but it doesn’t provide as clear or accurate measurements of the prostate itself.

24-Hour Voiding Diary

Your doctor might ask you to keep a 24-hour voiding diary, which is essentially a detailed record of your bathroom habits over a full day and night. In this diary, you’ll note every time you urinate, how much you urinate if possible, and any episodes of leaking or urgency. This diary is especially helpful if you’re waking up multiple times at night to use the bathroom, a condition called nocturia. The information helps your doctor understand patterns in your symptoms and can be useful for tailoring treatment to your specific situation.^[8]

Additional Specialized Tests

If your symptoms are complex or if initial treatments aren’t working, your doctor might recommend more specialized tests. A cystoscopy involves inserting a thin tube with a camera through your urethra and into your bladder. This allows your doctor to see inside your urethra and bladder to look for blockages, stones, or other problems. Another test called urodynamic testing measures how well your bladder and urethra store and release urine by filling your bladder with fluid and measuring pressures and flows.^[8]

In some cases, your doctor might order imaging tests of your kidneys and urinary tract, such as an intravenous pyelogram (IVP) or CT scan, to check for blockages, stones, or damage to the upper urinary tract. However, these tests aren’t routinely needed for most men with straightforward BPH symptoms.^[8]

Diagnostics for Clinical Trial Qualification

If you’re considering participating in a clinical trial for new BPH treatments, you’ll typically need to undergo a standard set of diagnostic tests to determine if you qualify. Clinical trials have specific criteria about who can participate, and these criteria ensure that the research results are reliable and that participants are appropriate candidates for the experimental treatment being studied.

Most clinical trials for BPH require participants to have moderate to severe symptoms as measured by the International Prostate Symptom Score. You’ll likely need to score above a certain threshold, often 13 or higher on the 0-35 point scale, to qualify. This ensures that the trial studies people who have significant enough symptoms that improvement can be measured.^[7]

Trials typically require objective measurement of your urine flow through uroflowmetry testing. There’s usually a maximum flow rate threshold, meaning your urine flow must be below a certain speed to demonstrate that you actually have urinary obstruction. For example, a trial might require a maximum flow rate of less than 12 or 15 milliliters per second. Similarly, your post-void residual urine volume must usually fall within a specific range. If you retain too little urine, it suggests your blockage isn’t severe enough. If you retain too much, it might indicate your condition is too advanced for the experimental treatment being tested.

Prostate size is another important qualification criterion. Many trials require transrectal ultrasound to document that your prostate is above a certain size, such as 30 or 40 milliliters. This is particularly important for trials testing treatments that work by shrinking the prostate. Blood work to check kidney function is typically required to ensure your kidneys haven’t been damaged by the condition, as severe kidney impairment often excludes people from trials.

Clinical trials also use PSA testing as part of their screening process, though not necessarily to diagnose BPH. Instead, PSA levels help exclude people who might have undiagnosed prostate cancer, which would make them inappropriate candidates for a trial focused on benign prostate enlargement. Some trials might also require a prostate biopsy if your PSA levels or digital rectal exam findings suggest you could have cancer, even if you haven’t been diagnosed.^[8]

Before enrolling in a clinical trial, you’ll undergo a comprehensive medical evaluation that includes a complete medical history and physical examination. This helps researchers understand your overall health and identify any conditions that might affect your safety during the trial or interfere with the results. You might need additional tests such as electrocardiograms to check your heart health, particularly if the experimental treatment could affect cardiovascular function.

It’s worth noting that clinical trials for BPH often exclude people taking certain medications or those with specific medical conditions. For instance, you might be excluded if you’ve recently had a urinary tract infection, if you have a history of prostate surgery, or if you’re taking medications that affect urinary function. These exclusions help ensure that the trial results accurately reflect how the experimental treatment works without confounding factors.