¹Associate Professor, ²Junior Resident, Department of General Surgery, Vilasrao Deshmukh Government Medical College, Latur, Maharashtra, INDIA.

Email: dranilmunde@gmail.com,  nansd5795@gmail.com

Table 1: IPSS SCORE: INTERNATIONAL-PROSTATE SYMPTOM SCORE (I-PSS)⁴

Data was entered using Microsoft excel and analyzed using SPSS version 22. Data were summarized in frequency tables, pie charts, and histograms. Categorical variables were reported as a proportion. Continuous data were described as means (standard deviation) or medians (interquartile range) depending on the distribution of data. The level of significance criteria was selected at P<0.05.

RESULTS

The majority of patients were >70 years (42%) followed by 61-70 years (41%), and 51-60 years (17%). Among patient’s majority had Hypertension (33%), diabetes (20%) and polycystic kidney disease (2%).

Table 1: General characteristics

In present study, majority of patients had grade 3 on Digital rectal examination (43%), followed by Grade 2 (35%), and grade 1 (22%). Among patients for prostate volume, majority were grade 2 (39%) followed by grade 3 (38%), and grade 1 (23%). Among patient’s majority had 50-100 ml Residual urine volume (50%) followed by >100 ml (34%) and <50 ml (16%).

Table 2: Distribution of patients according to Prostate Size on DRE

Among patient’s majority have IPSS score of 20-35 (44%), followed by 8-19 (30%) and score of 0-7 (26%). Among patient’s majority had IPSS score reduced significantly after treatment.

Table 3: Distribution of patients according to preoperative IPSS

Among voiding symptoms majority have incomplete bladder emptying (40%) and straining (24%), prolonged micturition (14%), and poor/intermittent stream (10%) and Dribbling, Hesitancy each 6 (6%).

Table 4: Distribution of patients according to Voiding symptoms

Among storage, symptoms majority had increased frequency (44%), followed by nocturia (39%), urge incontinence (9%) and urgency (8%).

Table 5: Distribution of patients according to Storage symptoms.

The majority of patients have PSA levels 4-10 (56%), <4 PSA levels (34%), and least is >10 PSA levels (10%).

Table 6: Distribution of study participants according to PSA levels

We noted highly significant statistical (p-0.0001) correlation between prostate volume and DRE, between prostate volume and IPSS, between IPSS and DRE and between prostate volume and Age.

Table 7: Various correlations

DISCUSSION

Clinical diagnosis of BPH is made by the assessment of IPSS, prostate size or volume and reduced urinary flow rate. Histopathologically, BPH is characterized by an increased number of epithelial and stromal cells in the periurethral transitional zones of the prostate.⁶ The fact that the development of benign prostatic enlargement (BPE), LUTS, and bladder outlet obstruction (BOO) are temporally related does not imply these events are causally related. Nevertheless, LUTS in the presence of some degree of prostatic enlargement have been sufficient to establish the clinical diagnosis of BPH.⁷ Uroflowmetry is one of the simplest and non-invasive urodynamic investigations used in the measurement of urinary flow rate using a flowmeter for the evaluation of obstructive LUTSs, information is plotted on a graph and interpreted by the treating doctor.⁸ In our study majority of patients are old age group and frequency decreased as age decreased. In a study done by Mohit G et al.,⁹ mean age was 62.18 ± 6.76 years and majority were from age group of 60-70 years. Similar findings were noted by Basawaraj NG et al.,¹⁰ as mean age of 65.06 ± 9.02 years. In a study done by Jaikant Paswan et al.,¹¹ majority of patients were from 60-70 years age group (34%), followed by 50-60 years (29%).  Among patient’s majority have Hypertension 33 (33%), diabetes 20 (20%), and polycystic kidney disease 2 (2%). In a study done by Mcvary KT et al.,¹² most frequently associated Comorbidities with prostatomegaly were hypertension, cardiovascular diseases, and erectile dysfunction. The majority of patients are grade 3 on Digital rectal examination 43 (43%), Grade 2 35 (35%), and least grade 1 22 (22%). Mohit G et al.,⁹ noted that 41.7% belong to grade II and 40% belong to Grade 1, and the least of 18.3% among grade III. Almost all these findings of DRE were radiologically confirmed by ultrasonography. Therefore, it can be stated that DRE is a very efficient tool in the diagnosis as well as grading of BPH. Similar findings were present in our study after doing DRE they were confirmed radiologically. In our study, prostate volume is measured using ultrasonography, the majority had grade 2 (39%), grade 3 (38%), and least grade 1 (23%). Mohit G et al.,⁹ noted that majority of patients have grade II prostrate volume (43.3%), followed by grade I (40%) and grade III (16.7%). In a study done by Basawaraj NG et al.,¹⁰ majority of patients, 35.7% has prostate volume 31-50 cc, followed by 30.9% of 21-30 cc volume and (19.8%) had the volume of more than 50 cc. Awaisu M et al.,¹³ noted that, median prostate volume was 45.05 cm³ with IQR (35 cm³ – 59 cm³), and the mean prostate volume was 52.58 cm³ ± 30.53 cm³ (range 24.60 cm³ – 319.00 cm³). Basawaraj NG et al.,¹⁰ noted that maximum number of patients had severe symptom scores (41.3%), followed by moderate symptom scores (37.3%) and mild symptom score (21.4%). In a study done by Eriawan Agung Nugroho et al.,¹⁴ majority, 63.4% belong to severe grade which is the score of 20-35, moderate grade 36.6% which is a score of 8-19, and no mild grade. Similarly, in a study done by Gnyawali D et al.,¹⁵ 74.5% of patients belonged to a score of 20-35 and followed by 25.5% of patients belonging to score of 8-19 and no cases of a mild score. In a study done by Mudi Awaisu et al.,¹³ majority of 55% of patients had moderate score and followed 33% of patients with severe score and 12% with a mild score. The findings in our study are consistent with above studies.^10,13,14,15 In our study majority of patients have symptoms of incomplete bladder emptying (40%) followed by straining (24%), prolonged micturition (14%), and the least frequent are dribbling and hesitancy (6% each). Basawaraj NG et al.,¹⁰ the commonest clinical presentation was incomplete emptying and straining (50%). While, CS Agrawal et al.,¹⁶ common voiding symptoms were incomplete bladder emptying and followed by straining, prolonged micturition, poor stream, and least frequent are dribbling and hesitancy. The findings in our study are consistent with study findings of previously mentioned studies. Among storage symptoms majority is increased frequency 44 (44%), followed by nocturia 39 (39%), urge incontinence 9 (9%), and urgency 8 (8%). Basawaraj NG et al.,¹⁰ noted that nocturia (93.6%) followed by increased frequency of micturition (83.3%) and urgency (76.9%) were common symptoms. In present study, highly statistically significant (p-0.0001) correlation between prostate volume and DRE, between prostate volume and IPSS, between IPSS and DRE and between prostate volume and Age. Mohit Goyal et al.,⁹ noted a statistically significant correlation between Prostrate volume and DRE. Almost all findings of Digital rectal examination were radiologically confirmed by ultrasonography. Therefore, it can be stated that DRE is a very efficient tool in the diagnosis as well as grading of prostate size. Similar findings noted in present study. In our study, there is a statistically significant correlation between prostate volume and age, but in a study done by Mohit Goyal et al.,⁹ there is no statistically significant correlation between prostate volume and Age. In our study, there is a statistically significant correlation between Prostrate volume on ultrasound and IPSS. Awaisu M et al.,¹⁴ noted that correlation of prostate volume with the International Prostate Symptoms Score (IPSS) was significant in their study (p=0.002). similarly, findings are found in a study done by Mohit goyal et al.⁵⁴ the statistical analysis of prostate volume against IPSS showed a strongly significant correlation between the two parameters as the P value was <0.001. The findings in our study are consistent with study findings of previously mentioned studies. Prostatomegaly affects almost all males with age and is one of the most common cause of elderly males visiting hospital with lower urinary tract symptoms. In peripheral centers where these modalities of radiological diagnosis are unavailable, this IPSS system along with the digital rectal examination can be a very reliable guide for the treatment of prostatomegaly. Patients keeping a record of their symptoms in voiding diary before and after treatment can be followed up regularly to check the efficacy of the ongoing treatment and any modifications required can thus be made.

CONCLUSION

The International prostate symptom score (IPSS) is a very useful diagnostic as well as prognostic tool in cases of prostatomegaly and is a directly related to the size of prostate gland as observed on clinical per rectal examination as well as confirmed by ultrasonography. IPSS is easy, reliable and cost-effective way in the management of prostatomegaly. Clinical symptoms can be a significant indicator of severity of the disease and thus can guide in the management of the same.

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