Benign prostatic hyperplasia (BPH) is the most common cause of bladder outlet obstruction in men over the age of 50 years. An association between the prostate specific antigen (PSA), International Prostate Symptoms Score (IPSS) and prostate volume (PV) may be instrumental in determining patients who may benefit from treatment. Targeted therapy will reduce the cost of care because it is unwise to treat all men with prostate enlargement to prevent complications when the risk of occurrence is negligible.
To determine the correlation between the PSA, IPSS and PV in men of African descent.
This was a cross sectional analysis involving 92 patients diagnosed as having symptomatic BPH at the Ho Teaching Hospital.
The data were collected using standardised questionnaires. The IPSS determined urinary symptom severity. The PV was determined using a transabdominal ultrasound machine. Serum PSA was retrieved from the electronic medical records.
The mean PV was 61.04 cm3 ± 21.95 cm3, the mean PSA was 4.21 ng/mL ± 3.85 ng/mL, and mean IPSS of 21.59 ± 3.78. The Pearson’s correlation between PV and PSA was 0.283 (
This study showed that serum PSA has a positive correlation with PV. However, IPSS had no significant association with PSA or PV in patients with BPH.
This study provides insights into the implications of clinical parameters on the management of prostate enlargement.
Benign prostatic hyperplasia (BPH) is the most common cause of bladder outlet obstruction in men over the age of 50 years and worsens with age without treatment.
This condition can be debilitating as men grow, it can result in significant psychological distress and advanced cases can cause urine retention. Pietrzyk and colleagues
This cross-sectional analysis was conducted among 92 patients at the urology department of the Ho Teaching Hospital, a public Teaching Hospital in Ghana. The urology department attends to an average of 5000 urological cases every year, with a significant proportion being BPH cases. Data were stored in an automated storage and retrieval system with highest assurances of patients’ privacy and confidentiality.
The study comprised men between 40 and 89 years of age, diagnosed as having clinical BPH and consented to participate. The study commenced on 03 January and ended on the 20 August 2021. A total of 32 men with co-existing medical conditions such as urethral stricture, prostate carcinoma and painful anal conditions such as thrombosed anal haemorrhoids, fissures and stenosis were excluded. Sample size was determined to be 92 using the Cochran’s formula, relying on a previous study by Yeboah,
Where:
Data were collected by consecutive (convenience) sampling, using face-to-face interviews. A structured questionnaire was used to collate data on socio-demographic factors, LUTS, trans-abdominal ultrasonography determined PV and serum PSA. The IPSS is routinely used in our unit for the assessment of storage and voiding symptoms. It was used for assessing the four voiding symptoms of BPH. These were incomplete bladder emptying, intermittency, weak stream and straining. In assessment of the three storage symptoms, questions were asked to determine the severity of frequency, urgency and nocturia. A symptom is scored from 0 to 5 and the maximum score is 35. In the interpretation of IPSS values, Mild is assigned for scores between 0 and 7; Moderate for scores from 8 to 19; and Severe is assigned when an assessment of both storage and voiding symptoms provides a score of 20–35. The PV was estimated using the (Guangzhou, China) machine with 2 MHz convex and 5 MHz linear probes at a bladder volume of about 200 mL. Prostate volume was then calculated using the ellipsoid formula π/6 × length × breadth × height, after capturing the prostate in the mid-sagittal and transverse planes. Serum PSA was retrieved from the electronic medical records. Quality control measures instituted prior to data collection included pre-testing of questionnaires among healthy males (no known medical condition) and validation and daily entry of completed questionnaires.
The data were analysed using (Atlanta, USA) and presented as tables and graphs with measures of central tendency (means and medians) and dispersion (standard deviation and interquartile ranges). Pearson correlation coefficient assessed for the inter-relationship between the study variables.
Ethical approval was sought from the Research and Ethics Committee (REC) of the University of Health and Allied Sciences (Reference number: UHAS-REC A.12 [100] 20-21). The procedures followed were in accordance with the declaration of Helsinki.
In all, 92 patients participated with a response rate of 100%. Participants’ ages ranged between 48 and 83 years with a mean age of 65.7. Most respondents (53.3%) were unemployed and 40.2% had secondary education.
Background characteristics of respondents.
Characteristic | Frequency | % |
---|---|---|
40–49 | 5 | 5.4 |
50–59 | 18 | 19.6 |
60–69 | 40 | 43.5 |
70–79 | 22 | 23.9 |
80–89 | 7 | 7.6 |
No education | 7 | 7.6 |
Primary education | 9 | 9.8 |
Secondary education | 37 | 40.2 |
Tertiary education | 39 | 42.4 |
Employed | 43 | 46.7 |
Unemployed | 49 | 53.3 |
Single | 5 | 5.4 |
Married | 61 | 66.3 |
Divorced | 16 | 17.4 |
Widowed | 10 | 10.9 |
Christian | 67 | 72.8 |
Muslim | 22 | 23.9 |
Others | 3 | 3.3 |
Yes | 87 | 94.6 |
No | 5 | 5.4 |
Out of the 92 participants, the mean PV was 61.04 cm3 ± 21.95 cm3, and a positive skew of 1.47. Similarly, the mean serum PSA was 4.21 ± 3.85, with a positive skew of 1.94. Lastly, the median IPSS score was 19 with a mean of 18.89 ± 4.23.
A frequency distribution of prostate volume, International Prostate Symptom Score and prostate specific antigen.
Variable | Mean | Standard deviation | Median | Range | Skew |
---|---|---|---|---|---|
Prostate volume | 61.04 | 21.95 | 55.5 | 25.8–135.0 | 1.47 |
Serum PSA | 4.21 | 3.85 | 2.8 | 0.2–18.4 | 1.94 |
IPSS | 18.89 | 4.23 | 19.0 | 6.0–31.0 | −0.30 |
PSA, prostate specific antigen; IPSS, International Prostate Symptom Score.
When the PV and serum PSA for the 92 patients were subjected to Pearson’s correlation coefficient test, there was a positive significant correlation (
A scatter diagram of prostate volume against serum PSA.
A scatter diagram of serum PSA and IPSS.
A scatter diagram of prostate volume and IPSS.
From this study, PV has been shown to have a weak positive correlation with PSA. International Prostate Symptom Score however had no significant association with PSA or PV. It can therefore be suggested that men with a high PV level will have an increased PSA.
To plan for appropriate urological surgical treatments, surgeons must first determine the size of the prostate gland.
The mean PSA value in this study was 4.21 ng/mL when compared with the normal PSA range it was slightly elevated, a result that differs slightly from other studies. Putra et al.,
This study recorded a mean IPSS value of 18.89 ± 4.29, similar to studies by Agrawal et al.,
Studies to determine the correlation between PV and IPSS had always yielded varying results. Basawaraj and associates
Serum PSA is affected by factors such as any pathology of the prostate (prostatitis, BPH and prostate cancer). Even trivial actions such as a digital rectal examination can cause the serum PSA to be elevated. International Prostate Symptom Score on the other hand is a list of questions that are specific in determining the severity of the LUTS, hence the interviewer and the interviewee’s understanding of the set of questions greatly affects the scoring. Coupled with the fact that patients sometimes exaggerate symptoms to receive faster medical attention or understate symptoms in order not to be admitted to the ward, the total IPSS that is obtained from different studies would always have that ‘operator variability’ element, which contributes to why associations vary so much.
Only a few studies have evaluated the relationship between IPSS and PSA. Tsukamoto and colleagues
The use of transabdominal ultrasound for the estimation of the PV might have influenced the PV estimates because it tends to be less reliable than TRUS. Whereas this study established an association between serum PSA and PV, further studies will be required to establish causality. Be that as it may, this study provides baseline data on these clinical parameters in this sub-population.
The authors conclude that that PSA levels have a weak positive correlation with PV, and can also be a reliable indicator of PV in Ghanaian men. The IPSS however had no significant association with PSA or PV. It can therefore be suggested that men with a high PV level will have an increased PSA. But a high PV or PSA does not suggest any bearing on the value of the IPSS or the degree of clinical presentation of LUTS. The authors will therefore caution against the assumption that symptom severity is related to prostate size. Physicians should therefore ensure thorough assessment of patients with prostatism before initiating management.
The authors are indebted to the patients who wholeheartedly accepted to participate in this study. Their deepest gratitude goes to Joy Agama for proofreading the manuscript.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
E.A. was responsible for conceptualisation, methodology, formal analysis, writing original draft and data curation. K.K.A. involved in writing review and editing and supervision. E.C.B. involved in methodology, formal analysis, investigation, writing-original draft.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
The data that support the findings of this study can by made available by the corresponding author, K.K.A., upon reasonable request.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.