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At the heart of general practice since 1960

Toolbox - the International Prostate Symptom Score (IPSS)

Urology GPSI Dr Jon Rees presents his guide to using this tool in primary care

 

The tool

The IPSS is a symptom score for use in men with LUTS secondary to benign prostatic hyperplasia (BPH). The score consists of two parts.

  • The first features seven questions regarding the severity of a range of urinary symptoms – three storage symptoms (urgency, frequency and nocturia) and four voiding symptoms (weak stream, hesitancy, intermittency and straining) – scoring from 1 to 5 for each question to make a maximum total score of 35.
  • This is followed by a single item which addresses the impact of these symptoms on the patient’s quality of life.

When to use it

The IPSS is a symptom score and not a diagnostic tool – men who present with LUTS have a number of potential causes for their symptoms, from excessive fluid intake, uncontrolled diabetes or heart failure, overactive bladder or urethral stricture.

The questionnaire is only validated for use in men with BPH. Therefore it is essential that men are fully assessed by history, examination, frequency volume chart and other investigations as per the NICE LUTS in men guideline1, and a diagnosis of BPH made before using the IPSS.

Remember that the IPSS will not measure the consequences of other facets of BPH and its treatments, such as worry about prostate cancer, sexual dysfunction or effects upon relationships.

In practical terms, the IPSS has a number of roles:

1. Allows the clinician to quickly see the symptoms affecting the patient, particularly to identify the presence of voiding symptoms and storage symptoms.

2. Allows stratification of the total symptom score into mild (total IPSS 0-7), moderate (8–19) and severe (20–35).

3. Shows, via question 8, the bother to the patient caused by their LUTS. This is incredibly useful when deciding whether to start medical treatment – moderate symptoms with low bother can often be managed conservatively, but the same symptom score in another patient, with a high bother score, may necessitate initiation of medical therapy.

4. By testing before and after treatment the IPSS can be used in conjunction with clinical assessment to objectively measure the response of a patient to treatment over time. This can be useful in a clinical setting and is extensively used in clinical trials of treatments for BPH.

5. Can be used to help risk stratify men at highest risk of clinical progression – that is. worsening symptoms, urinary retention or need for surgery. A high IPSS, alongside increasing age, a large prostate on rectal examination and a PSA level  over 1.4ng/ml indicates a man at highest risk of clinical progression and most likely to benefit from treatment with a 5-alpha reductase inhibitor, either alone or in combination with an alpha blocker.2

The NICE LUTS in men guideline recommends use of the IPSS before commencing treatment of LUTS/BPH.

The evidence

The 7 point symptom score of the IPSS was originally developed by the American Urological Association  as AUA7 – with the subsequent addition of the single quality of life question. The original AUA7 was extensively validated as being reliable and responsive to change following medical interventions, and as being suitable for self-administration by the patient.3,4 It is estimated that it requires a 3 point change in IPSS score in order to be clinically detectable to the patient.5

 

Dr Jon Rees is a GPSI in urology in Bristol

 

References

1. NICE. (2010) CG97 – the management of lower urinary tract symptoms in men

2. Emberton M, Cornel EB, Bassi PF et al. (2008) Benign prostatic hyperplasia as a progressive disease: a guide to the risk factors and options for medical management. International Journal of Clinical Practice, 62 (7); 1076–1086

3. Barry MJ, Fowler FJ, O’Leary MP et al. (1992) The American Urological Association symptom index for benign prostatic hyperplasia. Journal of urology, 148 (5): 1549-1557

4. Barry MJ, Fowler FJ, Chang Y et al. (1995) The American Urological Association symptom index: does mode of administration affect its psychometric properties? Journal of urology, 154 (3); 1056-1059

5. Barry MJ, Williford WO, Chang Y et al. (1995) Benign prostatic hyperplasia specific health status measures in clinical research: how much change in the American Urological Association symptom index and the benign prostatic hyperplasia impact index is perceptible to patients? Journal of Urology, 154 (5); 1770-1774

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