International Prostate Symptom Score (IPSS)

Score items

The international prostate symptom score evaluates how severe the urinary symptoms caused by prostate enlargement are.

There are 7 questions that patients who have been diagnosed with benign prostatic hyperplasia need to answer to:

1. Incomplete emptying - How often have you had the sensation of not emptying your bladder?

2. Frequency - How often have you had to urinate less than every two hours?

3. Intermittency - How often have you found you stopped and started again several times when you urinated?

4. Urgency - How often have you found it difficult to postpone urination?

5. Weak Stream - How often have you had a weak urinary stream?

6. Straining - How often have you had to strain to start urination?

7. Nocturia - How many times did you typically get up at night to urinate?

The above questions assess the symptoms that are of concern for the urinary tract function, as depicted in the American Urological Association Symptom Index.

The first 6 questions have assigned the following scale of answers:

■ Not at all (0 points);

■ Less than 1 in 5 times (1 point);

■ Less than half the time (2 points);

■ About half the time (3 points);

■ More than half the time (4 points);

■ Almost always (5 points).

The seventh question refers to nocturia frequency, therefore the available answer choices are “none, once, 2, 3, 4 respectively 5 times”.

There is an extra question, which refers to the quality of life, as recommended by the WHO in collaboration with the International Union Against Cancer (UICC):

Q: If you were to spend the rest of your life with your urinary condition just the way as it is now, how would you feel about that?

■ Delighted (0 points);

■ Pleased (1 point);

■ Mostly satisfied (2 points);

■ Mixed (3 points);

■ Mostly dissatisfied (4 points);

■ Unhappy (5 points);

■ Terrible (6 points).

BPH is a condition in which prostatic enlargement (hyperplasia of stromal and epithelial cells) is due to a cause different from cancer.

Nodules form in the transition zone and impinge on the urethra, thus increasing resistance to the urine flow. The more the surrounding tissue compresses the urethra, the greater the discomfort.

BPH is the main cause of lower urinary tract symptoms and if left untreated, usually leads to urinary tract infections.

If diagnosis needs to be pursued further, patient history, physical exam and laboratory determinations are taken, plus standard evaluations for prostate cancer.

IPSS result interpretation

The overall IPSS ranges from 0 to 35, where answers closer to 0 mean that the patient is asymptomatic or does not experience serious symptoms whilst 35 mean that the patient is likely to experience severe symptoms.

According to the American Urological Association, there are three categories of symptom intensity by which the IPSS is interpreted:

■ Mild intensity– scores between 0 and 7;

■ Moderate intensity – scores between 8 and 19;

■ Severe intensity – scores between 20 and 35.

About the study

The IPSS was created by Barry et al. in 1992, following a study on 210 patients diagnosed with benign prostatic hyperplasia and 108 control subjects, under the control of a multidisciplinary measurement committee of the American Urological Association.

On revalidation, the score was internally consistent (Cronbach's alpha = 0.86) and had an excellent test-retest reliability (r = 0.92).

Scores were found to be highly correlated with the global rating of magnitude of the urinary problem, as perceived by patients. The IPSS was also found to be sensitive to change with preoperative scores decreasing after prostatectomy.

Original source

Barry MJ, Fowler FJ Jr, O'Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK, Cockett AT. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol. 1992; 148(5):1549-57; discussion 1564.

Other references

1. de Jong Y, Pinckaers JH, ten Brinck RM, Lycklama à Nijeholt AA, Dekkers OM. Urinating standing versus sitting: position is of influence in men with prostate enlargement. A systematic review and meta-analysis. PLoS One. 2014; 9(7):e101320.

2. Jiang YH, Lin VC, Liao CH, Kuo HC. International Prostatic Symptom Score-voiding/storage subscore ratio in association with total prostatic volume and maximum flow rate is diagnostic of bladder outlet-related lower urinary tract dysfunction in men with lower urinary tract symptoms. PLoS One. 2013; 8(3):e59176.