A 68-year-old man comes to the physician because of increased urinary frequency and nocturia. He has not increased his daily oral fluid intake. He has no dysuria, hematuria, penile discharge, or difficulty urinating. His other medical problems include recently diagnosed hypertension and osteoarthritis of his knees.
His temperature is 36.7 C (98 F), blood pressure is 130/82 mm Hg, and pulse is 80/min. Cardiopulmonary examination is normal. There is no jugular venous distention or peripheral edema. The abdomen is soft and without suprapubic tenderness. The prostate gland is normal in size, has no distinct nodules, and is nontender.
Which of the following is the most appropriate next step in management?

Question

A 68-year-old man comes to the physician because of increased urinary frequency and nocturia.  He has not increased his daily oral fluid intake.  He has no dysuria, hematuria, penile discharge, or difficulty urinating.  His other medical problems include recently diagnosed hypertension and osteoarthritis of his knees.
His temperature is 36.7 C (98 F), blood pressure is 130/82 mm Hg, and pulse is 80/min.  Cardiopulmonary examination is normal.  There is no jugular venous distention or peripheral edema.  The abdomen is soft and without suprapubic tenderness.  The prostate gland is normal in size, has no distinct nodules, and is nontender.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_986f_e4d6_853d_2b11abba73bc_MD0002_00 Bladder storage symptoms such as frequency and nocturia are very common in older adults. Although benign prostatic hyperplasia (BPH) is a common etiology of these symptoms in men, potentially offending medications should be investigated and discontinued prior to further testing or treatment. Hydrochlorothiazide, a common first-line antihypertensive, is often the culprit in urinary frequency and nocturia. With discontinuation and change to an alternate nondiuretic antihypertensive medication, this patient's symptoms will likely resolve. If this patient is not taking hydrochlorothiazide or other diuretics, he needs urinalysis, serum chemistries, and blood glucose testing to further evaluate urinary frequency. Serum PSA testing is also reasonable in patients with prostate enlargement. (Choice B) Prostatitis and urinary tract infections are also common causes of bladder storage symptoms. A nontender, normal-sized prostate argues against a diagnosis of prostatitis. This patient has no fever, dysuria, or suprapubic tenderness. Therefore, empiric antibiotics are not warranted. (Choices C and D) First-line therapy for clinically diagnosed BPH is an alpha-adrenergic receptor blocker such as doxazosin (Cardura). If symptoms do not improve on this therapy alone, a 5-alpha reductase inhibitor such as finasteride (Proscar) is often added. However, these medications should be started only after a careful history (of bladder storage and obstructive symptoms), digital rectal examination, and laboratory studies (including a urinalysis and prostate-specific antigen serology) confirm the diagnosis. Close evaluation of possible external causes such as caffeine and daily fluid intake and offending medications should precede all further diagnostics and treatment. (Choice E) Urine culture is indicated only if the patient's urinalysis is positive or there are symptoms and signs of infection. Educational objective: Bladder storage symptoms such as frequency and nocturia are common side effects of diuretic therapy, which should be discontinued prior to further testing or treatment of benign prostatic hyperplasia. __________ References: The evaluation and treatment of nocturia: a consensus statement. (http://www.ncbi.nlm.nih.gov/pubmed/21676145)

A 68-Year-Old Man Comes to the Physician Because of Increased