A 67-year-old man comes to the office for an annual examination. He generally feels well, although when asked about urinary problems, the patient says that he urinates 2 or 3 times per night and occasionally has to strain to initiate urination. He takes no medications. The patient does not use tobacco, alcohol, or drugs. His father died of prostate cancer at age 84.
Temperature is 36.5 C (97.7 F), blood pressure is 126/74 mm Hg, pulse is 84/min, and respirations are 12/min. Cardiac, pulmonary, and abdominal examinations are within normal limits. Rectal examination reveals a prostate that is mildly enlarged, symmetric, and nontender. Rectal sphincter tone is normal.
Urinalysis and serum creatinine level are normal.
Which of the following is the most appropriate next step in management of this patient?

Question

A 67-year-old man comes to the office for an annual examination.  He generally feels well, although when asked about urinary problems, the patient says that he urinates 2 or 3 times per night and occasionally has to strain to initiate urination.  He takes no medications.  The patient does not use tobacco, alcohol, or drugs.  His father died of prostate cancer at age 84.
Temperature is 36.5 C (97.7 F), blood pressure is 126/74 mm Hg, pulse is 84/min, and respirations are 12/min.  Cardiac, pulmonary, and abdominal examinations are within normal limits.  Rectal examination reveals a prostate that is mildly enlarged, symmetric, and nontender.  Rectal sphincter tone is normal.
Urinalysis and serum creatinine level are normal.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98f7_8b36_853d_9b495a1084c1_MD0002_00 This patient has lower urinary tract symptoms (eg, nocturia, hesitancy), most likely due to benign prostatic hyperplasia (BPH). Other common BPH symptoms include urinary frequency and decreased force of stream. Examination may show prostate enlargement, but symptoms do not correlate well with prostate size. Initial evaluation should include urinalysis to rule out hematuria (eg, due to bladder cancer) and infection and serum creatinine to screen for obstructive renal injury. Many experts also advise prostate-specific antigen testing for patients with lower urinary tract symptoms. BPH symptoms usually progress gradually, but some patients may experience regression over time. Severity is often scored based on number of symptoms (eg, frequency, nocturia, weak urinary stream, hesitancy, intermittence, incomplete emptying, urgency). For those with mild symptoms, such as this patient, simple behavioral modifications may be adequate. Interventions include shifting fluid intake to earlier in the day, decreasing caffeine and alcohol intake, and double voiding to more thoroughly empty the bladder. Patients with more severe symptoms or obstructive complications (eg, bladder infections, bladder stones, renal impairment) warrant more aggressive management (eg, medication, invasive interventions). For those with mild symptoms, such as this patient, simple behavioral modifications may be adequate. Interventions include shifting fluid intake to earlier in the day, decreasing caffeine and alcohol intake, and double voiding to more thoroughly empty the bladder. Patients with more severe symptoms or obstructive complications (eg, bladder infections, bladder stones, renal impairment) warrant more aggressive management (eg, medication, invasive interventions). (Choice B) When medication is indicated, alpha-1-adrenergic antagonists (eg, tamsulosin, terazosin) are the preferred first-line treatment. 5-alpha-reductase inhibitors (eg, finasteride) are generally less effective and slower to act, and are most effective in men with a large prostate volume rather than in those with mild enlargement (as in this patient). (Choice C) Measuring postvoid residual volume is useful in patients with urge incontinence who are being considered for treatment with an anticholinergic agent or in those with BPH and symptoms of overflow incontinence (eg, involuntary leakage of urine). However, it is not indicated in patients with mild BPH symptoms. (Choice D) Abdominal ultrasound is indicated to evaluate obstructive uropathy or suspected hydronephrosis, which are less likely in this patient with mild symptoms and normal renal function. (Choice E) Urethrocystoscopy is not recommended for routine evaluation of BPH. It is typically used for patients with suspected calculi, urethral strictures, or bladder cancer, or for surgical planning in men with severe BPH. Educational objective: For patients with mild benign prostatic hyperplasia, simple behavioral modifications (eg, shifting fluid intake to earlier in the day, decreasing caffeine and alcohol intake, double voiding) may be adequate. Patients with more severe symptoms or obstructive complications (eg, bladder infections, bladder stones, renal impairment) warrant more aggressive management. __________ References: Common questions about the diagnosis and management of benign prostatic hyperplasia. (http://www.ncbi.nlm.nih.gov/pubmed/25611711)

A 67-Year-Old Man Comes to the Office for an Annual