A 63-year-old man comes to the physician for a periodic health evaluation. He reports nocturia once or twice per night, and he has noticed a decrease in the size and force of his urinary stream over the past six months. These symptoms mildly affect his quality of life. There is no additional past medical or surgical history and review of symptoms is otherwise unremarkable. His father suffered from benign prostatic hyperplasia and underwent prostate surgery. His mother passed away from breast cancer at the age of 74.
On examination, he appears healthy. His blood pressure is 128/82 mm Hg and pulse is 72/min. General physical examination is within normal limits. On digital rectal examination, his prostate is mildly enlarged. There is a firm 1 cm nodule in the right lateral lobe of the prostate.
Laboratory results are as follows:

Which of the following is the best next step in this patient's management?

Question

A 63-year-old man comes to the physician for a periodic health evaluation.  He reports nocturia once or twice per night, and he has noticed a decrease in the size and force of his urinary stream over the past six months.  These symptoms mildly affect his quality of life.  There is no additional past medical or surgical history and review of symptoms is otherwise unremarkable.  His father suffered from benign prostatic hyperplasia and underwent prostate surgery.  His mother passed away from breast cancer at the age of 74.
On examination, he appears healthy.  His blood pressure is 128/82 mm Hg and pulse is 72/min.  General physical examination is within normal limits.  On digital rectal examination, his prostate is mildly enlarged.  There is a firm 1 cm nodule in the right lateral lobe of the prostate.
Laboratory results are as follows:

Which of the following is the best next step in this patient's management?

Quizplus · Accepted Answer

11ec193a_9903_7231_853d_4f3bd5916075_MD0002_00 Digital rectal examination can detect focal prostatic abnormalities (nodule or significant asymmetry) in 2-3% of men > age 50; however, its positive predictive value for prostate cancer ranges from 5-30%. A significant number of men with prostate cancer have PSA values < 4.0 ng/mL, and a small but significant percentage have values < 2.0 ng/mL. Current guidelines (shown in the above table) recommend transrectal ultrasound (TRUS) guided prostate biopsy for all men with prostatic nodules, independent of the PSA value or symptoms (Choices B and C). Transrectal ultrasound is usually preformed in the urologist's office with antibiotic prophylaxis, and it can assess prostate volume in addition to improving biopsy accuracy. However, repeat biopsy may be indicated in many patients. (Choice A) Endorectal coil MRI involves placing an endorectal probe to better visualize seminal vesical involvement or extraprostatic extension in patients with localized prostate cancer. It is typically used in conjunction with TRUS biopsy for staging the extent of known prostate cancer, but not for the initial investigation of a prostate nodule. (Choice E) Tamsulosin may improve the mild signs and symptoms of benign prostatic hyperplasia seen in this patient, but the management of this patient's prostate nodule takes priority. Additionally, even without pharmacotherapy, many patients with mild BPH experience improvement or stabilization of symptoms. Educational objective: Prostatic nodules found on digital rectal examination should be promptly evaluated by transrectal ultrasound (TRUS) guided prostatic biopsy, regardless of the PSA level. __________ References: Transrectal sonography in prostate evaluation. (http://www.ncbi.nlm.nih.gov/pubmed/17030220) Indications and timing for prostate biopsy, diagnosis of early stage prostate cancer and its definitive treatment: a clinical conundrum in the PSA era (http://www.ncbi.nlm.nih.gov/pubmed/19282170) Early detection of prostate cancer. Part I. Prior probability and effectiveness of tests. (http://www.ncbi.nlm.nih.gov/pubmed/9054286)

A 63-Year-Old Man Comes to the Physician for a Periodic