A 60-year-old man with a past medical history of hypertension comes to the physician complaining of urinary symptoms. Over the last 6 months, he has had a decreased urinary stream and an occasional uncomfortable sensation while urinating. He awakens once a night to urinate but sometimes feels that he needs to go again. The symptoms do not bother him much at this point, but he is afraid that they may worsen. He has no family history of prostate problems. He has no fever, malaise, back pain, cloudy urine, or blood in the urine.
Digital rectal examination shows a moderately enlarged and rubbery prostate. The remainder of the physical examination is unremarkable.
Laboratory results are as follows:

Which of the following is the best next step in managing this patient?

Question

A 60-year-old man with a past medical history of hypertension comes to the physician complaining of urinary symptoms.  Over the last 6 months, he has had a decreased urinary stream and an occasional uncomfortable sensation while urinating.  He awakens once a night to urinate but sometimes feels that he needs to go again.  The symptoms do not bother him much at this point, but he is afraid that they may worsen.  He has no family history of prostate problems.  He has no fever, malaise, back pain, cloudy urine, or blood in the urine.
Digital rectal examination shows a moderately enlarged and rubbery prostate.  The remainder of the physical examination is unremarkable.
Laboratory results are as follows:

Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_9906_0a47_853d_ef6c46ed8362_MD0002_00 This patient's presentation of irritative and obstructive lower urinary tract symptoms, normal urinalysis, large prostate without a focal lesion, and prostate-specific antigen (PSA) > 10 ng/mL is consistent with a prostatic disorder. PSA values have a log-linear relationship with prostate volume. However, elevated PSA has a lower specificity for prostatic cancer in men with obstructive symptoms than asymptomatic men. Prostate cancer screening is an individualized decision, and clinicians should first discuss the risks and benefits. If the patient prefers screening, most clinicians perform a digital rectal examination (DRE) and test serum PSA. Patients with normal DRE and PSA < 3 ng/mL may be followed routinely. Men with PSA > 7 ng/mL or abnormal DRE should be referred to a urologist for possible biopsy. Patients with PSA of 3-7 ng/mL should be retested in a few weeks and referred to a urologist if PSA remains > 3 ng/mL (Choice C). Although the most common cause of elevated PSA is benign prostatic hyperplasia (BPH), the positive predictive value of a PSA > 10 for prostate cancer is 15%-40%. Thus, this patient should be referred to a urologist. (Choices A and B) 5-alpha-reductase inhibitors and alpha-1-adrenergic blockers may relieve moderate to severe BPH symptoms. Treatment usually requires several weeks for optimal effect. However, this patient's mild BPH symptoms and elevated PSA require further investigation. (Choice E) A renal ultrasound would not be helpful with a normal serum creatinine. However, transrectal prostatic ultrasound can help guide prostate biopsy in selected cases. Educational objective: Patients with a normal digital rectal examination (DRE) and prostate-specific antigen (PSA) < 3 ng/mL may be followed routinely. Men with PSA > 7 ng/mL or abnormal DRE should be referred to a urologist for possible biopsy. __________ References: Clinical practice: benign prostatic hyperplasia and lower urinary tract symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/22808960) Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. (http://www.ncbi.nlm.nih.gov/pubmed/7512659)

A 60-Year-Old Man with a Past Medical History of Hypertension