A 64-year-old man comes to the office due to frequent urination. He has a history of benign prostatic hyperplasia with mild hesitancy and occasional nocturia. During the past 8 weeks, he has been bothered by 2 or 3 episodes of nocturia each night and increased urinary urgency. The patient has no dysuria or hematuria and says that his daytime urinary frequency is unchanged. He also has shortness of breath with exertion. His medical history includes hypertension, hypercholesterolemia, and non-ischemic cardiomyopathy with a left ventricular ejection fraction of 40% on an echocardiogram a year ago. The patient's medications include furosemide, carvedilol, lisinopril, spironolactone, and atorvastatin.
Blood pressure is 140/80 mm Hg, pulse is 76/min, and respirations are 16/min. Pulmonary examination reveals bilateral basal crackles. Rectal examination shows a diffusely enlarged prostate. He has 2+ pitting edema of the bilateral lower extremities.
Serum sodium is 133 mEq/L, potassium is 3.9 mEq/L, and creatinine is 1.1 mg/dL. Urinalysis is normal.
Which of the following is the most appropriate next step in management of this patient?

Question

A 64-year-old man comes to the office due to frequent urination.  He has a history of benign prostatic hyperplasia with mild hesitancy and occasional nocturia.  During the past 8 weeks, he has been bothered by 2 or 3 episodes of nocturia each night and increased urinary urgency.  The patient has no dysuria or hematuria and says that his daytime urinary frequency is unchanged.  He also has shortness of breath with exertion.  His medical history includes hypertension, hypercholesterolemia, and non-ischemic cardiomyopathy with a left ventricular ejection fraction of 40% on an echocardiogram a year ago.  The patient's medications include furosemide, carvedilol, lisinopril, spironolactone, and atorvastatin.
Blood pressure is 140/80 mm Hg, pulse is 76/min, and respirations are 16/min.  Pulmonary examination reveals bilateral basal crackles.  Rectal examination shows a diffusely enlarged prostate.  He has 2+ pitting edema of the bilateral lower extremities.
Serum sodium is 133 mEq/L, potassium is 3.9 mEq/L, and creatinine is 1.1 mg/dL.  Urinalysis is normal.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient with benign prostatic hyperplasia (BPH) has worsening nocturia without increase in daytime urinary frequency. He also has signs of fluid retention suggesting worsening heart failure (HF). Patients with congestive HF have decreased renal plasma flow and increased filtration fraction during ambulation. These are associated with sodium retention. Nighttime recumbency improves renal perfusion and sodium excretion, resulting in nocturia. Uncontrolled congestive HF (volume overload) or conditions such as chronic obstructive pulmonary disease (increased intra-abdominal pressure from coughing and downward displacement of the diaphragm) can worsen symptoms of BPH. The first step in management is to optimize volume status by increasing the dose of diuretics. (Choices B and C) If symptoms of BPH persist in the absence of other inciting factors and after instituting behavioral interventions, an alpha-1-adrenergic antagonist and, if necessary, a 5-alpha-reductase inhibitor should be started. (Choice D) Anticholinergic agents such as tolterodine or oxybutynin may be used in BPH with significant irritative symptoms (eg, urgency, incontinence) but should not be started until the patient is euvolemic. (Choice E) Beta blockers should be continued in patients with mild CHF exacerbations without signs of hypotension; discontinuing beta blockers during mild exacerbations has been associated with increased mortality. Educational objective: Decompensated heart failure can worsen symptoms of benign prostatic hyperplasia (BPH). Volume overload should be treated with increased diuretic doses before adjustments are made to the BPH regimen. __________ References: Diagnosis and management of benign prostatic hyperplasia. (http://www.ncbi.nlm.nih.gov/pubmed/18533373) Reducing readmissions for congestive heart failure. (http://www.ncbi.nlm.nih.gov/pubmed/11327436)

A 64-Year-Old Man Comes to the Office Due to Frequent