A 68-year-old man comes to the office due to a weak urinary stream, hesitancy, and straining on micturition. These symptoms have been present for the past 2 years but have gradually become more severe and are beginning to affect his quality of life. The patient recently started noticing continuous urine leakage, nocturia, frequent urination, and urgency. He has no other medical problems and takes no medications. The patient does not use tobacco or alcohol. He is a business management consultant and motivational speaker. Vital signs are normal. BMI is 27 kg/m². The patient's kidneys are most likely to demonstrate which of the following findings?

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11ec160b_3a2b_9a5f_9249_9f96181329fd_MD0001_00 This patient has progressive lower urinary tract symptoms, likely due to benign prostatic hyperplasia (BPH). BPH is common in older men and is characterized by a combination of epithelial and stromal hyperplasia, predominantly in the periurethral and transition zones. On palpation, the prostate has a rubbery consistency, in contrast to prostate cancer, in which the gland is nodular and very firm. As the prostate enlarges it impinges on the prostatic urethra, causing progressively worsening bladder outlet obstruction. This leads to problems voiding (eg, hesitancy, straining, weak urinary stream) and impaired urine storage (eg, daytime frequency, urgency, nocturia). As BPH progresses, incomplete bladder emptying leads to overflow incontinence (involuntary urine spillage from an overly full bladder). Increased hydrostatic force is needed to overcome the obstruction, causing hypertrophy of the bladder wall musculature and dilation of the ureters, renal pelvis, and calyces (hydronephrosis). If left untreated, urinary reflux can lead to significant pressure-induced parenchymal atrophy with scarring and eventual chronic kidney disease. (Choice A) Glomerular sclerosis and hyalinosis are typical of diabetic nephrosclerosis and focal segmental glomerulosclerosis (FSGS). Diabetes can cause autonomic neuropathy with overflow incontinence, but it is rare and typically occurs in poorly controlled chronic diabetes. FSGS does not cause lower urinary tract symptoms. (Choice B) Hyperplastic arteriolar changes are seen in severe (malignant) hypertension. Hypertension does not cause lower urinary tract symptoms. Additionally, this patient does not have a history of high blood pressure or symptoms associated with malignant hypertension (eg, headache, blurred vision). (Choice C) Ischemic tubular necrosis results from decreased renal perfusion (eg, sepsis, hemorrhage, heart failure). Patients develop oliguria, azotemia (elevated blood levels of nitrogenous wastes), elevated serum creatinine, and electrolyte disturbances. (Choice E) Epithelial dysplasia (eg, alterations in cell shape and size, nuclei size, and staining) is considered a precursor of malignancy. BPH does not predispose to renal tubular dysplasia or prostate cancer. Educational objective: Benign prostatic hyperplasia leads to progressive bladder outlet obstruction. Over time, increased urinary pressures can cause hydronephrosis and renal parenchymal atrophy with scarring. This can progress to chronic kidney disease.

A 68-Year-Old Man Comes to the Office Due to a Weak