A 68-year-old man comes to the office due to worsening nocturia for the past several months. Lately, he has been waking up every 3-4 hours at night to urinate, which is severely disrupting his sleep. The patient also has increased urinary urgency and frequency during the day but no pain or burning sensation. He has a history of hypertension and takes lisinopril. The patient has a remote history of smoking and does not use alcohol or illicit drugs. Blood pressure is 130/80 mm Hg and pulse is 82/min. The abdomen is soft and nontender. There is no costovertebral angle tenderness. Rectal examination shows a diffusely enlarged and nontender prostate with a smooth surface. Which of the following is the best next step in evaluation of this patient?

Question

A 68-year-old man comes to the office due to worsening nocturia for the past several months.  Lately, he has been waking up every 3-4 hours at night to urinate, which is severely disrupting his sleep.  The patient also has increased urinary urgency and frequency during the day but no pain or burning sensation.  He has a history of hypertension and takes lisinopril.  The patient has a remote history of smoking and does not use alcohol or illicit drugs.  Blood pressure is 130/80 mm Hg and pulse is 82/min.  The abdomen is soft and nontender.  There is no costovertebral angle tenderness.  Rectal examination shows a diffusely enlarged and nontender prostate with a smooth surface.  Which of the following is the best next step in evaluation of this patient?

Quizplus · Accepted Answer

11ec25c8_d28d_3922_bc81_030c3696fc34_MD0003_00 This patient has lower urinary tract symptoms (LUTS) (eg, urinary frequency, nocturia, hesitancy) most likely due to benign prostatic hyperplasia (BPH). However, LUTS are not specific for BPH and can sometimes occur in advanced prostate cancer. Rectal examination may help differentiate prostate cancer from BPH; nodules, induration, and asymmetry favor malignancy, whereas BPH is characterized by smooth, symmetric enlargement of the prostate. Patients with LUTS should have a urinalysis to evaluate for hematuria (eg, bladder cancer, kidney stones) and infection. Although routine screening for prostate cancer in asymptomatic individuals is not advised, a prostate-specific antigen (PSA) level should be obtained in symptomatic patients to assess the risk for prostate cancer unless predicted life expectancy is <10 years. A serum creatinine test is not required in the routine evaluation of uncomplicated BPH but is recommended by some expert panels, especially for patients with more significant symptoms or additional risk factors (eg, hypertension, diabetes) for chronic kidney disease. (Choice A) Cystoscopy in patients with BPH can reveal signs of chronic bladder obstruction but is nonspecific and usually reserved for those who have failed initial management. It is also used to visualize the lower urinary tract in patients with hematuria, usually in combination with imaging of the upper tract (eg, CT scan of the kidneys and ureters). (Choice B) Intravenous urography (also called intravenous pyelography) is used to evaluate ureteral obstruction (eg, kidney stones) or anatomic variants (eg, horseshoe kidney). It can also be used in conjunction with other modalities in the evaluation of renal cell or transitional cell carcinoma. (Choices C and D) Prostate biopsy is indicated for patients with signs of prostate cancer, such as grossly asymmetric enlargement of the prostate, palpable nodules, or persistently elevated PSA levels. Prostate ultrasound is useful for guiding needle biopsy in the evaluation of suspected prostate cancer. Educational objective: Patients with lower urinary tract symptoms (eg, urinary frequency, nocturia, hesitancy) should have a urinalysis to evaluate for hematuria and infection. Prostate-specific antigen should also be obtained in symptomatic patients to assess the risk for prostate cancer unless predicted life expectancy is <10 years. References: Update on AUA guideline on the management of benign prostatic hyperplasia. (http://www.ncbi.nlm.nih.gov/pubmed/21420124)

A 68-Year-Old Man Comes to the Office Due to Worsening