A 67-year-old man comes to the office due to worsening urinary frequency, hesitancy, and nocturia for the past year. He wakes up 2 or 3 times a night to void. The patient also says that the force of his urinary stream is decreased and he feels that his bladder is not completely evacuated after voiding. He has a history of hypertension and osteoarthritis. The patient has a 35-pack-year smoking history but stopped smoking 10 years ago. Temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, and pulse is 78/min. Physical examination shows a soft and nontender abdomen. Rectal examination reveals an enlarged, smooth prostate with no nodules and normal rectal sphincter tone. Postvoid bladder scan shows 75 mL of urine (normal,

Question

A 67-year-old man comes to the office due to worsening urinary frequency, hesitancy, and nocturia for the past year.  He wakes up 2 or 3 times a night to void.  The patient also says that the force of his urinary stream is decreased and he feels that his bladder is not completely evacuated after voiding.  He has a history of hypertension and osteoarthritis.  The patient has a 35-pack-year smoking history but stopped smoking 10 years ago.  Temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, and pulse is 78/min.  Physical examination shows a soft and nontender abdomen.  Rectal examination reveals an enlarged, smooth prostate with no nodules and normal rectal sphincter tone.  Postvoid bladder scan shows 75 mL of urine (normal, <12 mL).  Serum creatinine and urinalysis are normal.  Serum prostate-specific antigen is 2.8 ng/mL (age-adjusted reference value <4.5 ng/mL).  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d477_f142_bc81_77b3df8c3363_MD0003_00 This patient's presentation is consistent with benign prostatic hyperplasia (BPH). BPH typically affects men age >50 and is the most common cause of lower urinary tract symptoms (eg, urinary frequency, urgency, weak stream, nocturia) in these patients. Prostate cancer (which is associated with elevated prostate-specific antigen levels) can also cause lower urinary tract symptoms. However, prostate cancer more often involves the periphery of the gland and presents with firm asymmetric or nodular enlargement, whereas BPH involves the center (transitional zone) and presents with smooth, nonindurated, symmetric enlargement. The preferred initial treatment for uncomplicated BPH includes alpha-1 blockers (eg, terazosin, tamsulosin), which can provide rapid relief of symptoms by relaxing bladder neck and prostatic smooth muscle. 5-alpha-reductase inhibitors (eg, finasteride) can be used in addition to alpha blockers for patients with persistent symptoms or as an alternate therapy for those who do not tolerate alpha blockers (eg, hypotension). However, they act by reducing prostate size and have a much slower onset of action (ie, months) (Choice A). (Choice C) Intermittent urinary catheterization can be used for patients with BPH who develop acute, severe urinary retention (eg, due to infection, anticholinergic medication). However, catheterization can cause significant discomfort in patients with prostatic enlargement and is not advised for those with mild to moderate obstruction. (Choice 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 prostate-specific antigen levels. (Choice E) Invasive interventions for BPH (eg, transurethral resection, radiofrequency ablation) are generally advised only for patients who fail medical management or have more significant obstructive complications (eg, hydronephrosis, recurrent infection). (Choice F) Urodynamic studies are used to assess detrusor function in patients with symptoms of overactive bladder or known neurologic disease. They are also used in patients with BPH who fail initial treatment or have an atypical presentation (eg, age <50). Educational objective: The preferred initial treatment for uncomplicated benign prostatic hyperplasia includes alpha-1 blockers, which can provide rapid relief of symptoms. 5-alpha-reductase inhibitors can be used as an alternative or in addition to alpha blockers but have a much slower onset of action. References: Update on AUA guideline on the management of benign prostatic hyperplasia. (http://www.ncbi.nlm.nih.gov/pubmed/21420124) Alpha-blockers for the treatment of benign prostatic hyperplasia. (http://www.ncbi.nlm.nih.gov/pubmed/27476124)

A 67-Year-Old Man Comes to the Office Due to Worsening