A 64-year-old man comes to the office due to urinary urgency, straining to urinate, a sensation of incomplete bladder evacuation, and frequent nocturia over the past several months. He has had no dysuria, fever, chills, abdominal or perineal pain, or penile discharge. The patient had similar symptoms in the past, which had improved after undergoing transurethral resection of the prostate (TURP) 5 years ago. He has no other medical conditions and takes no medications. Vital signs are within normal limits. Physical examination shows a soft and nontender abdomen. There are no external genital lesions, and the perineal sensation is normal. Digital rectal examination shows normal anal sphincter tone and a nontender prostate. Urine dipstick is negative for blood, leukocyte esterase, or nitrites. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 64-year-old man comes to the office due to urinary urgency, straining to urinate, a sensation of incomplete bladder evacuation, and frequent nocturia over the past several months.  He has had no dysuria, fever, chills, abdominal or perineal pain, or penile discharge.  The patient had similar symptoms in the past, which had improved after undergoing transurethral resection of the prostate (TURP) 5 years ago.  He has no other medical conditions and takes no medications.  Vital signs are within normal limits.  Physical examination shows a soft and nontender abdomen.  There are no external genital lesions, and the perineal sensation is normal.  Digital rectal examination shows normal anal sphincter tone and a nontender prostate.  Urine dipstick is negative for blood, leukocyte esterase, or nitrites.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d928_5a2b_bc81_cb9783004e28_MD0003_00 Although this patient with a history of benign prostatic hyperplasia (BPH) had a transurethral resection of the prostate (TURP) 5 years ago to reduce the size of the prostate, this surgical procedure does not prevent remaining prostate tissue from growing back. Under the influence of androgens, the leftover prostate tissue will continue to enlarge and may obstruct the bladder again. Therefore, symptoms of BPH (eg, urinary urgency, straining to urinate, a sensation of incomplete bladder evacuation, frequent nocturia) may return years after the procedure. Physical examination is not sensitive for BPH and may show a normal prostate. If the urinary symptoms are bothersome, then recurrent BPH can be treated medically with alpha blockers, 5-alpha reductase inhibitors, or phosphodiesterase type 5 inhibitors; alternatively, a repeat TURP or another surgical procedure can also be performed. (Choice B) Chronic prostate inflammation (ie, chronic prostatitis/chronic pelvic pain syndrome) can present with urinary frequency, hesitancy, and retention with an unremarkable urinalysis; however, the main symptom is pain (usually perineal), and dysuria or pain with ejaculation are also often present. Physical examination may show a mildly tender prostate. (Choice C) Common complications of TURP include urethral stricture formation, urinary incontinence, and bladder neck stenosis, but not iatrogenic pudendal nerve injury. Moreover, pudendal nerve injury is likely to present immediately after surgery, and loss of sensation in the perineum would be evident on physical examination. (Choice D) Neurogenic detrusor overactivity usually presents with frequent urination or urinary urgency but not straining to urinate. It can be caused by stroke, spinal cord injury, Parkinson disease, and multiple sclerosis. (Choice E) Pelvic floor muscle dysfunction may present with frequent urination, straining to urinate, and nocturia. However, it is much more prevalent in women, and additional symptoms (eg, constipation, difficulty eliminating stool) may be present. Because this dysfunction is caused by impaired relaxation of pelvic muscles, anal sphincter tone is often increased. Educational objective: Transurethral resection of the prostate is an effective treatment for benign prostatic hyperplasia. However, this procedure does not preclude the prostate tissue from growing back and causing bladder outlet obstruction. Other common complications of this procedure are urinary incontinence and urethral stricture. References: The changing practice of transurethral resection of the prostate. (http://www.ncbi.nlm.nih.gov/pubmed/29543050)

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