Benign Prostatic Hyperplasia

BENIGN PROSTATIC HYPERPLASIA 39A

A 68-year-old man presents to the primary care clinician with a complaint of urinary frequency. The patient has noted increased urinary urgency and frequency for approximately 1 year, which have progressively worsened. He now seems to have to urinate “all the time,” including four times each night, and often feels like he has not completely emptied his bladder. In addition, in the past month, he sometimes has postvoid dribbling. The family history is negative for malignancy. On examination, he appears healthy. His prostate is diffusely enlarged without focal nodule or tenderness.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Man of advancing age; chronic progressive urinary frequency and urgency; poor bladder emptying; nocturia; postvoid dribbling; prostate enlargement without nodules or tenderness

How to think through: Progressive lower urinary tract symptoms are so common in older men that clinicians must maintain a broad differential diagnosis before reaching a diagnosis of benign prostatic hyperplasia (BPH). In addition to BPH, what other processes could account for this patient’s symptoms? (Urinary tract infection [UTI], prostatitis, polyuria caused by metabolic disturbance such as diabetes mellitus or insipidus, neurogenic bladder, urethral stricture, anticholinergic and sympathomimetic medications, or bladder or prostate cancer.) Is BPH a risk factor for prostate cancer? (Because both are common, analysis of data is complicated, but evidence suggests that it is not.) How should this patient be evaluated? (Thorough review of systems, including constitutional symptoms and bone pain suggesting cancer; family history; abdominal examination; prostatic digital rectal examination [DRE]; neurologic examination; urinalysis [to detect infection or blood]. If there is concern for urinary retention, obtain a postvoid ultrasound of the bladder for residual urinary volume and serum creatinine.) How should he be treated? (α-Blockers are the first-line therapy; 5-α-reductase inhibitors are adjunct agents, taking several months for maximal effect and being minimally effective without concurrent α-blocker. Surgical intervention, such as transurethral resection of the prostate, is considered for refractory symptoms, urinary retention, recurrent UTI, and obstructive nephropathy.)