Reproductive · Year 2 · from Reproductive
Case 1: Benign Prostatic Hyperplasia
Clinical Image
Source: Wikipedia - Benign prostatic hyperplasia - Public Domain
Case Presentation
A 68-year-old male presents to his primary care physician with a 2-year history of progressive urinary symptoms. He reports urinary frequency (voiding every 2-3 hours during the day), nocturia (3-4 times per night), weak urinary stream, hesitancy, and a sensation of incomplete bladder emptying. He denies hematuria, dysuria, or incontinence. His International Prostate Symptom Score (IPSS) is 22 (severe). Medical history includes hypertension controlled with lisinopril. Physical examination reveals a non-tender, symmetrically enlarged prostate estimated at 50 grams on digital rectal examination, with a rubbery consistency and no nodules. PSA is 3.8 ng/mL (within normal range for his age). Urinalysis is normal. Post-void residual volume is 120 mL. The diagnosis is benign prostatic hyperplasia with moderate-to-severe lower urinary tract symptoms. Treatment is initiated with combination therapy: tamsulosin (alpha-blocker) for rapid symptomatic relief and finasteride (5-alpha reductase inhibitor) for long-term prostate volume reduction. The patient is counseled that finasteride will reduce his PSA by approximately 50%, which must be accounted for in future prostate cancer screening.
Key Learning Points
- BPH develops in the transition zone of the prostate and causes lower urinary tract symptoms (LUTS) through both static (mechanical obstruction) and dynamic (smooth muscle tone) components
- Alpha-blockers (tamsulosin, alfuzosin) provide rapid symptomatic relief by relaxing prostatic smooth muscle; 5-alpha reductase inhibitors (finasteride, dutasteride) shrink the prostate over 6-12 months
- Combination therapy is most effective for larger prostates (>40 mL) with moderate-to-severe symptoms
- PSA is elevated in BPH as well as prostate cancer; 5-alpha reductase inhibitors reduce PSA by approximately 50%