Family Medicine · Year 3 · from Family Medicine

Case 1: Benign Prostatic Hyperplasia

Patient Demographics

  • Age: 67 years old
  • Sex: Male
  • Occupation: Retired postal worker

Chief Complaint

"I'm getting up to urinate four or five times every night and it's really affecting my sleep."

History of Present Illness

Mr. Robert Chen is a 67-year-old man presenting with progressive lower urinary tract symptoms over the past 18 months. He reports nocturia four to five times nightly, urinary frequency during the day (voiding every 2-3 hours), hesitancy taking 30-60 seconds to initiate urination, weak urinary stream, and a sensation of incomplete bladder emptying. He denies dysuria, hematuria, or urinary incontinence. He has not had any episodes of acute urinary retention. The symptoms have significantly impacted his quality of life, causing daytime fatigue and difficulty concentrating due to disrupted sleep.

Past Medical History

  • Type 2 diabetes mellitus (well-controlled, HbA1c 6.8%)
  • Hypertension on lisinopril
  • Hyperlipidemia on atorvastatin

Medications

  • Lisinopril 20 mg daily
  • Atorvastatin 40 mg daily
  • Metformin 1000 mg twice daily

Family History

  • Father: BPH, prostatectomy at age 72
  • No family history of prostate cancer

Social History

  • Non-smoker
  • Occasional alcohol (1-2 beers on weekends)
  • Married, two adult children
  • Moderate caffeine intake (2-3 cups coffee daily)

Physical Examination

  • Vital Signs: BP 132/78 mmHg, HR 72, BMI 28
  • General: Well-appearing, no acute distress
  • Abdomen: Soft, non-tender, no suprapubic fullness or masses
  • Digital Rectal Examination:
  • Prostate: Symmetrically enlarged, approximately 50 grams
  • Smooth, rubbery consistency
  • No nodules or asymmetry
  • Non-tender
  • Median sulcus palpable

Clinical Image

Image: Anatomical diagram demonstrating benign prostatic hyperplasia with enlargement of the transition zone compressing the prostatic urethra, leading to bladder outlet obstruction.

Image Source: Wikimedia Commons Attribution: BruceBlaus, CC BY-SA 4.0 URL: https://commons.wikimedia.org/wiki/File:Benign_Prostatic_Hyperplasia.png

Laboratory and Diagnostic Studies

  • Urinalysis: Normal, no infection
  • PSA: 3.2 ng/mL (within normal limits for age)
  • Serum creatinine: 1.1 mg/dL (normal)
  • Post-void residual (bladder scan): 120 mL (mildly elevated)
  • International Prostate Symptom Score (IPSS): 19 (moderate symptoms)
  • IPSS Bother Score: 5/6 (significantly bothered)

Assessment and Diagnosis

  1. Benign prostatic hyperplasia with moderate lower urinary tract symptoms (IPSS 19)
  2. Nocturia - significantly impacting quality of life
  3. Type 2 diabetes mellitus - well controlled
  4. Hypertension - controlled

Management Plan

Lifestyle Modifications:

  • Reduce evening fluid intake, especially 2-3 hours before bedtime
  • Reduce caffeine consumption
  • Avoid alcohol close to bedtime
  • Practice double voiding (void, wait, void again)
  • Avoid over-the-counter decongestants containing pseudoephedrine

Pharmacologic Treatment:

  • Tamsulosin 0.4 mg daily (alpha-1 adrenergic blocker)
  • Start at bedtime to minimize orthostatic hypotension
  • Expect symptom improvement within 1-2 weeks
  • Counseled about potential side effects: dizziness, retrograde ejaculation, nasal congestion
  • Warned about intraoperative floppy iris syndrome if cataract surgery needed

Patient Education:

  • Explained the nature of BPH and that it is not prostate cancer
  • Discussed the natural history: variable progression
  • Reviewed when to seek urgent care (complete inability to urinate)

Follow-Up

  • Return in 4-6 weeks to assess symptom response
  • Repeat IPSS at follow-up to quantify improvement
  • If inadequate response, consider adding a 5-alpha reductase inhibitor (finasteride) given prostate size >30-40g
  • Annual PSA monitoring with shared decision-making discussion

Teaching Points

  1. IPSS scoring guides treatment: Mild (0-7) = watchful waiting; Moderate (8-19) = medical therapy; Severe (20-35) = consider surgery referral
  1. Alpha-blockers provide rapid relief (days to weeks) through smooth muscle relaxation in the prostate and bladder neck
  1. 5-alpha reductase inhibitors (finasteride, dutasteride) take 6-12 months for full effect but reduce prostate size and progression risk; remember they reduce PSA by approximately 50%
  1. Digital rectal examination findings: Smooth, rubbery, symmetric enlargement suggests BPH; nodules, asymmetry, or firmness require urology referral and further evaluation for malignancy
  1. Tamsulosin and cataract surgery: Patients should inform ophthalmologists about alpha-blocker use due to intraoperative floppy iris syndrome risk

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