Benign Prostatic Hyperplasia (BPH)

Elderly male presents with chronic urinary frequency. Reports urgency, weak stream, straining, and nocturia. Denies fever, dysuria, gross hematuria, flank pain. No history of tobacco use, DM, prostate cancer, excessive caffeine intake, or sexual dysfunction. No h/o urologic surgery. Digital rectal exam reveals normal sphincter tone, enlarged prostate, and bladder distention.

  • Obtain urinalysis

  • Life expectancy >10 years: Obtain PSA s/p shared decision making

  • Post void residual showing >100 mL urine

  • Moderate/severe symptoms and no plans for cataract surgery: Start tamsulosin 0.4 mg daily

  • Pt encouraged to keep voiding diary between now and next appointment

  • Pt counseled against using alternative therapies such as saw palmetto

Notes

  • Differential diagnosis

    • Rule out common causes of neurogenic bladder, e.g. diabetes

    • Urinalysis

      • If normal, rules out UTI, nephrolithiasis, bladder cancer

      • Positive for hematuria in approximately 10% of cases

  • Alpha blocker (e.g. tamsulosin) are contraindicated in patients undergoing cataract surgery due to risk for intraoperative floppy iris syndrome

  • Referral for surgery (transurethral resection of the prostate) may be considered for the following:

    • Symptoms uncontrolled with medical therapy

    • Development of bladder calculi

    • Gross and/or microscopic hematuria

    • Recurrent urinary tract infections

    • Renal insufficiency