BPH Diagnosis and management

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DISCUSSION POST # 1   Reply to Nozomi

 

Benign prostatic hyperplasia (BPH).

 

Based on the patient’s history and the results of the physical exam, the most likely diagnosis is benign prostatic hyperplasia (BPH). According to Cash et al. (2021), some of the common presenting symptoms of BPH are difficulty with initiating urine, feeling that bladder is not completely emptied after voiding, post-void dribbling, nocturia, and urinary frequency. Furthermore, digital rectal examination (DRE) for patients with BPH often shows enlarged, non-tender prostate that is symmetrical (McVary, 2023). Additionally, some of the predisposing factors to BPH include the African American race, advanced age, family history of BPH, diabetes, obesity, sedentary lifestyle, and high amounts of alcohol consumption (Cash et al., 2021). This patient in this scenario has some characteristics that may predispose him to higher risk of developing BPH, and several of his symptoms resemble those of BPH.

Diagnosis of BPH is established when there is a presence of voiding and storage urinary symptoms, such as urinary frequency and stream change, and other causes of lower urinary symptoms, such as urinary frequency and altered urine stream, are ruled out (McVary, 2023). For example, urinalysis and urine culture may be done to rule out cystitis and urinary tract infection (Cash et al., 2021). Prostate-specific antigen is often elevated with BPH, but it is not necessary in the diagnosis of BPH (Cash et al., 2021). Thus, the diagnosis of BPH is usually made based on clinical findings and patient history.

Non-pharmacological approaches for the treatment of BPH include lifestyle modifications, such as limiting fluid prior to bedtime, limiting diuretics such as caffeine, avoiding constipation, Kegel exercises, and weight management (McVary, 2023). Pharmacological treatment options include long-acting alpha-1 antagonists, such as terazosin, or 5-alpha-reductase inhibitors, such as finasteride (Cash et al., 2021). Patients should be seen for a follow-up appointment in 2 to 3 weeks to monitor symptoms and to assess for reaction to treatment. If medical management fails, or if there are complicated lower urinary symptoms present, the patient may need to be referred to urology for other interventions, such as transurethral incision of the prostate (Cash et al., 2021). Some examples of complicated symptoms that warrant referral to urology are history of prostate cancer, stroke, and microscopic hematuria, and persistent urinary tract infections (Cash et al., 2021).

One possible differential diagnosis is chronic prostatitis, which may manifest with urinary frequency, hesitancy, fever, low back pain, and nocturia (Cash et al., 2021). Although this patient in the scenario denies pain with urination, it is important to note that prostatitis, especially chronic bacterial prostatitis, may be asymptomatic between acute episodes, and therefore may not cause fever or chills (Cash et al., 2021). Other possible symptoms are perineal or suprapubic pain, hematuria, and recurrent UTI (Cash et al., 2021). Even though urinary frequency may be a possible symptom in prostatitis, it can be ruled out at this time, since this patient has no signs symptoms of infection. Additionally, this patient denies suprapubic or perineal tenderness.

Another possible differential diagnosis is prostate cancer, which is often asymptomatic at the time of presentation. Though uncommon, some of the possible lower urinary tract symptoms are frequency, urgency, nocturia, and hesitancy (Taplin & Smith, 2023). On DRE, prostate cancer may present with nodules, induration, or asymmetry (Taplin & Smith, 2023), which are not what was seen in the examination for this patient. It is crucial to remember that DRE may not always be able to detect tumors, because it only allows the practitioner to palpate the posterior and lateral aspects of the prostate gland (Taplin & Smith, 2023). It is estimated that 25% to 35% of tumors are not reachable and they are too small to be detected by DRE (Taplin & Smith, 2023). Thus, even though prostate cancer may be ruled out at this time due to its unlikeliness compared to BPH, it cannot be completely ruled out.

A third possible differential diagnosis urethral stricture, which may present with chronic obstructive voiding symptoms, such as incomplete bladder emptying and decreased urine stream (Peterson, 2021), which are two symptoms the patient in this scenario is reporting. Other possible symptoms are spraying of urinary stream and dysuria. According to Peterson (2021), urethral strictures are often idiopathic, and it is a fairly common condition. Although some characteristics of urethral stricture resemble those obtained from this patient’s history, BPH is more likely due to the DRE findings.

 

DISCUSSION POST # 2  Reply to Claire

This is a 65 y/o African American male with cues for benign prostate enlargement. The cues for this diagnosis are complaints of painless, frequent urination every 45 minutes to an hour for the past five months, and lack of a recent physical examination or labs drawn. A digital rectal exam reveals an enlarged, firm, smooth, symmetrical prostate. Madersbacher et al. (2019) states:

Benign prostatic hyperplasia (BPH) is the most frequent disease in aging men. In the 4th decade of life, BPH is demonstrable in 30–40% of men, and its prevalence increases almost linearly to 70–80% in those older than 80 years. BPH, however, is a purely histological definition and must be distinguished from benign prostatic enlargement (BPE), which describes an enlarged prostate, and lower urinary tract symptoms (LUTS), which usually lead to medical consultation. LUTS can be separated into storage symptoms (urgency, frequency, nocturia, and urge urinary incontinence), voiding symptoms (reduced flow and feeling of incomplete emptying), and post-void dribbling.

 

Differential Dx:

      1) Neurogenic bladder

Leslie et al. (2022) state:

The micturition process is controlled by the central nervous system, which coordinates the activity of the sympathetic and parasympathetic networks with the somatic nervous system to maintain urinary continence. Therefore, the timing and clinical course of the voiding dysfunction should be documented, as well as any bowel issues, sexual dysfunction, or neurological deficits. Classic presentations include patients with a preserved sensation of bladder fullness and an inability to empty (neurogenic motor bladder) and patients who can void but have decreased sensation (sensory neurogenic bladder).

      2) Prostatitis

The National Library of Medicine (2021) states:

Prostatitis is inflammation of the prostate gland. An infection with bacteria can cause this problem. However, this is not a common cause. Acute prostatitis starts quickly. Long-term (chronic) prostatitis lasts for three months or more. Ongoing prostate irritation not caused by bacteria is called chronic nonbacterial prostatitis. Symptoms can start quickly, including chills, fever, flushing of the skin, lower stomach tenderness, and body aches. Symptoms of chronic prostatitis are similar but not as severe. They often begin more slowly. Some people have no symptoms between episodes of prostatitis. Urinary symptoms include burning or pain with urination, difficulty starting to urinate, or emptying the bladder.

      3) Prostate Carcinoma

Magi-Galluzi (2022) states:

Most frequently, prostate carcinoma is asymptomatic. Approximately 70% of prostate carcinomas arise in the peripheral zone, and some can result in abnormal findings on digital rectal examination. Incidence and mortality are higher in African-Americans and lower in Japanese. Rarely, prostate carcinoma can lead to urinary obstruction when a large tumor arises in the transition zone, extends into the transition zone from the peripheral zone, or invades the bladder neck. Locally aggressive prostate carcinoma involves the bladder and rectum and can cause hematuria, rectal bleeding, or obstruction.

Treatment:

Miernik & Gratzke (2020) state:

Treatment with alpha₁-receptor inhibitors (alpha-blockers), phosphodiesterase 5 (PDE5) inhibitors, or 5-alpha-reductase inhibitors may be considered in patients with predominantly voiding dysfunction. Alpha-blockers such as terazosin, doxazosin, alfuzosin, tamsulosin, and silodosin act by inhibiting norepinephrine-mediated contraction of the smooth muscle cells of the prostate and the bladder outlet, reducing tissue tone. Alpha-blockers + 5-alpha-reductase inhibitors can further increase improvement in LUTS. Combining an alpha-blocker and a muscarinic receptor antagonist leads to improved quality of life. It is more effective than alpha-blocker monotherapy in reducing urinary urgency, urinary incontinence, urinary frequency, and nocturia. Currently, only tadalafil 5 mg/day is approved for BPH.