Discussion: Benign Prostatic Hyperplasia
A 50 year old male presents to the office for his annual physical examination. He complains of urinary frequency and decreased libido. How will you approach these complaints with the patient? What specific actions are important to the planned care? What resources are available and provide evidence to support the suggested diagnostics?
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The International Continence Society defines nocturia as having to wake up during the night more than one time to void, every time being preceded and then followed by sleep (Cornu et al., 2012). Erectile dysfunction and lower urinary tract symptoms happen recurrently as men age. Adult men usually void 5-6 times and once or not at all during the day and night, respectively. Nocturia is commonly a sign of a prostate problem as men age, mostly benign prostatic hyperplasia (BPH). Most men with BPH, a noncancerous prostate enlargement, tend to experience erectile dysfunction as well as ejaculatory problems. The first approach to reviewing the patient’s complaints is determining the subjective data such as the number of times the patient urinates at night and reasonable estimates of the amount voided (Kaplan & McVary, 2014). A systematic evaluation will include medical history, physical examination, bladder diary, validated symptom questionnaire, and flow rate inclusive of post-void residual measurements (Abdelmoteleb et al., 2016). There is also a need to inquire about the patient’s past medical history, social history, and medications. The standardized questionnaire, the American Urological Association Symptom Index, can be used to assess the impact of benign prostatic hyperplasia on the patient. The AUASI will aid in disclosing the level of symptomatology and determining the severity of irritative or obstructive symptoms (Barry et al., 2017). The symptom scores are useful in quantifying the symptoms since the score of 7 or more on the AUASI could emphasize the need for additional investigations of the cause of the patient’s symptoms.
Objective data can be obtained by conducting a digital rectal exam to establish the prostate gland’s enlargement and rule out prostate problems. Furthermore, a urinalysis can be performed to exclude infection or hematuria. Other laboratory tests include a prostate-specific antigen blood test to assess for prostate cancer and the Prostate Health Index to identify the [-2] proPSA isoform of the PSA. A uroflow will aid in measuring the quantity of urine voided per time unit. Flows of below 10 mL/sec can be indicative of bladder obstruction. The test results could indicate the need for additional testing. Urine cytology can also be done to rule out the carcinoma, mainly if hematuria is present. The intravenous pyelogram can help identify the increased postvoid residual urine volume of urine, big prostatic impression on the bladder, bladder diverticula, trabeculated bladder, upper tract dilation, and bladder stones. The American Urological Association does not recommend serum creatinine in the initial evaluation.
Differential diagnoses should be considered in assessing the patient into three distinctive categories: obstruction of the bladder outlet, nonobstructive etiologies, as well as irritative symptoms. The treatment of nocturia is dependent on identifying the causes. The patient can be treated as an outpatient; the goal is relieving the symptoms, especially nocturia. A watchful waiting medical treatment can be used for BPH with mild to moderate symptoms, minimal PVR, plus no objective changes in the tract that require monitoring only. But, as lifestyle occurs and there is an increase in the AUA score, several treatment options might be offered to the patient. It is also recommended to avoid alcohol, spicy food, and caffeine as they are bladder irritants. The patients should be educated to void at least once 2 hours to lessen the possibility of UTI.
If the patient has a high AUA score, urinary retention, or other BPH complications need more vigorous treatment. The medication plan will include selective alpha1-adrenergic agonist, silodosin 4 or 8 mg daily with a meal, 5-alpha-reductase inhibitors, finasteride (Proscar) to block the testosterone conversion to DHT by inhibiting enzyme 5-alpha-reductase. Complementary therapies, such as herbal therapies, can be used in the treatment, together with mineral and vitamin therapies (Dunphy et al., 2019). Finally, urological surgery is a treatment option when there the patient has urinary retention, or other symptoms are intractable due to prostatic obstruction as measured by the AUA index of more than 8. Transurethral resection of the prostate is the surgical treatment for patients with severe symptoms, higher PVRs, upper urinary tract changes, complications, and failed medical therapy. Patient monitoring and follow up includes AUA symptom index that is monitored every one to six months; urodynamic testing every three to six months; and PSA and DRE yearly. Furthermore, urodynamic studies need to be done every 3 to 6 months to assess the flow rate and voiding pressures.
References
Abdelmoteleb, H., Jefferies, E. R., & Drake, M. J. (January 01, 2016). Assessment and management of male lower urinary tract symptoms (LUTS). International Journal of Surgery, 25, 164-171.
Barry, M. J., Fowler, F. J., O’leary, M. P., Bruskewitz, R. C., Holtgrewe, H. L., Mebust, W. K., & Cockett, A. T. K. (January 01, 2017). The American Urological Association Symptom Index for Benign Prostatic Hyperplasia. Journal of Urology, 197, 2.)
Cornu, J. N., Abrams, P., Chapple, C. R., Dmochowski, R. R., Lemack, G. E., Michel, M. C., Tubaro, A., … Madersbacher, S. (January 01, 2012). A contemporary assessment of nocturia: definition, epidemiology, pathophysiology, and management–a systematic review and meta-analysis. European Urology, 62, 5, 877-90.
Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing. Philadelphia, PA: F.A. Davis Company,
Kaplan, S. A., & McVary, K. T. (2014). Male Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia. Hoboken: Wiley.