Case

G.M., a 69-year-old male, presents to the emergency department with

increasing difficulty initiating urination, a significant decrease in the force of
his urinary stream, occasional midstream stoppage, and post-void dribbling.
He states that these symptoms started 4 days ago and have been persistent.
Physical examination:
reveals abdominal distension and tenderness.
Digital rectal exam: confirmed a severely enlarged, firm, and rubbery prostate
gland without nodules or undue hardness.
G.M. reports urinary frequency of 8 to 10 times per day and 4 to 5 times per
night. G.M. indicates that upon urination, he notices weak stream dribbling
and does not feel relieved.
• Laboratory findings are as follows:
• Blood urea nitrogen (BUN), 45 mg/dL
• Serum creatinine (SCr), 3.2 mg/dL
• Serum prostatic acid phosphatase, 3 units/L
• Serum prostate-specific antigen (PSA), 7.1 ng/mL
• A urethral catheter was inserted, and 900 mL of urine was
obtained.
• G.M. subsequently was scheduled for a urologic workup.
1 . What is the pathophysiologic basis for G.M.’s
symptoms?
• Prostate enlargement has static and dynamic components.
• Static component:
involves smooth muscle cell proliferation due to age and androgen-
induced factors.
• Growth spurts associated with aging contribute to the enlargement of the
prostate, resulting in a physical blockage at the bladder neck.
• The prostate's type II 5α-reductase enzyme converts testosterone to
dihydrotestosterone (DHT), promoting prostate growth.
• Despite age-related testosterone decline, intra-prostatic DHT levels remain.
• In the periphery, declining testosterone-to estrogen-ratio is theorized to induce
androgen receptors, contributing to stromal prostate growth.
1 . What is the pathophysiologic basis for G.M.’s
symptoms?
• Dynamic factors:
• involve an exaggerated α-adrenergic tone, causing smooth muscle
contraction, urethral compression, and reduced bladder emptying.
• In an enlarged prostate, the usual 2:1 ratio of stromal to epithelial
tissue is exaggerated to 5:1, with stimulated α1-adrenergic receptors in
the stromal tissue.
 2. What subjective and objective findings in G.M. are
associated with BPH?

G.M. presents with classic symptoms of BPH, including obstructive and

irritative symptoms.
The increasingly severe symptoms culminated in an episode of acute urinary
retention, as evidenced by an inability to void and lower abdominal discomfort.
2. What subjective and objective findings in G.M. are
associated with BPH?

(a) abdominal tenderness

(b) the finding of an enlarged bladder
(c) an enlarged, firm, and rubbery prostate gland
(d) a return of 900 mL of urine via the urinary catheter.
• The normal serum acid phosphatase, slightly elevated PSA, and digital rectal examination of the
prostate suggest that G.M. does not have prostatic carcinoma at this time.
• The PSA result for G.M. is slightly above the upper limit for his age:
• As such, he should have a transrectal ultrasound (TRUS) to determine the prostate gland volume and,
hence, the PSA density. Once the prostate gland volume is determined, the significance of his PSA
level of 7.1 ng/mL can be determined.
• The elevated BUN and SCr may suggest hydronephrosis as a result of his BPH.
3. What additional tests/information should be completed to
evaluate G.M.?
1.American Urological Association Urinary Symptoms Score/International
Prostate Symptom Score
American Urological Association Urinary Symptoms Score/International
Prostate Symptom Score Patient sheet
Categories of Benign Prostatic Hyperplasia Disease
Severity Based on Symptoms and Signs
3. What additional tests/information should be completed to
evaluate G.M.?
• URINALYSIS
• Because patients with BPH also may have a urinary tract infection, a urinalysis with
microscopic examination is essential.
• G.M. must provide a urine specimen for urinalysis before the digital rectal examination to
prevent contamination from prostatic secretions, ensuring accurate identification of any
infection source.
• Urinary flow rate
• Urinary flow rate (UFR) is the rate of urine flow out of the bladder and typically should be at
least 10 mL/second. It is a noninvasive objective measure of bladder emptying, and if
reduced, indicates failure of bladder emptying and risk of acute urinary retention.
• Post void residual volume PVR
• A measure of bladder emptying that is defined as volume of urine remaining in the bladder
after complete voiding. Normal PVR levels are defined variably; however, a PVR of ≥25 to 50
mL implies failure of bladder emptying, whereas >100 mL indicates worsening of BPH
symptoms.
4. What drug therapy should be prescribed to treat G.M.’s
prostatic hyperplasia?

• G.M. most likely will be scheduled for a Transurethral resection of

the prostate( TURP) because he presents with acute urinary retention
and hydronephrosis( BPH complications)owing to a severely enlarged
prostate gland.
• He should be started and maintained on an α1-adrenergic receptor
antagonist to reduce the tension of the bladder neck, the prostate
adenoma, and the prostatic capsule.
• Similarly, he should receive a 5α-reductase inhibitor (5ARI) to induce
atrophy of the prostate gland and halt the progression of the disease.
Non-pharmacologic Treatment
TRANSURETHRAL RESECTION OF THE PROSTATE
A transurethral resection of the prostate (TURP) is a surgical procedure that involves
cutting away a section of the prostate.
5. G.M. has an annual PSA test. Will androgen suppression
alter his results?

• Antiandrogen treatment of BPH could possibly adversely affect the

interpretation of the PSA screening test for prostate cancer because serum
PSA levels are suppressed by ~50% with 5ARIs.

• To ensure that suppressed PSA levels are not mistaken as “normal” PSA
levels in regard to prostate cancer monitoring, it is recommended to obtain
baseline PSA before initiating 5ARI therapy. Retest at 6 months and
consider that level the new baseline, and then continue monitoring for
increases in levels thereafter compared to the new baseline level.
6. G.M. asks whether there are nonprescription treatments that are
effective for BPH available. What OTC medications are available for
prostate disorders?
•Saw palmetto is an herbal product, Several trials have shown that it significantly improves
BPH symptoms to a degree similar to that of finasteride.
•Pygeum (Pygeum africanum bark extract) has been observed to moderately reduce urinary
symptoms associated with enlargement of the prostate gland at a dose of 75 to 200 mg/day.
Herbal products may be tried by males with mild symptoms that would usually be managed by
watchful waiting;
However, the use of complementary and alternative medicines for BPH is not currently
recommended by the AUA guidelines
7. What are the options if drug therapy does not work for G.M.?
When should prostate surgery be undertaken in general?

• G.M.’s subjective and objective findings, particularly the acute urinary

retention and hydronephrosis, collectively indicate the need for a TURP.
• The need for a TURP in G.M.’s situation is fairly clear.
• In most cases, however, the need for a TURP is less clear because the
symptoms do not inevitably worsen.
• males often are willing to live with their symptoms.
• Therefore, clinicians need to talk with patients and help them answer the
question of whether the discomfort, risk, and problems during the
postsurgical recovery period are outweighed by the high probability that
surgery will relieve symptoms.