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A 58-year-old black male presents to your clinic complaining of urinary hesitancy, frequency, and three to four episodes of nocturia per night, which have been worsening over the past few years. His urinary stream is weaker than it was a few years ago and he feels he does not empty his bladder completely. He denies any history of urinary tract infections (UTIs) or painful urination. He is otherwise well with no significant past medical or surgical history. Currently, he takes no medications and has no allergies. On reviewing his family history, he notes his father and older brother died of prostate cancer in their 50s. His general physical examination is normal and a genital examination is unremarkable. Digital rectal examination reveals a smooth prostate with no nodules or tenderness.
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Question 16.1.1 Based on this patient's history and physical examination, all of the following would be appropriate at this stage EXCEPT:
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A) Serum assay for prostate-specific antigen (PSA)
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B) American Urological Association (AUA) symptom score
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C) Post-void residual urine volume
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D) Transrectal ultrasound with prostate biopsies
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E) Urinalysis and microscopic examination of the urine
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Answer 16.1.1 The correct answer is "D." Although your patient has an increased risk of prostate cancer, transrectal ultrasound with prostate biopsies is not indicated at this stage. This diagnostic test should be reserved for a higher suspicion of prostate cancer. Based on this patient's family history and the fact that he is black (black males have a 50% higher incidence of and mortality from prostate cancer compared with whites), PSA testing ("A") is appropriate in this setting, as opposed to general population screening, which is discussed later in the chapter. The AUA symptom score ("B") is a seven-item questionnaire about symptoms of urinary outlet obstruction, which can be used to assess severity and assist in management of prostate disease. It is not very useful for diagnosis, but on the bright side, it is freely available online. There is also the International Prostate Symptom Score, which is remarkably similar but has an additional question regarding how symptoms affect the patient's quality of life. Since your patient may not empty his bladder well, a post-void residual urine volume and urinalysis will help determine if he is experiencing urinary retention ("C") or an infection ("E").
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Question 16.1.2 When considering benign prostatic hyperplasia (BPH), you reflect on the common symptoms of this syndrome, which include all of the following EXCEPT:
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Answer 16.1.2 The correct answer is "E." Hematuria is not usually associated with BPH. However, it can occur if a man's prostatic urethra is very enlarged and friable. Enlargement of the prostate often results in obstructive flow symptoms (e.g., hesitancy and slow, weak stream), which in turn can lead to irritative symptoms (e.g., frequency, urgency, and nocturia). Obstruction from an enlarged prostate alone can cause hypertrophy of the detrusor, or it can lead to an infection that results in detrusor instability—the cause of irritative symptoms. If irritative symptoms are present without obstructive symptoms, other diagnoses should be considered, including bladder cancer, urolithiasis, infection, and neurogenic bladder.
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Your patient's urinalysis and PSA are normal. After emptying 250 mL of urine, the postvoid residual urine volume is 50 mL.
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Question 16.1.3 With this information, you recommend which of the following strategies?
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D) Scheduled bladder catheterization
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Answer 16.1.3 The correct answer is "B." You have enough information to diagnose symptomatic BPH, and further studies are not necessary. Depending on the patient's preferences, the next step is to begin treatment, and in most cases, medical therapy is initiated first. If medical therapy fails or if a patient has severe BPH with ongoing obstruction, retention of large volumes of urine, bladder stones, or recurrent UTIs, surgical therapy should be considered. The most commonly performed surgery is transurethral resection of the prostate (TURP), but other techniques can be employed as well, including transurethral incision of the prostate, minimally invasive procedures, and open surgery for very enlarged prostate glands. "D" is incorrect. Scheduled bladder catheterization is unlikely to benefit your patient since his post-void residual is not very large. A post-void residual greater than 200 mL is associated with an increased risk of UTIs, and such patients may benefit from scheduled catheterizations if medical or surgical interventions do not correct the problem or are contraindicated. Kegel exercises and biofeedback ("E") may be used to treat incontinence but are not used in BPH. Also, biofeedback is helpful for voiding dysfunction due to incomplete urinary sphincter relaxation.
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Your powers of deduction lead you to the conclusion that the patient's urinary symptoms are due to BPH. Embarrassed that he is taking more bathroom stops than his wife on their road trips, your patient desires treatment.
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Question 16.1.4 To give him the most immediate relief, you prescribe which of the following?
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Answer 16.1.4 The correct answer is "C." Timing and type of intervention should depend on how much the patient is bothered by his symptoms and whether complications of BPH are present. If the symptoms do not significantly interfere with your patient's life, he may choose to wait and take no treatment once he is reassured that he does not have a life-threatening illness. In general, medical management begins with a selective alpha-1a receptor blocker, such as tamsulosin, which relaxes the prostate at the bladder neck. In the past, non-uroselective alpha-1 blockers (e.g., terazosin, doxazosin) were considered first-line; but this is no longer the case. Let's face it: if your patient is on an alpha-1 receptor blocker for any reason—including hypertension—he has tried a few other things first. The risk–benefit ratio does not favor them when compared with other drugs for BPH or hypertension (see next question).
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If the patient does not receive sufficient relief from maximum doses of an alpha-1a blocker, consider adding a 5-alpha-reductase inhibitor (e.g., finasteride, dutasteride). These drugs work by reducing the size of the prostate gland by interfering with the effects of androgens on prostate tissue. However, it may take up to 6 months for a 5-alpha-reductase inhibitor to result in a noticeable difference in symptoms (thus, "A" should not be the first treatment); whereas the full benefit of an alpha-blocker will be apparent within 4 to 6 weeks. "B" and "D" are incorrect because these anticholinergic drugs are used for incontinence due to detrusor instability and may make urinary retention worse in patients with outlet obstruction. Furosemide, "E," is a potent diuretic and would be a cruel joke to play on this patient.
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HELPFUL TIP:
Since 5-alpha-reductase inhibitors shrink prostate tissue, they reduce the production of prostate-specific antigen (PSA). Be aware that PSA levels decrease by approximately 50% within 6 months of initiating one of these drugs. Therefore, if for some reason you check a PSA in a man on finasteride or dutasteride, the value should be doubled when comparing to normal ranges.
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Question 16.1.5 Before you tear up the prescription for terazosin you accidentally wrote, you review its side effects. Potential side effects of alpha-blockers include all the following EXCEPT:
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A) Retrograde ejaculation
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C) Intraoperative floppy iris syndrome
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Answer 16.1.5 The correct answer is "B." Hypotension (not hypertension) is the most commonly encountered problem with terazosin and other alpha-blockers, including the uroselective alpha-blockers, although to a lesser degree. In elderly males, the hypotension can be particularly problematic as the propensity for falling may increase. Additionally, alpha-blockers in combination with phosphodiesterase inhibitors (e.g., sildenafil) can cause dangerously low blood pressures. Retrograde ejaculation ("A") and priapism ("D") are not common but have been reported. And, as if we needed it, here is more evidence for a direct link between the male ocular and genital systems: intraoperative floppy iris syndrome has been observed in men taking alpha-blockers and undergoing cataract surgery; causality has not been proven. Yes, you may have thought we made this up but we didn't.
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You start tamsulosin. Unfortunately, the patient is not able to tolerate it due to dizziness. His symptoms are bothersome enough that he wishes to try something else. You consider finasteride.
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Question 16.1.6 Which of the following is true of finasteride?
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A) It permanently reduces prostate volume, even after the drug is stopped
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B) It is approved by the Food and Drug Administration (FDA) for abnormal hair growth in women
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C) It may reduce the overall risk of developing prostate cancer but increase the risk of developing high-grade prostate cancers
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D) It improves symptoms within 1 week of starting the drug
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Answer 16.1.6 The correct answer is "C." This is important: 5-alpha-reductase inhibitors lower the overall risk of cancer but increase the risk of those cancers diagnosed being high grade. Finasteride (and dutasteride) works by inhibiting 5-alpha-reductase, which is the enzyme that converts testosterone to dihydrotestosterone. Dihydrotestosterone stimulates hyperplasia of the prostate gland, and removing this stimulus results in decreased prostate volume. However, removal of finasteride allows hyperplasia to continue, and thus answer "A" is incorrect. "B" is also incorrect because finasteride for hirsutism in women is not approved by the FDA. Additionally, finasteride is category X in pregnancy, with potential teratogenic effects on the fetus. "D" is incorrect because finasteride takes time to work—a lot of time. As previously mentioned, its peak effectiveness is not seen for 3 to 6 months after starting the medication.
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HELPFUL TIP:
In comparison trials with alpha-blockers, 5-alpha-reductase inhibitors have shown variable results. The addition of a 5-alpha-reductase inhibitor to an alpha-blocker does not seem to have additional benefit over alpha-blocker therapy alone in the near term, but combination therapy has shown reduced incidence of clinical progression of BPH in longer trials.
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You decide to add finasteride. You see him again 2 months later when he presents with a febrile illness. He thinks that he might have the flu, but his BPH symptoms worsened at the same time. For the last 2 days, he has felt feverish with back pain, perineal pain, and generalized malaise. He complains of dysuria and worsening urinary frequency and urgency.
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Question 16.1.7 During your examination, you make sure NOT to:
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A) Perform a rectal examination
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C) Swab the urethra for chlamydia
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D) Perform urinalysis and microscopic examination of the urinary sediment
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Answer 16.1.7 The correct answer is "B." There is a risk of seeding bacteria into the bloodstream when an infected prostate is massaged. This patient has symptoms of prostatitis; thus, you should avoid prostatic massage. Nonetheless, you should perform a prostate examination. The following physical findings are associated with prostatitis: tenderness, warmth, enlargement, and bogginess.
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You suspect prostatitis and obtain urine for analysis.
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Question 16.1.8 All of the following laboratory abnormalities are consistent with the diagnosis of acute prostatitis EXCEPT:
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Answer 16.1.8 The correct answer is "D." Tests of renal function should not be abnormal in simple, acute prostatitis. Chronic partial or complete urinary outlet obstruction may cause abnormal renal function but not acute prostatitis. Abnormal serum BUN and/or creatinine in the setting of prostatitis should prompt further investigation. The urine often shows bacteriuria, pyuria, and hematuria. However, the urine may also be negative. Urine should be sent for culture and sensitivity to definitively determine the pathogen and direct further treatment. "E" is true: the PSA is often elevated in prostatitis. However, it is not necessary nor is it recommended to obtain a PSA to diagnose prostatitis. When the PSA is elevated due to acute prostatitis, it may not return to normal levels for 1 month or more after the resolution of inflammation.
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HELPFUL TIP:
Obtaining urine is important in the diagnosis of prostatitis, but you should avoid bladder catheterization due to the potential to spread infection. Besides, you want urine that has been in contact with the prostate.
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On examination, you find an uncomfortable appearing male in no distress. His temperature is 38.4°C, and the rest of his vital signs are normal. The prostate on digital rectal examination is tender, enlarged, warm, and boggy. The remainder of the examination is unremarkable. Urinalysis is consistent with an infection. He has a sulfa allergy.
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Question 16.1.9 Which of the following is the most appropriate treatment plan for this patient?
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A) Prescribe amoxicillin 500 mg orally TID for 10 days
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B) Prescribe ciprofloxacin 500 mg orally BID for 28 days
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C) Admit for IV levofloxacin 500 mg daily for 14 days
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D) Admit for IV levofloxacin 500 mg daily, followed by completion of therapy with oral levofloxacin 500 mg daily for 14 days when the patient is stable
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E) Perform transrectal ultrasound to rule out prostatic abscess
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Answer 16.1.9 The correct answer is "B." The most appropriate treatment for this patient is a fluoroquinolone, such as ciprofloxacin, for at least 28 days. Some authorities recommend longer treatment (up to 6 weeks) to reduce the risk of chronic prostatitis. In patients who are not allergic, a sulfa antibiotic could be considered as an alternative to a fluoroquinolone. In this case, "C" and "D" are overkill. Admission is appropriate for patients who appear septic, have not responded to oral antibiotics, or who have significant comorbidities. However, fluoroquinolones have 100% bioavailability PO. Thus, there is no indication for giving these drugs IV unless the oral route is unavailable (e.g., vomiting). Additionally, the treatment course for "C" and "D" is too short. "E" is incorrect because abscesses are rare and imaging for an abscess is only undertaken if the patient does not respond to appropriate antibiotics.
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HELPFUL TIP:
The most common cause of acute prostatitis is Escherichia coli (58–88% of men).
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When you see this patient again, his symptoms of prostatitis have cleared, but he does not think that finasteride is really helping. His AUA symptoms score is 21 (severe). He is wondering if a transurethral re-section of the prostate (TURP) might help him, and he wants to discuss the downsides of the operation.
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Question 16.1.10 Compared with watchful waiting, all of the following are observed at greater rates in men who undergo TURP EXCEPT:
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E) Decreased post-void residual urine volume
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Answer 16.1.10 The correct answer is "A." TURP is a commonly performed procedure for BPH. Indications for TURP include failure of medical therapy, recurrent infections, bladder calculi, renal insufficiency, and patient preference. Patients who undergo TURP typically experience decreased AUA symptom scores, increased urine flow rates, and decreased post-void residual volumes. There are downsides to TURP, including urinary incontinence, urethral stenosis, and the need to repeat the surgery. Strange as it may seem, several studies have shown that erectile dysfunction does NOT occur at increased rates in patients undergoing TURP compared with watchful waiting. However, men can have retrograde ejaculation status post-TURP.
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HELPFUL TIP:
Daily low-dose Cialis (taladafil) has been approved for treating BPH. But, the benefit over placebo is only 2.3 points on a 35-point scale…don't expect miracles.
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Your patient is so happy with his care that he shared his story over beers, and his friend comes to see you. This patient is a 50-year-old male, in no apparent distress, who presents with a 6-month history of recurrent irritative voiding symptoms (frequency, urgency, etc.), low back and distal penile pain, and recurrent UTIs with the same organism. Today he is afebrile with a mildly tender prostate on digital rectal examination.
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Question 16.1.11 Based on this patient's history and physical examination, all would be the most appropriate at this stage, EXCEPT:
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A) Have the patient complete the NIH Chronic Prostatitis Symptom Index questionnaire
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B) Perform a 2 glass pre- and post-prostatic massage test
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C) Obtain urine culture and if positive, treat based on sensitivities for at least 4 weeks
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Answer 16.1.11 The correct answer is "D." There is no indication for a pelvic MRI at this time. The 2 glass pre- and post-prostatic massage test is a very useful method of diagnosing chronic prostatitis. A mid-stream voided urine specimen is collected and sent for culture. If the urinalysis has greater than 10 WBCs per high-power field, next prostatic massage is performed, and then the first 10 mL of voided urine after the massage that should include expressed prostatic secretions should be sent for culture. Treatment is based on the culture and sensitivity results. A 4- to 6-week course of treatment is recommended with an appropriate antibiotic with good tissue penetration. The most common organisms isolated in chronic bacterial prostatitis are E. coli, Klebsiella, Proteus, Pseudomonas, and Gram-positive Enterococcus. The NIH Chronic Prostatitis Symptom Index questionnaire is a reliable, valid method to assess symptoms and quality of life impact in men with chronic prostatitis (http://www.prostatitis.org/symptomindex.html).
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Objectives: Did you learn to…
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Recognize the pattern of voiding dysfunction seen in BPH?
Manage a patient with BPH and understand the potential adverse effects of medications used to treat BPH?
Diagnose and treat acute prostatitis?
Describe indications for and complications of TURP?
Evaluate chronic prostatitis?