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CASE 16.1

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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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A) Urinary retention

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B) Post-void dribbling

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C) Frequency

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