Man with lower urinary tract symptoms
Objectives
- Recognize lower urinary tract symptoms (LUTS).
- Differentiate voiding and storage symptoms.
- Perform an appropriate initial evaluation.
- Recognize differential diagnoses.
- Interpret PSA, digital rectal exam, renal function, and ultrasound.
- Understand the initial treatment of BPH.
- Identify complications and indications for referral to the urologist.
The visit
He reports hesitancy, a weaker stream than before, and occasionally needs to strain. He also gets up 2 or 3 times at night to urinate.
He has no fever, hematuria, or flank pain.
What is the most likely syndromic diagnosis?
Interpreting the symptoms
- Weak urinary stream.
- Hesitancy.
- Straining to start urination.
- Occasional sensation of incomplete emptying.
- Increased urinary frequency.
- Nocturia of 2–3 episodes.
Which ones correspond mainly to voiding symptoms?
What should we ask?
Which of the following is especially important to investigate before assuming this is simply BPH?
Physical examination
A digital rectal exam is performed: enlarged prostate with a smooth surface, fibroelastic consistency, symmetric, and with no palpable nodules.
What is the most appropriate interpretation?
Initial tests
Which of the following strategies is the most appropriate to continue the evaluation?
Test results
Results
- Creatinine: 0.9 mg/dL
- Urinalysis: no hematuria or signs of infection
- Total PSA: 2.8 ng/mL
- Ultrasound: prostate of approximately 55 cc
- Postvoid residual: 80 mL
- No hydronephrosis
What is the most likely diagnosis considering the full picture?
Treatment
What could be a reasonable initial approach?
Choosing medical treatment
Which drug class can be used to relatively quickly improve symptoms related to prostatic obstruction?
A change of scenario
He has hypogastric pain and a distended bladder.
What is the most likely complication?
When should surgical treatment be considered?
Which of the following situations is a reason for urological assessment and possible surgical treatment of prostatic obstruction?
Explain the case in 30 seconds
Imagine you have to present this case on ward rounds in 30 seconds. How would you summarize it? This exercise is not scored — it is for practicing clinical communication.
Suggested answer
"A 67-year-old patient with mixed LUTS predominantly voiding, an enlarged prostate with benign features on digital rectal exam, PSA with no particularly suspicious findings, and a 55 cc prostate. The picture is consistent with LUTS associated with BPH. Initially it can be managed medically, but the subsequent onset of acute urinary retention requires bladder decompression and urological reassessment."
Final result
Key takeaways
- LUTS are divided into voiding, storage, and postvoid symptoms; they do not all point to the same thing.
- The digital rectal exam guides but does not by itself confirm the cause of LUTS: a prostate that feels benign does not rule out cancer, and PSA and other tests complete the evaluation.
- Alpha-blockers improve symptoms relatively quickly; 5-alpha-reductase inhibitors act more slowly and are reserved for larger prostates.
- Acute urinary retention is an emergency that requires immediate bladder decompression.
- Recurrent urinary retention and other complications of prostatic obstruction are an indication for surgical assessment.