What is the best management approach for a 78-year-old male with a slightly enlarged prostate (Benign Prostatic Hyperplasia - BPH) measuring 47 cc, incomplete emptying of the bladder with signs of outlet obstruction, and a small non-obstructing right renal calculus?

Management of BPH with Outlet Obstruction in a 78-Year-Old Male

Alpha-blocker therapy is the most appropriate first-line treatment for this 78-year-old male with BPH (47cc), incomplete bladder emptying, and outlet obstruction, with consideration of adding a 5-alpha reductase inhibitor due to prostate size >30cc. 1

Initial Assessment and Diagnosis

The patient presents with classic signs of BPH with complications:

• 78-year-old male
• Prostate size of 47cc (moderately enlarged)
• Incomplete bladder emptying
• Signs of outlet obstruction
• Small non-obstructing right renal calculus

This presentation indicates moderate-to-severe BPH with evidence of progression beyond just symptoms to actual functional issues (outlet obstruction).

Treatment Algorithm

Step 1: Medical Therapy

• First-line treatment: Alpha-blocker (alfuzosin, doxazosin, tamsulosin, or terazosin)

  • These medications relieve symptoms by inhibiting alpha1-adrenergic-mediated contraction of prostatic smooth muscle 1
  • Expect 4-6 point improvement in AUA Symptom Index within 4 weeks 1
  • Common side effects include orthostatic hypotension, dizziness, tiredness, ejaculatory problems, and nasal congestion 1

• Add 5-alpha reductase inhibitor (finasteride) since prostate size >30cc 1, 2

  • Finasteride reduces prostate size over time (6-12 months for maximum effect)
  • Combination therapy is indicated to:
    • Improve symptoms
    • Reduce risk of acute urinary retention
    • Reduce risk of needing surgery 2
    • Reduce risk of symptomatic progression of BPH 2

Step 2: Monitoring Response

• Evaluate in 4-12 weeks after initiating treatment 1
• Assessment should include:
  • IPSS score to measure symptom improvement
  • Post-void residual (PVR) to assess emptying
  • Uroflowmetry to evaluate obstruction improvement 1

Step 3: Consider Surgical Intervention

If inadequate response to medical therapy or worsening of symptoms occurs, surgical intervention should be considered, as this patient already has:

• Incomplete emptying of the bladder
• Signs of outlet obstruction 1

Surgical options include:

• Transurethral resection of the prostate (TURP) - considered the benchmark 1
• Transurethral needle ablation (TUNA) - for prostates ≤60g with lateral lobe enlargement 1
• Laser procedures (e.g., HoLEP) - particularly suitable for varying prostate sizes 3

Management of Renal Calculus

The small non-obstructing right renal calculus should be monitored but does not require immediate intervention. However, it's important to ensure adequate hydration to prevent stone growth or complications.

Pitfalls and Caveats

1. Avoid watchful waiting: While watchful waiting is appropriate for mild symptoms, this patient has outlet obstruction and incomplete emptying, indicating the need for active treatment 1

2. Beware of alpha-blocker side effects: In elderly patients, start with lower doses to minimize orthostatic hypotension risk, particularly if the patient has cardiovascular comorbidities 1

3. Patient expectations: Inform the patient that while alpha-blockers provide rapid symptom relief (within weeks), 5-alpha reductase inhibitors require 6-12 months for maximum benefit 2, 4

4. Avoid prostatic stents: These are associated with significant complications (encrustation, infection, chronic pain) and should be reserved only for high-risk patients with urinary retention 1

5. Monitor for progression: BPH can progress, with increasing risk of acute urinary retention (particularly in men over 70), requiring close follow-up 1