What is the recommended treatment for a patient with Benign Prostatic Hyperplasia (BPH) and a urinary tract infection (UTI) with leukocytes, proteinuria, and specific gravity (SG) of 1.020?

Treatment of BPH Patient with UTI

For a patient with BPH and urinary tract infection (UTI) showing leukocytes, proteinuria, and specific gravity of 1.020, the recommended treatment is appropriate antibiotic therapy for the UTI followed by optimization of BPH management with combination therapy of an alpha-blocker and 5-alpha reductase inhibitor if the prostate is enlarged (>30cc).

Diagnosis Assessment

UTI Confirmation

• Urinalysis findings consistent with UTI:
  • Leukocytes 25 (elevated)
  • Protein 30 (mild proteinuria)
  • Negative nitrites (does not rule out UTI)
  • pH 5 (acidic urine)
  • SG 1.020 (normal concentration)

BPH Assessment

• Current symptoms should be evaluated using AUA Symptom Index 1
• Post-void residual (PVR) measurement is essential to assess the degree of obstruction
• Determine if the UTI is a complication of BPH (recurrent UTIs are an indication for surgical intervention) 1

Treatment Algorithm

Step 1: Treat the UTI

• First-line antibiotic options:

  • Nitrofurantoin 100mg BID for 5 days
  • Fosfomycin 3g single dose
  • Cefuroxime 500mg BID for 5-7 days 2, 3

• Avoid fluoroquinolones due to high resistance rates (39.9% for E. coli) and trimethoprim/sulfamethoxazole (46.6% resistance) 3

Step 2: Optimize BPH Management

• For patients with moderate-to-severe symptoms (AUA score ≥8) and bothersome symptoms:

Medical Therapy Options:

1. Alpha-blocker therapy:

   • Tamsulosin 0.4mg once daily, taken 30 minutes after the same meal each day 4
   • Can be increased to 0.8mg daily if inadequate response after 2-4 weeks

2. For enlarged prostate (>30cc):

   • Add 5-alpha reductase inhibitor (5-ARI) such as finasteride 5mg daily 5
   • Combination therapy reduces risk of:
     • Acute urinary retention by 67%
     • BPH-related surgery by 64% 6, 5

3. For persistent storage symptoms (urgency, frequency, leakage):

   • Consider adding anticholinergic or beta-3 agonist (mirabegron) to alpha-blocker therapy 6
   • Always check PVR before starting anticholinergics to avoid urinary retention

Step 3: Consider Surgical Intervention

• Surgery is indicated if the patient has 1:

  • Recurrent UTIs due to BPH
  • Refractory urinary retention
  • Renal insufficiency secondary to BPH
  • Recurrent bladder stones or gross hematuria

• Surgical options include:

  • Transurethral resection of the prostate (TURP) - gold standard 1
  • For large prostates: open, laparoscopic, or robotic-assisted prostatectomy 1
  • Minimally invasive options: prostatic urethral lift (PUL), water vapor thermal therapy 1

Follow-up Plan

• Schedule follow-up in 3-6 months after initiating therapy to assess:
  • Symptom improvement using AUA Symptom Index
  • Medication adherence and side effects
  • Uroflowmetry and post-void residual volume 6
  • Urine culture to confirm resolution of UTI

Important Considerations

Medication Side Effects

• Alpha-blockers: orthostatic hypotension, dizziness, retrograde ejaculation
• 5-ARIs: sexual dysfunction (ED, decreased libido), gynecomastia (2.2%)
• Anticholinergics: dry mouth, constipation, cognitive effects (especially in elderly)

Pitfalls to Avoid

1. Don't treat asymptomatic bacteriuria in the absence of symptoms 7
2. Don't overlook post-void residual measurement before starting anticholinergics
3. Don't miss recurrent UTIs as an indication for surgical intervention rather than continued medical therapy 1
4. Don't forget to inform ophthalmologists about alpha-blocker use before cataract surgery (risk of intraoperative floppy iris syndrome) 6

By following this treatment approach, both the acute UTI and underlying BPH can be effectively managed to improve symptoms and prevent complications.