How to manage a 74-year-old male with benign prostatic hyperplasia (BPH) symptoms, urine analysis (U/A) showing unidentified crystals and calcium oxalate crystals, and a renal/bladder ultrasound indicating mild BPH and a large dystrophic calcification in the prostate?

Management of Prostatic Calcification in a 74-Year-Old Male with BPH Symptoms

For a 74-year-old male with mild BPH and a large dystrophic calcification in the prostate, no specific intervention is required for the prostatic calcification itself, as it is an incidental finding that does not typically require treatment beyond managing the underlying BPH symptoms.

Assessment of Current Findings

• The patient presents with:
  • BPH-like symptoms
  • Urine analysis showing unidentified crystals and calcium oxalate crystals
  • Ultrasound findings of mild BPH and large dystrophic calcification in the prostate
  • No history of prostate surgery

Management Approach

Step 1: Evaluate BPH Symptom Severity

• Assess symptom severity using the International Prostate Symptom Score (IPSS) 1
• Determine the level of bother caused by symptoms
• Categorize as mild (IPSS <7) or moderate-to-severe (IPSS ≥8)

Step 2: Treatment Based on Symptom Severity

For Mild Symptoms (IPSS <7):

• Watchful waiting is the preferred management strategy 2
• Implement lifestyle modifications:
  • Decrease fluid intake at bedtime
  • Reduce caffeine and alcohol consumption
  • Schedule yearly follow-up examinations

For Moderate to Severe Symptoms (IPSS ≥8):

1. First-line therapy: Alpha blockers (tamsulosin, alfuzosin, doxazosin, or terazosin)

   • Tamsulosin 0.4 mg once daily, taken approximately 30 minutes after the same meal each day 3
   • Evaluate response after 4 weeks 1

2. For enlarged prostate (if prostate volume >30cc or PSA >1.5ng/mL):

   • Consider adding 5-alpha reductase inhibitor (finasteride 5 mg daily) 4
   • Finasteride reduces prostate volume by approximately 18% over 4 years 4
   • Combination therapy reduces risk of acute urinary retention and need for surgery 1, 4

Step 3: Addressing the Prostatic Calcification

• The dystrophic calcification itself does not require specific treatment
• Prostatic calcifications are common incidental findings and rarely cause symptoms directly 5
• Focus on treating the underlying BPH symptoms rather than the calcification

Step 4: Addressing Urinary Crystals

• Increase fluid intake to promote urine dilution (2.5-3L per day) to help prevent further crystal formation 2
• Consider potassium citrate supplementation if urine pH is low, as citrate binds to calcium and may decrease calcium oxalate crystal formation 2
• Limit intake of foods very high in oxalate (spinach, rhubarb, chocolate, nuts) but a strict low-oxalate diet is not necessary 2

Follow-up Plan

• Schedule follow-up in 4-12 weeks after initiating treatment 1

• At follow-up, assess:

  • IPSS score to evaluate symptom improvement
  • Medication side effects
  • Post-void residual volume (if available)
  • Uroflowmetry (if available)

• If no improvement or worsening symptoms:

  • Reassess diagnosis
  • Consider changing medication or adding another agent
  • Consider urological referral for further evaluation

Important Considerations

• Prostatic calcifications are often incidental findings and rarely require specific intervention
• Calcium oxalate crystals in urine may be associated with prostatic calculi but the primary focus should be on managing BPH symptoms 5
• If the patient is scheduled for cataract surgery, inform the ophthalmologist about alpha blocker use due to risk of Intraoperative Floppy Iris Syndrome 1
• If starting finasteride, inform the patient about potential sexual side effects 1

When to Consider Urological Referral

• Failure of medical therapy after adequate trial
• Development of complications (urinary retention, recurrent UTIs, hematuria)
• Patient preference for surgical intervention
• Worsening symptoms despite medical therapy