What is the next step in managing a patient with chronic cystitis visible on ultrasound (USG) without active infection and concurrent benign prostatic hyperplasia (BPH), will BPH medication suffice or are additional investigations or treatments for chronic cystitis required?

Management of Chronic Cystitis with Concurrent BPH

For a patient with chronic cystitis visible on ultrasound without active infection and concurrent BPH, BPH medication alone is insufficient - you should initiate alpha-blocker therapy for BPH while also investigating the underlying cause of chronic cystitis through additional diagnostic tests.

Initial Assessment and Management

BPH Management

• Alpha-adrenergic blockers (alfuzosin, doxazosin, tamsulosin, or terazosin) should be the first-line medication for BPH treatment, as they provide effective symptom relief by inhibiting alpha1-adrenergic-mediated contraction of prostatic smooth muscle 1
• These medications produce on average a 4-6 point improvement in the AUA Symptom Index, which most patients perceive as meaningful improvement 1
• The choice between alpha-blockers can be based on side effect profiles; tamsulosin may have fewer blood pressure effects compared to others 2

Chronic Cystitis Investigation

• Chronic cystitis visible on ultrasound without active infection requires further investigation, as it may indicate underlying bladder dysfunction that won't be addressed by BPH treatment alone 3
• Urethrocystoscopy should be performed to evaluate the bladder mucosa and rule out other conditions like bladder cancer, especially with history of hematuria 1
• Post-void residual (PVR) measurement is essential to assess bladder emptying and potential urinary retention 1

Diagnostic Algorithm

1. Urinalysis and urine culture: To confirm absence of active infection 4
2. Post-void residual measurement: To assess the degree of urinary retention 1
3. Urethrocystoscopy: To directly visualize the bladder mucosa and assess for inflammatory changes, lesions, or other pathology 1
4. Uroflowmetry: To objectively measure the degree of obstruction 3

Treatment Approach

Combined Therapy Approach

• Alpha-blocker therapy for BPH symptoms (tamsulosin, alfuzosin, doxazosin, or terazosin) 1
• For patients with both BPH and storage symptoms (which may be related to chronic cystitis), consider combination therapy with an alpha-blocker plus an antimuscarinic medication or beta-3 agonist 1
• This combination approach has shown significant improvements in symptoms compared to monotherapy in patients with mixed voiding and storage symptoms 1

Monitoring and Follow-up

• Regular follow-up to assess symptom improvement and medication side effects 1
• Repeat PVR measurement to ensure adequate bladder emptying, especially if antimuscarinic medications are added 1
• If symptoms persist despite medical therapy, consider urodynamic studies to better characterize the bladder dysfunction 1

Special Considerations

• If chronic cystitis is associated with recurrent UTIs, recurrent gross hematuria, or bladder stones, surgical intervention for BPH may be indicated rather than continued medical therapy 1
• Large PVR volumes (>350 ml) may indicate significant bladder dysfunction and predict a less favorable response to medical treatment 1
• Patients with moderate to severe symptoms who are not bothered by them may be managed with watchful waiting rather than active treatment 1

Treatment Pitfalls to Avoid

• Don't ignore chronic cystitis: Treating only the BPH component without addressing the bladder pathology may lead to persistent symptoms 3
• Don't assume all symptoms are from BPH: Lower urinary tract symptoms can be caused by multiple factors including bladder dysfunction, not just prostatic enlargement 3
• Avoid antimuscarinic medications in patients with very high PVR: While combination therapy can be effective, antimuscarinic medications should be used cautiously in patients with significant urinary retention 1
• Don't delay appropriate referral: If symptoms persist despite medical therapy or if complications develop (recurrent UTIs, hematuria, bladder stones), prompt urological referral is indicated 1