How to manage a 35-year-old male with a slightly enlarged prostate (prostate enlargement) and post-void residual volume of 26 mL?

Management of Slightly Enlarged Prostate in a 35-Year-Old Male

Watchful waiting is the appropriate management strategy for this 35-year-old male with a slightly enlarged prostate (31cc) and minimal post-void residual volume (26 mL). 1, 2

Assessment of Current Findings

• The ultrasound findings show a slightly enlarged prostate (31cc) with normal kidney morphology and no evidence of hydronephrosis 1
• Post-void residual (PVR) volume is minimal at 26 mL, which is well below concerning levels 1
• Both ureteric jets were observed, indicating normal urinary flow 1
• Initial bladder volume was 661 mL with good emptying capacity demonstrated 1

Management Recommendations

Initial Approach: Watchful Waiting

• Watchful waiting is the standard approach for patients with minimal symptoms and/or those who are not bothered by their symptoms 1, 2
• The American Urological Association recommends watchful waiting for patients with mild symptoms and those with moderate to severe symptoms who are not bothered by them 2
• During watchful waiting, patients should be reexamined yearly, repeating the initial evaluation 2

Lifestyle Modifications

• Implement simple measures to reduce symptom distress:
  • Decrease fluid intake at bedtime 2
  • Reduce caffeine and alcohol consumption 2
  • Implement behavioral modifications to minimize symptom impact 2

When to Consider Medical Therapy

Medical therapy would only be indicated if:

• Symptoms progress and become bothersome 1, 2
• The patient develops complications such as:
  • Urinary retention
  • Recurrent urinary tract infections
  • Bladder stones 1

Medical Treatment Options (if needed in future)

1. Alpha-Adrenergic Blockers:

   • First-line drugs for symptomatic BPH when medical therapy is indicated 1, 2
   • Options include alfuzosin, doxazosin, tamsulosin, and terazosin 1
   • These medications typically provide a 4-6 point improvement in symptom scores 2

2. 5-Alpha-Reductase Inhibitors:

   • Only appropriate for patients with demonstrable prostatic enlargement (>30cc) 3, 4
   • This patient's prostate size (31cc) just meets the threshold where 5-ARIs might be considered effective 3, 4
   • These medications reduce prostate size by 15-25% within 6 months 4

Monitoring Recommendations

• Annual evaluation is recommended to assess for symptom progression 3
• Monitoring should include:
  • Assessment of symptom severity using validated tools (IPSS/AUA Symptom Score) 1
  • Measurement of post-void residual volume if symptoms worsen 1
  • Urinary flow rate recording if symptoms progress 1

Common Pitfalls to Avoid

• Initiating medical therapy for patients with minimal symptoms who are not bothered by them 2
• Using 5-alpha-reductase inhibitors in patients without significant prostatic enlargement 3, 4
• Failing to recognize that PVR values under 200 mL generally do not mandate invasive therapy 1

When to Consider Referral to Urology

• Development of complications such as:
  • Renal insufficiency
  • Urinary retention
  • Recurrent urinary tract infections 1, 2
• Significant increase in symptom severity or bother 1