What is the likely cause and treatment for a 70-year-old male with Benign Prostatic Hyperplasia (BPH) presenting with urinary hesitancy and pressure sensation in the bladder area, with no evidence of urinary infection?

Differential Diagnosis and Management for 70-Year-Old with BPH and Urinary Symptoms

Primary Differential Diagnoses

The most likely diagnosis is symptomatic benign prostatic hyperplasia (BPH) causing bladder outlet obstruction, given the lobulated prostate on CT, urinary hesitancy, and bladder pressure sensation in a 70-year-old male with no prior treatment. 1

Key Differentials to Consider:

• Bladder outlet obstruction from BPH - Most probable given age, lobulated prostate morphology, obstructive symptoms (hesitancy), and irritative symptoms (pressure sensation) 1, 2

• Detrusor dysfunction/bladder decompensation - Must be considered when BPH is longstanding, as chronic obstruction can lead to bladder dysfunction that may not respond to outlet-directed therapy 1

• Urethral stricture - Less likely without history of urethritis, urethral injury, or prior instrumentation, but should be considered if symptoms persist despite appropriate BPH treatment 1

• Bladder calculi - Can present with similar irritative symptoms and may develop secondary to chronic obstruction and incomplete emptying 2

• Prostate cancer - The lobulated prostate warrants consideration, though typically presents with similar LUTS rather than distinct symptoms 1

• Neurogenic bladder - Consider if patient has history of stroke, Parkinson's disease, diabetes with neuropathy, or other neurologic conditions affecting bladder function 1

Essential Initial Workup

Post-void residual (PVR) measurement is critical - Large PVR volumes (>200-350 mL) indicate significant bladder dysfunction and predict poor response to medical therapy, potentially requiring earlier surgical intervention 3, 1

• Uroflowmetry assessment - Maximum flow rate (Qmax) <10 mL/sec suggests urodynamic obstruction and predicts better response to surgical rather than medical therapy 1, 3

• Prostate size estimation - Either by digital rectal exam or PSA as proxy (PSA also predicts natural history and response to 5-alpha reductase inhibitors) 1

• Symptom severity quantification - Use International Prostate Symptom Score (IPSS) or AUA Symptom Index to objectively measure baseline severity and track response 1, 3

Red Flags Requiring Urgent Urological Referral

Immediately refer to urology if any of the following are present: 3, 2

• Gross hematuria
• Acute urinary retention
• Recurrent urinary tract infections
• Renal insufficiency or failure
• Bladder stones
• Renal failure

Initial Treatment Algorithm

For Prostate <30cc (Smaller Glands):

Start with alpha-blocker monotherapy - Tamsulosin 0.4 mg daily (can increase to 0.8 mg after 2-4 weeks if inadequate response), doxazosin, terazosin, or alfuzosin are equally effective 1, 3, 4

• Alpha-blockers typically take effect within 3-5 days and should be trialed for 4-12 weeks before declaring treatment failure 3
• Expected improvement: 4-6 point reduction in AUA Symptom Index 1
• Doxazosin and terazosin show greatest IPSS improvement in meta-analyses 3

For Prostate >30cc (Enlarged Glands):

Initiate combination therapy with alpha-blocker PLUS 5-alpha reductase inhibitor 3, 5

• Finasteride 5 mg daily or dutasteride reduces prostate size by 15-25% at 6 months 3, 5
• Combination therapy reduces risk of symptomatic BPH progression, acute urinary retention (57% risk reduction), and need for surgery (55% risk reduction) 3, 5
• Critical caveat: Finasteride requires 6 months to assess effectiveness and 12 months for maximum benefit - this is NOT a rapid-acting therapy 5, 6, 7

Common Pitfalls to Avoid

• Inadequate trial duration - Declaring treatment failure before 4-12 weeks for alpha-blockers or 6 months for finasteride leads to premature escalation 3, 6

• Ignoring prostate size - Failing to assess prostate size misses patients who would benefit from 5-alpha reductase inhibitor therapy; finasteride should not be used in prostates <40 mL 3, 7

• Missing complications - Large PVR (>200-350 mL), recurrent UTIs, hematuria, and renal insufficiency may necessitate surgical rather than continued medical management 3, 1

• Relying on subjective recall - Always use IPSS questionnaire at follow-up rather than patient's subjective impression of improvement 3

Optional Advanced Testing (Not for Initial Evaluation)

These tests are NOT recommended for initial evaluation but may be appropriate before invasive therapy: 1

• Pressure-flow urodynamic studies - Only if considering surgery AND Qmax >10 mL/sec, or if concomitant neurologic disease present 1

• Cystoscopy - Only indicated if history of hematuria, urethral stricture risk factors, bladder cancer history, or prior lower urinary tract surgery 1

• Transrectal ultrasound - Only when minimally invasive or surgical interventions are being selected, particularly to guide choice between TUIP versus TURP 1

When Medical Therapy Fails

Surgical intervention becomes appropriate when: 1, 3

• Medical therapy fails after adequate trial (4-12 weeks for alpha-blockers, 6 months for finasteride)
• Development of complications (refractory retention, recurrent UTIs, bladder stones, renal insufficiency, recurrent gross hematuria)
• Patient preference after informed discussion of risks/benefits

TURP remains the benchmark surgical therapy with greatest efficacy, though minimally invasive options (TUMT, TUNA, laser procedures) offer less morbidity with intermediate efficacy between medical therapy and TURP 1, 7