What is the treatment plan for a 73-year-old male with occasional daytime urgency and frequency, nocturia, and a heterogeneous prostate (Prostate-Specific Antigen (PSA) 0.07), with normal renal function (Creatinine (Cr) 0.95) and a negative Urinalysis (UA)?

From the Guidelines

The treatment plan for this 73-year-old male with urinary frequency, urgency, and nocturia should focus on managing his lower urinary tract symptoms (LUTS), which are likely related to benign prostatic hyperplasia (BPH) given his enlarged prostate (59g on ultrasound, 50g on exam). I recommend starting him on an alpha-blocker such as tamsulosin 0.4mg daily, taken at bedtime to minimize orthostatic hypotension side effects, as suggested by the AUA guideline on management of benign prostatic hyperplasia 1. This medication relaxes smooth muscle in the prostate and bladder neck, improving urine flow without affecting prostate size. Additionally, implementing behavioral modifications including fluid restriction in the evening, limiting caffeine and alcohol intake, and scheduled voiding can help manage his symptoms. The patient should be reassessed in 4-6 weeks to evaluate symptom improvement. If symptoms persist, adding a 5-alpha reductase inhibitor like finasteride 5mg daily could be considered for long-term prostate size reduction, particularly beneficial with his prostate over 40g, as recommended by the American Society of Clinical Oncology/American Urological Association 2008 clinical practice guideline 1. The patient's normal PSA (0.07), normal renal function (Cr 0.95), and negative urinalysis are reassuring, ruling out infection or malignancy as causes of his symptoms, as indicated by the AUA guideline on management of benign prostatic hyperplasia 1. The 4.2cm left renal cyst is likely a simple cyst but should be monitored with follow-up imaging in 6-12 months to ensure stability. If symptoms worsen or don't respond to medical therapy, urodynamic studies may be indicated to further evaluate bladder function, as suggested by the evaluation and treatment of lower urinary tract symptoms in older men guideline 1.

Some key points to consider in the treatment plan include:

• The use of alpha-blockers as a first-line treatment for LUTS, as recommended by the AUA guideline on management of benign prostatic hyperplasia 1
• The potential benefits of adding a 5-alpha reductase inhibitor for long-term prostate size reduction, as recommended by the American Society of Clinical Oncology/American Urological Association 2008 clinical practice guideline 1
• The importance of monitoring the patient's symptoms and adjusting the treatment plan as needed, as suggested by the evaluation and treatment of lower urinary tract symptoms in older men guideline 1
• The need to rule out other potential causes of LUTS, such as infection or malignancy, as indicated by the AUA guideline on management of benign prostatic hyperplasia 1

From the FDA Drug Label

In the two U. S. placebo-controlled, double-blind, 13-week, multicenter studies [Study 1 (US92-03A) and Study 2 (US93-01)], 1486 men with the signs and symptoms of BPH were enrolled. The primary efficacy assessments included: 1) total American Urological Association (AUA) Symptom Score questionnaire, which evaluated irritative (frequency, urgency, and nocturia), and obstructive (hesitancy, incomplete emptying, intermittency, and weak stream) symptoms, where a decrease in score is consistent with improvement in symptoms; Mean changes from baseline to Week 13 in total AUA Symptom Score were significantly greater for groups treated with Tamsulosin Hydrochloride Capsules 0.4 mg and 0.8 mg once daily compared to placebo in both U. S. studies.

The patient's symptoms of frequency, urgency, and nocturia are consistent with Benign Prostatic Hyperplasia (BPH).

• The patient has a heterogeneous prostate of 59g, which is indicative of BPH.
• The patient's PSA is 0.07, which is within normal limits.
• The patient's urinalysis is negative for bacteria or proteinuria. Based on the patient's symptoms and the results of the studies, a treatment plan with tamsulosin 0.4mg once daily may be considered to alleviate the patient's symptoms of BPH, as it has been shown to improve total AUA Symptom Score and peak urine flow rate in patients with BPH 2. However, it is essential to continue monitoring the patient's symptoms and adjust the treatment plan as needed. The patient should also be educated on prostate health and the importance of regular follow-up appointments to monitor the progression of BPH.

From the Research

Treatment Plan

The patient, a 73-year-old male, presents with symptoms of benign prostatic hyperplasia (BPH), including occasional daytime urgency and frequency, nocturia, and occasional slow stream. The patient's renal sonogram and pelvic sonogram revealed a heterogeneous prostate of 59g, with no evidence of obstruction.

• The patient's symptoms and test results are consistent with BPH, which is a common condition in elderly men 3.
• The patient's prostate size is enlarged, which is a risk factor for BPH-related symptoms and disease progression 4.
• The patient's PSA level is low (0.07), which suggests a low risk of prostate cancer.

Medical Management

The patient's treatment plan may include medical management with alpha-1 adrenergic antagonists and 5-alpha reductase inhibitors.

• Alpha-1 adrenergic antagonists, such as tamsulosin, can help relax the smooth muscle of the bladder neck and prostate, improving urine flow and reducing symptoms 4.
• 5-alpha reductase inhibitors, such as finasteride and dutasteride, can help reduce prostate size and prevent disease progression 4, 5.
• Combination therapy with alpha-1 adrenergic antagonists and 5-alpha reductase inhibitors may be more effective than monotherapy in reducing symptoms and preventing disease progression, especially in patients with enlarged prostates and more severe symptoms 6, 7.

Monitoring and Follow-up

The patient should be monitored regularly for changes in symptoms, urine flow, and prostate size.

• Follow-up appointments should be scheduled to assess the patient's response to treatment and adjust the treatment plan as needed.
• The patient's PSA level should be monitored regularly to assess the risk of prostate cancer.
• The patient's urine flow and prostate size should be monitored regularly to assess the effectiveness of treatment and prevent disease progression.