Diagnosis: Benign Prostatic Hyperplasia (BPH) - Answer C
The diagnosis is benign prostatic hyperplasia (BPH), based on the classic presentation of an elderly male with voiding difficulties and frequency, combined with a digital rectal examination revealing a hypertrophic, soft, and non-tender prostate. 1
Clinical Reasoning for BPH Diagnosis
The clinical presentation strongly supports BPH through the following key features:
The enlarged, soft, non-tender prostate on DRE is the hallmark finding for benign prostatic enlargement, which is the presumptive diagnosis based on prostate size assessment by digital examination 1
Voiding difficulties (obstructive symptoms) combined with frequency (storage symptom) represent the typical lower urinary tract symptom pattern seen in men with BPH-related bladder outlet obstruction 1
The absence of urgency distinguishes this from overactive bladder syndrome, which is defined as urgency with or without urgency incontinence, usually accompanied by frequency and nocturia 1
Why Other Diagnoses Are Excluded
Prostatic cancer (Option A) is effectively ruled out by the soft, non-tender prostate texture on DRE—prostate cancer typically presents with a hard, nodular, or indurated gland on examination 1. The American Urological Association emphasizes that DRE should exclude locally advanced prostate cancer, which produces palpable abnormalities 1. While PSA testing should still be offered to this patient with >10-year life expectancy to definitively exclude cancer, the DRE findings make cancer unlikely 1.
Prostatitis (Option B) is excluded by the absence of tenderness on DRE and the lack of dysuria, which are characteristic features of prostatic inflammation 2. Acute bacterial prostatitis presents with a tender, boggy prostate and systemic symptoms including fever, while chronic prostatitis causes pelvic pain and irritative voiding symptoms 2.
Urethral stricture (Option D) is unlikely given the enlarged prostate finding—urethral stricture would not cause prostatic hypertrophy and typically presents with a history of urethral trauma, instrumentation, or infection 1. The American Urological Association notes that urethral strictures can produce LUTS but are a distinct form of bladder outlet obstruction separate from benign prostatic obstruction 1.
Critical Diagnostic Considerations
The terminology matters significantly in this case:
"Benign prostatic hyperplasia" (BPH) should technically be reserved for the histological pattern, while "benign prostatic enlargement" describes gland enlargement based on clinical assessment 1
However, in clinical practice and for examination purposes, "BPH" remains the accepted diagnostic term for this presentation of lower urinary tract symptoms with prostatic enlargement 1
The patient has "LUTS in an older man with probable benign prostatic obstruction" using precise terminology, but this corresponds to the clinical diagnosis commonly called BPH 1
Essential Next Steps After Diagnosis
While not asked in the question, the complete evaluation should include:
Quantification of symptom severity using the International Prostate Symptom Score (IPSS) or AUA Symptom Index to guide treatment decisions 1, 2
Urinalysis to exclude infection, hematuria, or other pathology (already mentioned as absent in this case) 1
PSA measurement should be offered given this patient's age and presumed >10-year life expectancy, both to exclude prostate cancer and to predict BPH progression risk 1
Common Diagnostic Pitfalls to Avoid
Do not assume all LUTS in elderly men are due to BPH—the differential includes bladder cancer, urethral stricture, neurogenic bladder, and medication effects, but the enlarged prostate on DRE makes BPH the most likely diagnosis 1
Do not diagnose prostate cancer based on prostate size alone—cancer is diagnosed by texture abnormalities (hard, nodular) on DRE, elevated PSA, and ultimately by biopsy 1, 3
Do not overlook the absence of irritative symptoms—the lack of urgency and dysuria helps distinguish uncomplicated BPH from conditions like overactive bladder or urinary tract infection 1