From the Guidelines
For this 67-year-old male with mild lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH), I recommend continuing with watchful waiting and lifestyle modifications as he prefers, while adding the following interventions: 1) Refer to endocrinology for diabetes management given his HbA1c of 6.8, which falls in the prediabetic range and may contribute to his nocturia, as recommended by the 2018 standards of medical care in diabetes 1; 2) Implement fluid restriction in the evening hours to reduce nocturia; 3) Schedule a follow-up in 3-6 months to reassess symptoms and determine if medical therapy is needed; 4) Consider a trial of tamsulosin 0.4mg daily if symptoms become bothersome, given his reduced urinary flow rate (Qmax 8.9 mL/s), as alpha-1 adrenoceptor antagonists are the first-line pharmacological treatment for male LUTS, according to the 2023 European Association of Urology guidelines on the management of non-neurogenic male lower urinary tract symptoms 1; 5) Continue annual PSA monitoring despite current low value (0.68) due to age and enlarged prostate (43g).
His symptoms appear mild and stable, with minimal post-void residual (5mL), supporting his preference to avoid medication for now. However, his reduced maximum flow rate and enlarged prostate suggest underlying BPH that may progress. Addressing his prediabetes is particularly important as hyperglycemia can cause osmotic diuresis contributing to nocturia, and diabetes is a risk factor for more severe urinary symptoms over time. The patient's medical history, physical examination, and laboratory results, including his creatinine level of 0.86, should be taken into account when making treatment decisions, as recommended by the 2023 European Association of Urology guidelines 1.
Some key points to consider in the management of this patient include:
- The importance of lifestyle modifications, such as fluid restriction and regular follow-ups, in managing LUTS
- The potential benefits and risks of alpha-1 adrenoceptor antagonists, such as tamsulosin, in treating LUTS
- The need for regular monitoring of PSA levels, despite the current low value, due to the patient's age and enlarged prostate
- The importance of addressing the patient's prediabetes, as recommended by the 2018 standards of medical care in diabetes 1, to reduce the risk of complications and improve overall health outcomes.
From the FDA Drug Label
14 CLINICAL STUDIES Four placebo-controlled clinical studies and one active-controlled clinical study enrolled a total of 2296 patients (1003 received Tamsulosin Hydrochloride Capsules 0.4 mg once daily, 491 received Tamsulosin Hydrochloride Capsules 0.8 mg once daily, and 802 were control patients) in the U.S. and Europe.
The patient's decision to postpone starting any new medications, such as tamsulosin, and instead continue with behavioral and lifestyle modifications is reasonable given his current satisfaction with his micturition and the fact that his symptoms are not bothersome.
- The patient should continue to follow up with his PCP for better control of his elevated Hgb A1c, as this may contribute to his nocturia.
- The patient's urinary symptoms and prostate health should be monitored, and tamsulosin or other treatments can be reconsidered if his symptoms worsen or become more bothersome 2.