What is the best course of treatment for a patient with a normal size prostate gland and concretions, with or without symptoms such as difficulty urinating, frequent urination, or pain?

Management of Normal-Sized Prostate with Concretions

Primary Recommendation

If you have no bothersome urinary symptoms, no treatment is needed—only reassurance and follow-up if symptoms develop. 1 Prostatic concretions (calculi) in a normal-sized prostate are typically incidental findings that do not require intervention in asymptomatic patients.

Clinical Approach Based on Symptom Status

For Asymptomatic or Minimally Bothersome Symptoms

• Watchful waiting is the appropriate management strategy when lower urinary tract symptoms (LUTS) cause little or no bother, regardless of prostatic findings including concretions. 2

• Patients with non-bothersome LUTS are unlikely to experience significant health problems in the future due to their condition, supporting conservative management. 1

• Annual follow-up is recommended to detect any changes in symptom severity or development of complications. 1

• At follow-up visits, reassess symptom severity using a standardized tool (such as the AUA Symptom Index/IPSS) and determine if symptoms have become bothersome enough to warrant intervention. 3

For Bothersome Symptoms (If Present)

If urinary symptoms become bothersome (difficulty urinating, frequent urination, or pain), the management algorithm proceeds as follows:

Initial Conservative Management

• Start with lifestyle modifications including reducing evening fluid intake, avoiding bladder irritants (alcohol, caffeine, highly seasoned foods), increasing physical activity, and reviewing medications that may worsen urinary symptoms (anticholinergics, decongestants). 2, 3

• Assess nocturia specifically: If getting up to void ≥2 times per night, complete a 3-day frequency-volume chart to identify nocturnal polyuria (>33% of 24-hour urine output at night). 2

• If nocturnal polyuria is present, advise reducing fluid intake to achieve approximately 1 liter urine output per 24 hours. 2

Pharmacological Treatment (If Conservative Measures Fail)

• For a normal-sized prostate with bothersome symptoms, alpha-blockers (alfuzosin, tamsulosin) are the first-line pharmacological option. 2, 3

• 5α-reductase inhibitors (finasteride, dutasteride) are not appropriate for normal-sized prostates, as they are indicated specifically for LUTS in men with enlarged prostates (>40 mL). 2, 3

• Reassess treatment success at 2-4 weeks for alpha-blocker therapy. 2

Surgical Considerations

• Surgery is not indicated for prostatic concretions alone in a normal-sized prostate. 2

• Surgical intervention is reserved for patients with moderate-to-severe LUTS refractory to medical therapy, recurrent urinary retention, recurrent urinary tract infections due to bladder outlet obstruction, bladder stones, or renal insufficiency due to obstruction. 2

Essential Initial Evaluation Components

Even for asymptomatic patients, the following baseline assessment should be performed:

• Medical history focusing on urinary symptom duration, severity, and bother using the AUA Symptom Index/IPSS. 3

• Digital rectal examination (DRE) to confirm normal prostate size and assess for nodularity or asymmetry that might suggest malignancy. 3

• Urinalysis to screen for hematuria, infection, or other abnormalities. 2, 3

• PSA measurement should be offered if life expectancy is >10 years and prostate cancer detection would change management. 3

Critical Pitfalls to Avoid

• Do not treat based on imaging findings alone: The presence of prostatic concretions on imaging does not mandate treatment if symptoms are absent or non-bothersome. 1, 4

• Do not assume all urinary symptoms are due to the prostate: LUTS can result from bladder dysfunction, neurologic disease, urinary tract infections, or other conditions unrelated to prostatic pathology. 3, 4

• Treatment decisions should be driven by symptom bother and quality of life impact, not simply by the presence of prostatic findings or mild urinary frequency. 1, 4

• Do not perform cystoscopy or advanced imaging routinely: These have specific indications (such as hematuria or suspected malignancy) and are not part of standard evaluation for prostatic concretions. 3

When to Refer to Urology

Referral to a urologist is indicated if:

• Symptoms persist or worsen despite conservative management and medical therapy. 2
• Complications develop such as recurrent urinary retention, recurrent infections, or bladder stones. 2
• There are concerning findings on DRE or elevated PSA suggesting possible malignancy. 3
• Hematuria is present on urinalysis. 3