What is the management plan for a patient with Lower Urinary Tract Symptoms (LUTS), a non-obstructing calculus in the right kidney, tiny medullary or vascular calcifications in the left kidney, and an enlarged prostate (Benign Prostatic Hyperplasia, BPH) with a volume of 37cc, and a post-void residual volume of 33mL?

Management of LUTS with Non-Obstructing Kidney Stones and BPH

Start with an alpha-blocker (tamsulosin, doxazosin, or terazosin) as first-line therapy for this patient's LUTS attributed to BPH, with reassessment at 4-12 weeks; the small non-obstructing kidney stones require no active intervention, only conservative management with observation. 1, 2

Kidney Stone Management

The renal calculi identified require no active treatment:

• The 9 x 5 mm non-obstructing right interpolar calculus is asymptomatic and does not require intervention 1
• The tiny left medullary calcific foci (likely vascular calcifications given lack of posterior shadowing) are clinically insignificant 1
• Conservative management includes adequate hydration and periodic imaging surveillance if symptomatic episodes develop 3
• No metabolic workup or stone prevention therapy is indicated for asymptomatic, non-obstructing stones of this size 3

BPH/LUTS Management Algorithm

Initial Medical Therapy

Alpha-blocker monotherapy is the appropriate first-line treatment:

• Initiate an alpha-blocker (tamsulosin, doxazosin, alfuzosin, or terazosin) for moderate-to-severe LUTS 1, 2
• Doxazosin and terazosin demonstrate the greatest IPSS improvement in meta-analyses, though all alpha-blockers have equal clinical effectiveness 2, 4
• Alpha-blockers provide rapid symptom relief within 3-5 days and improve both voiding and storage symptoms 1, 4
• The post-void residual of 33 mL is excellent (normal <50 mL, clinically significant >200-300 mL), indicating no bladder dysfunction 5

Prostate Size Consideration

The prostate volume of 37cc is borderline for combination therapy:

• Prostates >30cc benefit from adding a 5-alpha reductase inhibitor (5-ARI) to alpha-blocker therapy 1, 2
• However, given the prostate is only marginally enlarged (37cc vs. threshold of 30cc), initial monotherapy with an alpha-blocker is reasonable 1, 2
• If PSA is >1.5 ng/mL, this would strengthen the indication for adding a 5-ARI 1

Follow-Up Protocol

Structured reassessment is mandatory:

• Evaluate at 4-12 weeks after initiating alpha-blocker therapy (unless adverse events require earlier consultation) 1, 2
• Reassessment must include IPSS questionnaire, side effect evaluation, and quality of life assessment 1, 2
• Measure post-void residual and consider uroflowmetry at follow-up 1, 2

Treatment Modification if Initial Therapy Fails

If symptoms persist or worsen after 4-12 weeks:

• Add finasteride 5mg daily or dutasteride to the existing alpha-blocker regimen 1, 4, 6
• Combination therapy with alpha-blocker plus 5-ARI reduces prostate volume by 15-25% at 6 months and reduces risk of acute urinary retention and need for surgery 2, 4, 6
• Finasteride decreases prostate volume by 17.9% over 4 years and reduces symptom scores by an additional 2 points compared to placebo 6
• The combination of finasteride and doxazosin specifically reduces risk of symptomatic BPH progression (confirmed ≥4 point increase in AUA symptom score) 1, 6

Alternative considerations if alpha-blocker monotherapy fails:

• Switch to a different alpha-blocker (doxazosin or terazosin if not already tried) 2, 4
• Consider tadalafil 5mg daily if patient has concomitant erectile dysfunction 1, 3
• For predominant storage symptoms, consider adding an antimuscarinic or beta-3 agonist to alpha-blocker therapy 1, 3

Indications for Urological Referral

Refer to urology if any of the following develop:

• Gross hematuria 4
• Recurrent urinary tract infections 5, 4
• Acute urinary retention 5, 4
• Renal insufficiency or failure 5, 4
• Bladder stones 5, 4
• Post-void residual >200-300 mL (not present in this case) 5
• Failure of medical therapy with persistent bothersome symptoms 1

Common Pitfalls to Avoid

• Do not treat asymptomatic kidney stones: The non-obstructing calculi require no intervention; avoid unnecessary urological procedures 3
• Do not start combination therapy immediately: With a prostate of only 37cc and excellent PVR, alpha-blocker monotherapy is appropriate first-line treatment 1, 2
• Do not skip the 4-12 week reassessment: Failure to reassess with IPSS leads to missed treatment failures and delayed escalation 2, 4
• Do not ignore prostate size when planning long-term therapy: If symptoms recur or persist, the prostate size >30cc indicates need for 5-ARI addition 1, 2
• Do not wait 3-6 months for initial follow-up: Alpha-blockers work within days to weeks, not months; 5-ARIs require 3-6 months, but this patient should start with alpha-blocker alone 2, 4

Summary of Immediate Actions

1. Initiate alpha-blocker therapy (tamsulosin 0.4mg daily, doxazosin, or terazosin) 1, 2
2. Provide lifestyle counseling regarding fluid intake timing, caffeine/alcohol reduction, and bladder training 1, 3
3. Schedule 4-12 week follow-up with IPSS reassessment 1, 2
4. Reassure patient that kidney stones require no treatment 3
5. Plan to add 5-ARI if inadequate response to alpha-blocker monotherapy given prostate size of 37cc 1, 2, 4