How should I evaluate and manage a man over 50 with benign prostatic hyperplasia and intraprostatic calculi presenting with lower urinary tract symptoms and recurrent prostatitis?

Evaluation and Management of Prostatomegaly with Concretions

Begin with alpha-blocker monotherapy (tamsulosin 0.4 mg or alfuzosin 10 mg once daily after the same meal) for immediate symptom relief, then add a 5-alpha-reductase inhibitor (finasteride 5 mg or dutasteride 0.5 mg daily) only if prostate volume exceeds 30cc or PSA is elevated. 1, 2, 3

Initial Diagnostic Workup

Complete the following essential evaluations before initiating treatment:

• Obtain a detailed medical history focusing on duration and severity of voiding symptoms (weak stream, hesitancy, incomplete emptying), storage symptoms (urgency, frequency, nocturia), history of recurrent prostatitis episodes, sexual function, and current medications 1

• Administer the International Prostate Symptom Score (IPSS) to objectively quantify symptom severity and bother—this is mandatory before starting any treatment, as therapy indication depends on documented symptom burden, not just symptom presence 1, 2

• Perform digital rectal examination (DRE) to assess prostate size (estimate volume), consistency, symmetry, and exclude nodules or induration suggestive of prostate cancer 1

• Order urinalysis with dipstick testing to detect hematuria, pyuria, proteinuria, or signs of infection; if abnormal, proceed with microscopy and culture 1

• Measure serum PSA in this patient with >10-year life expectancy to exclude prostate cancer and predict BPH progression risk—discuss benefits and risks of testing including false-positive/negative results and biopsy complications 1, 2

• Complete a 3-day frequency-volume chart (bladder diary) to quantify voiding patterns, distinguish nocturnal polyuria from bladder dysfunction, and guide nocturia management 1, 2

• Measure post-void residual (PVR) urine volume using bladder ultrasound to assess bladder emptying efficiency and detect significant retention 2

Addressing Intraprostatic Calculi (Concretions)

Prostatic calculi are common incidental findings in men with BPH and chronic prostatitis, typically requiring no specific intervention unless associated with recurrent infection. 4

• Prostatic calculi occur in 5-20% of men with BPH and are frequently associated with chronic prostatitis-like symptoms including pelvic pain, dysuria, and recurrent urinary tract infections 4

• Do not pursue imaging or invasive procedures specifically for prostatic calculi unless there is recurrent culture-proven bacterial prostatitis, persistent hematuria, or suspicion of bladder stones 1

• The presence of calculi does not alter the standard BPH treatment algorithm—alpha-blockers remain first-line therapy 4

Managing Recurrent Prostatitis in the Context of BPH

Differentiate between BPH-related LUTS and prostatitis-based symptoms:

• Pain is the key distinguishing feature—pelvic, perineal, or ejaculatory pain clearly identifies chronic prostatitis, while BPH typically presents with painless voiding and storage symptoms 4

• Approximately one-third of men diagnosed with BPH have had prior prostatitis, and these conditions frequently co-occur in older men 4

• For recurrent bacterial prostatitis, obtain urine culture and treat with appropriate antibiotics (typically fluoroquinolones for 4-6 weeks for chronic bacterial prostatitis), but avoid empiric antibiotics without documented infection 2

• Alpha-blockers provide dual benefit in men with overlapping BPH and chronic prostatitis symptoms by relaxing prostatic smooth muscle and improving both voiding symptoms and prostatitis-related discomfort 4

First-Line Medical Therapy

Initiate alpha-blocker monotherapy immediately for symptom relief:

• Tamsulosin 0.4 mg once daily (taken 30 minutes after the same meal each day) is highly effective, requires no dose titration, and has minimal cardiovascular effects 1, 3, 5

• Alfuzosin 10 mg once daily (extended-release formulation taken after the same meal each day) provides comparable efficacy with superior tolerability compared to non-selective alpha-blockers 3, 5

• Alpha-blockers work rapidly (within 2-4 weeks) by relaxing prostatic smooth muscle and reducing the dynamic component of bladder outlet obstruction, regardless of prostate size 1, 3

• Avoid doxazosin and terazosin as they require stepwise dose titration and carry higher risk of orthostatic hypotension and dizziness 3

• Counsel patients about potential orthostatic hypotension, especially during the first few doses—advise lying down with legs elevated if dizziness occurs 5

• Warn patients taking alpha-blockers to inform their ophthalmologist before cataract surgery due to risk of intraoperative floppy iris syndrome (IFIS) 1, 5

Adding 5-Alpha-Reductase Inhibitor Therapy

Add a 5-ARI only when specific criteria are met:

• Measure prostate volume (via DRE estimation, transrectal ultrasound, or MRI) before prescribing a 5-ARI—these agents offer no benefit in prostates <30cc 1, 3, 6

• Finasteride 5 mg daily or dutasteride 0.5 mg daily should be added to alpha-blocker therapy when prostate volume exceeds 30-40cc or PSA is elevated 1, 3, 6

• 5-ARIs work slowly (requiring 6-12 months for maximal effect) by shrinking the prostate through inhibition of testosterone conversion to dihydrotestosterone 1, 6

• Combination therapy (alpha-blocker plus 5-ARI) is superior to monotherapy for preventing long-term disease progression, reducing acute urinary retention risk by 57%, and decreasing need for BPH-related surgery by 48% over 2-4 years 3, 6

• Counsel patients about sexual side effects of 5-ARIs including erectile dysfunction (3-10%) and ejaculatory dysfunction (4-10%), though these rates are lower than with surgical interventions 6, 7

• PSA values will decrease by approximately 50% after 6-12 months of 5-ARI therapy—double the measured PSA to estimate true value for prostate cancer screening 6

Follow-Up and Monitoring

Reassess patients 4-12 weeks after initiating therapy:

• Re-administer the IPSS to objectively measure treatment response—lack of improvement warrants therapy adjustment or urologic referral 1, 3

• Remeasure PVR if initially elevated to ensure adequate bladder emptying 3

• Evaluate medication adherence and tolerability—address side effects promptly to prevent treatment discontinuation 1

Indications for Urologic Referral

Refer to urology immediately for:

• Acute urinary retention requiring catheterization 1, 3
• Renal insufficiency attributable to bladder outlet obstruction 1, 3
• Recurrent gross hematuria despite negative malignancy workup 1
• Bladder stones 1
• Recurrent urinary tract infections despite appropriate antibiotic therapy 1
• Persistent severe symptoms (IPSS >19) despite maximal medical therapy 1
• Patient preference for definitive surgical management 3

Critical Pitfalls to Avoid

• Never prescribe 5-ARIs as monotherapy for immediate symptom relief—they take 6-12 months to work and should always be combined with an alpha-blocker for symptomatic patients 3

• Never prescribe 5-ARIs without documented prostate enlargement (>30cc)—they are ineffective in small prostates 1, 3

• Never treat with empiric antibiotics based solely on prostatic calculi or trace leukocytes—require documented bacterial infection with positive culture 2, 4

• Never delay alpha-blocker initiation while waiting for additional testing or specialty referral—symptom relief should begin immediately 8

• Never assume infection based on intraprostatic calculi alone—calculi are common incidental findings that do not require treatment unless associated with recurrent culture-proven bacterial prostatitis 4