What is the appropriate work‑up and treatment for an older man with benign prostatic hyperplasia, prostatic calculi, and an elevated prostate‑specific antigen?

Management of Prostatomegaly with Concretions and Elevated PSA

In an older man with benign prostatic hyperplasia, prostatic calculi, and elevated PSA, the priority is to exclude prostate cancer through proper risk stratification before initiating BPH treatment, followed by combination medical therapy with an alpha-blocker plus 5α-reductase inhibitor if the prostate is enlarged and PSA exceeds 1.5 ng/ml. 1

Initial Diagnostic Workup

Cancer Exclusion Strategy

• Verify the elevated PSA with a second measurement before proceeding to biopsy, as a single elevated value should not prompt immediate invasive testing. 2
• Perform digital rectal examination (DRE) to assess for suspicious findings including hard nodules, asymmetry, or loss of capsular integrity that would warrant immediate biopsy regardless of PSA level. 2
• Obtain urinalysis and urine culture to exclude urinary tract infection, as active infection can dramatically elevate PSA and must be treated before further evaluation. 2
• Consider PSA density (PSA/prostate volume), free/total PSA ratio, and patient-specific factors including age, ethnicity, and family history when deciding on biopsy rather than relying solely on absolute PSA cutoffs. 2

Critical Age Considerations

• In men over age 70-75 years, PSA testing and subsequent cancer workup should only be pursued if the patient has at least a 10-year life expectancy and knowledge of prostate cancer would change management. 2
• Most experts believe men older than 75 years have little to gain from PSA testing, as they are more likely to die of other causes than prostate cancer. 2

Understanding PSA Elevation in BPH Context

• Approximately two-thirds of all elevated PSA values (>4 ng/ml) in men over 50 years are due to BPH rather than cancer. 3
• PSA values are strongly correlated with prostate volume and are poorly affected by age itself, suggesting that PSA values between 4-10 ng/ml may be considered indicative of benignity when associated with relevant increase in prostate volume and PSA-free ratio greater than 10%. 4
• The proportion of free PSA is smaller in prostate cancer than in BPH, making free PSA determination useful for improving cancer specificity especially in the "grey zone" (4-10 ng/ml). 3

Symptom Assessment and Severity Stratification

Mandatory Evaluations

• Complete a validated symptom questionnaire such as the AUA Symptom Index or International Prostate Symptom Score to objectively document symptom frequency and severity. 5, 6
• Perform uroflowmetry with post-void residual (PVR) measurement, obtaining at least two flow rate measurements with voided volumes greater than 150 ml due to intra-individual variability. 5
• Maximum flow rate (Qmax) less than 10 ml/s suggests bladder outlet obstruction, while Qmax greater than 10 ml/s requires pressure-flow studies before considering invasive therapy. 5

Additional Testing for Specific Presentations

• If hematuria is present, obtain urine cytology and perform cystoscopy to rule out bladder cancer, carcinoma in situ, urethral strictures, and bladder stones. 7
• If nocturia is the predominant symptom, obtain a 3-day frequency-volume chart to distinguish primary bladder pathology from systemic causes. 5

Treatment Algorithm

Medical Management (First-Line)

• For patients with enlarged prostate and/or PSA greater than 1.5 ng/ml, combination therapy with an alpha-blocker plus 5α-reductase inhibitor has shown the highest efficacy for LUTS due to bladder outlet obstruction. 1
• Alpha-1 adrenergic blockers are first-line pharmacotherapy for bladder outlet obstruction and should be assessed for treatment success at 2-4 weeks. 1, 5
• 5α-reductase inhibitors require at least 3 months for assessment of treatment success and are most effective in men with larger glands and higher serum PSA. 1

Follow-Up Strategy

• If treatment is successful and the patient is satisfied, follow-up should be repeated approximately once a year by repeating the initial evaluation. 1
• This follow-up strategy allows detection of symptom progression, development of complications, or imperative indications for surgery (mainly upper tract dilatation and/or increased creatinine). 1

Watchful Waiting Option

• Watchful waiting is an accepted treatment option for patients with mild, moderate, or even severe symptoms as long as they are not bothered by them and imperative indications for surgery have not developed. 1
• Progression of LUTS and BPH is more likely in men with larger glands and higher serum PSA (≥1.5 ng/ml), while many men with smaller glands and/or lower serum PSA may have minimal progression. 1

Surgical Intervention Indications

• TURP remains the gold standard for interventional treatment when there is sufficient evidence of obstruction (Qmax <10 ml/s). 1
• Surgical referral is indicated if BPH-related complications develop, medical therapy fails, or the patient chooses it. 6
• If Qmax is greater than 10 ml/s, pressure-flow studies are indicated before surgery as treatment failure rates are higher in the absence of confirmed obstruction. 1, 5

Common Pitfalls to Avoid

• Do not assume BPH is the cause without excluding prostate cancer, urinary tract infection, diabetes, medications, urethral stricture, and neurogenic bladder. 5
• Do not rely on DRE alone to estimate prostate size, as it tends to underestimate true prostate size. 5, 2
• Do not obtain a single uroflowmetry measurement, as volume dependency and intra-individual variability require at least two measurements for reliability. 5
• Do not ignore prostatic calculi (concretions), as they can be associated with chronic inflammation that may elevate PSA independent of cancer or BPH progression. 4