What is the treatment for a 64-year-old patient with Post Void Residual (PVR) volume of 650 mL, presenting with mild to moderate left hydronephrosis and mild right hydronephrosis, who experiences urinary straining during micturition?

From the Guidelines

For a 64-year-old patient with a post-void residual (PVR) of 650 mL, bilateral hydronephrosis (moderate-left, mild-right), and straining to urinate, I recommend immediate urological intervention. The patient should start on an alpha-blocker such as tamsulosin 0.4 mg daily or alfuzosin 10 mg daily to relax the bladder neck and prostate smooth muscle, as suggested by the AUA guideline on management of benign prostatic hyperplasia 1. Clean intermittent catheterization (CIC) should be initiated 3-4 times daily to decompress the bladder and protect the upper urinary tract. Urgent urological consultation is necessary for comprehensive evaluation including renal function tests, PSA, uroflowmetry, and possibly cystoscopy.

The elevated PVR and bilateral hydronephrosis indicate significant urinary retention with potential kidney damage, which is a concern as hydronephrosis can lead to acute kidney injury and permanent nephron loss if not corrected 1. This condition likely stems from bladder outlet obstruction, possibly due to benign prostatic hyperplasia given the patient's age and symptoms. Without prompt intervention, the patient risks deteriorating renal function, urinary tract infections, and possible bladder decompensation.

Some key points to consider in the management of this patient include:

• The use of urinary flow-rate recording and measurement of post-void residual urine (PVR) as optional tests to aid in the decision-making process 1
• The importance of prompt treatment to prevent permanent renal damage in cases of obstructive hydronephrosis 1
• The need for comprehensive evaluation and management of hydronephrosis, including consideration of the underlying cause and potential complications 1

Surgical options like transurethral resection of the prostate (TURP) may ultimately be necessary depending on the underlying cause and response to medical therapy. It is essential to prioritize the patient's morbidity, mortality, and quality of life in the management of this condition, and to base treatment decisions on the most recent and highest-quality evidence available.

From the FDA Drug Label

Effect on Symptom Score Symptoms were quantified using a score similar to the American Urological Association Symptom Score, which evaluated both obstructive symptoms (impairment of size and force of stream, sensation of incomplete bladder emptying, delayed or interrupted urination) and irritative symptoms (nocturia, daytime frequency, need to strain or push the flow of urine) by rating on a 0 to 5 scale for six symptoms and a 0 to 4 scale for one symptom, for a total possible score of 34. Although an early improvement in urinary symptoms was seen in some patients, a therapeutic trial of at least 6 months was generally necessary to assess whether a beneficial response in symptom relief had been achieved The improvement in BPH symptoms was seen during the first year and maintained throughout an additional 5 years of open extension studies. Effect on Acute Urinary Retention and the Need for Surgery In A Long-Term Efficacy and Safety Study, efficacy was also assessed by evaluating treatment failures Compared with placebo, finasteride tablets was associated with a significantly lower risk for acute urinary retention or the need for BPH-related surgery [13.2% for placebo vs 6. 6% for finasteride tablets; 51% reduction in risk, 95% CI: (34 to 63%)].

Treatment for 64 yo with PVR 650, mild to moderate left hydronephrosis, mild right hydronephrosis, passing urine with straining

• The patient's symptoms are consistent with Benign Prostatic Hyperplasia (BPH).
• Finasteride may be considered as a treatment option to relieve symptoms of BPH, as it has been shown to improve symptom scores, reduce the risk of acute urinary retention, and decrease the need for surgery.
• However, it is essential to monitor the patient's condition and adjust the treatment plan as needed, considering the potential risks and benefits of finasteride therapy 2, 2.
• A therapeutic trial of at least 6 months may be necessary to assess the patient's response to finasteride treatment 2.
• It is also crucial to consider other urological conditions that may cause similar symptoms and to carefully monitor patients with large residual urinary volume and/or severely diminished urinary flow for obstructive uropathy 2.

From the Research

Treatment Options for 64-year-old with PVR 650, Mild to Moderate Left Hydronephrosis, Mild Right Hydronephrosis, and Passing Urine with Straining

• The patient's symptoms suggest benign prostatic hyperplasia (BPH), which can be treated with alpha blockers or 5 alpha-reductase inhibitors 3, 4.
• Alpha blockers, such as tamsulosin, can relax the smooth muscle in the prostate and bladder neck, improving urine flow and reducing symptoms 3, 5.
• Tamsulosin has been shown to be effective in improving maximal urine flow (Qmax) and alleviating lower urinary tract symptoms (LUTS) in patients with BPH, including those with mild to severe symptoms 3.
• Low-dose tamsulosin (0.2 mg) has also been shown to be effective in treating LUTS associated with BPH, with improvements in IPSS, Qmax, and quality of life 5.
• 5 alpha-reductase inhibitors, such as finasteride, can reduce the size of the prostate and improve symptoms, but may have a slower onset of action compared to alpha blockers 6.
• Combination therapy with an alpha blocker and a 5 alpha-reductase inhibitor may be considered for patients with more severe symptoms or those who do not respond to monotherapy 6.

Potential Benefits and Risks of Treatment

• Alpha blockers, such as tamsulosin, are generally well-tolerated, with common side effects including dizziness, abnormal ejaculation, and hypotension 3, 7.
• 5 alpha-reductase inhibitors, such as finasteride, may cause sexual health dysfunctions, such as erectile dysfunction and decreased libido, but are generally well-tolerated otherwise 6.
• The use of alpha blockers prior to removal of a catheter for acute urinary retention has been shown to increase the success rate of trial without catheter (TWOC) 7.

Considerations for Treatment

• The patient's age, medical history, and severity of symptoms should be taken into account when selecting a treatment option 3, 4.
• The patient's response to treatment should be monitored, and adjustments made as necessary to optimize symptom relief and minimize side effects 3, 5.
• Further studies are needed to fully understand the efficacy and safety of different treatment options for BPH, including combination therapy and the use of alpha blockers prior to TWOC 7, 6.