Benign Prostatic Hyperplasia 1: The Case of Mr. Jones and the Urinal of Doom
Mr. Jones, a noted archeologist, presents to his primary care physician with lower urinary tract symptoms (LUTS). You are expected to direct the evaluation, education, and management of this patient.
LEARNING OBJECTIVES for The Case of Mr. Jones and the Urinal of Doom
Identify and name the major anatomic and histologic features of the prostate gland
Identify the predominant location in the prostate where BPH develops and describe how this fact relates to the symptoms and signs of BPH
Describe the natural history and distinctive epidemiological features of BPH
List the symptoms and signs of BPH
List the important components of the history and physical examination when evaluating a patient with BPH
List what laboratory, radiologic, or urodynamic tests, if any, should be ordered in a patient with BPH
List the indications for treatment of BPH
List the medical treatment options for BPH and describe their side effects and the mechanisms by which these medications work
List and briefly describe the surgical treatment options for BPH
Describe when a patient with BPH should be referred to a urologist
Mr. Jones' Visit to his Primary Care Physician - 1
Mr. Jones, a 78-year old male, enters his primary care physician's clinic walking with a limp and carrying a plastic urinal on his belt along with his signature whip and pistol. The doctor greets him warmly and with admiration, after all he is the discoverer of the Holy Grail. Mr. Jones states that he has been extremely bothered over the last few months with the need to urinate every half hour to hour. He is only able to continue worldly travels if he carries a plastic urinal with him at all times. "It's always there, right next to the whip." He reports that this greatly reduces the speed at which he can draw his pistol and urine spills all over him when he uses his whip. The doctor feels that Mr. Jones may be suffering from benign prostatic hyperplasia (BPH). The symptoms of BPH about which the doctor should inquire include: (please select all appropriate answers)
a. Nocturia b. Pyuria c. Hematuria d. Incomplete emptying e. Urgency
Mr. Jones' Visit to his Primary Care Physician - 2
The doctor mentions to Mr. Jones that he likely is suffering from benign prostatic hyperplasia (BPH), an extremely common disorder in elderly males. Mr. Jones is relieved to know that this condition is not caught from reptiles, like snakes. In fact, it can be detected histologically in 70% of men aged 70 and 90% of men aged 90.(1) He explains that progression of this microscopic hyperplasia can result in enlargement of the prostate. It is estimated that one man in four (25%) will have significant urinary symptoms from BPH in their lifetime. Where in the prostate does BPH occur? (please select the single best answer)
a. Peripheral zone – encompassing the posterior portion of the gland b. Central zone – surrounding the ejaculatory ducts c. Transition zone – surrounding the urethra d. Anterior fibromuscular zone – anterior to the urethra e. None of the above
Mr. Jones' Visit to his Primary Care Physician - 3
The doctor asks Mr. Jones further questions to learn more about his urinary status and to rule out other causes of his urinary symptoms: - does anything (including over-the-counter medications) make his urinary symptoms better or worse? - has he ever had an episode of urinary retention? - does he have any dysuria or history of urinary tract infections? - does he have diabetes or other neurologic disorders which can result in bladder dysfunction? - does he have any history of urethral strictures or sexually-transmitted diseases? - has he ever had any previous endoscopy or surgery of the urinary tract? After mentioning that he had fewer questions when kidnapped by desert nomads, Mr. Jones responded that his past medical history is notable only for snake bites, gunshot wounds, scalp lacerations from broken bottles and several concussions. He is currently taking no medication. On physical examination, Mr. Jones has no costovertebral angle tenderness and his bladder does not feel distended on palpation or percussion. His genital exam is normal. Digital rectal examination reveals a prostate which is 4cm in breadth, smooth, and non-tender with no nodules. On neurologic exam, Mr. Jones anal sphincter tone and perineal sensation is normal, and his sacral reflexes (knee and ankle jerks) are intact. At this point, what further evaluation(s) should be performed by the primary care physician on Mr. Jones to work-up his likely BPH? (please select all appropriate answers)
a. completion of prostate symptom questionnaire (IPSS) b. urinalysis c. voiding diary (recording the volume and timing of oral fluid intake and urination) d. measurement of serum creatinine level e. uroflowmetry (measurement of urinary flow rate) f. measurement of post-void residual [PVR] (bladder volume remaining upon completion of voiding) g. urodynamic evaluation (cystometry, pressure-flow analysis)
Mr. Jones' Visit to his Primary Care Physician - 4 A
Mr. Jones completes an International Prostate Symptom Score (IPSS) questionnaire which documents his moderate-to-severe urinary symptoms. As he hands the questionnaire to the doctor, he says, "Doc, I don't know if this is important, but a few weeks back I got the sniffles after hanging out with a scrappy, snot-nosed kid. So I took a decongestant pill, and boy, I had one heck of a time peeing!. Why would Mr. Jones have more trouble passing urine? (please select the single best answer)
a. Inflammation caused by viral cystitis b. Side effect of the alpha adrenergic medication common in cold remedies c. Side effect of the antihistamine medication common in cold remedies
Mr. Jones' Visit to his Primary Care Physician - 4 B
Mr. Jones' urinalysis shows no evidence of infection or hematuria, and his post-void residual urine is low (15cc). What is the most appropriate next step in Mr. Jones' management? (please select the single best answer)
a. Treatment with an alpha-blocker b. Treatment with a 5-alpha reductase inhibitor c. Referral to a urologist for urodynamic evaluation d. Refer to a urologist for resection of the prostate
Mr. Jones' Visit to his Primary Care Physician - 5
The doctor decides to start Mr. Jones on the alpha-blocker terazosin (Hytrin). He plans to start him at 2mg PO QHS, and over the next few weeks, will slowly increase the dose up to 8-10mg PO QHS. Mr. Jones then asks "Are you sure there are no poisons in this pill?" What is the most common side effect of alpha-blocker therapy for BPH and the side effect about which Mr. Jones should be counseled to stop the medication or reduce the dose? (please select the single best answer)
a. palpitations b. dizziness c. reduced libido d. headache e. double vision
Mr. Jones' Referral to a Urologist
Over the next few weeks, Mr. Jones titrates his medication up to 10mg PO QHS with minimal improvement of his urinary symptoms. During a car chase, he became drenched in urine as his plastic urinal tipped over as he was rounding a corner. His primary care physician refers him to a urologist for further evaluation and treatment of his symptoms. The urologist repeats a thorough history and physical examination and agrees with the findings of the primary care physician. Since Dr. Jones' symptoms did not improve much with alpha-blocker therapy, the urologist performs a urodynamic evaluation which confirms that his symptoms are due to obstruction from the prostate and not from neurologic problems or a poorly-contracting bladder. The urologist recommends that he undergo a procedure to relieve the obstruction caused by the prostate. All of the following would potentially be appropriate procedures for Mr. Jones: (please check all appropriate answers)
a. Transurethral resection of the prostate b. Open radical prostatectomy c. Microwave thermotherapy d. Open simple prostatectomy e. Transurethral radiofrequency needle ablation of the prostate
Mr. Jones Undergoes a TURP
The Urologist discussed the therapy options in detail with Mr. Jones. He refuses to undergo transurethral microwave thermotherapy (TUMT) because it reminds him of a torture technique used on him forty years ago. He does, though, decide to undergo a TURP. After obtaining 'cardiac and medical clearance,' the TURP procedure was performed without any difficulties. Following removal of the catheter, his lower urinary tract symptoms improve dramatically. Now Dr. Jones can ride off into the sunset…without his plastic urinal on his belt and the tipped Fedora hat on his head.
Take-Home Messages - from 'The Case of Mr. Jones and the Urinal of Doom'
BPH usually presents with 'lower urinary tract symptoms' which can be obstructive (WISE) and/or irritative (FUN) in nature. These symptoms are not specific to BPH.
BPH is a common cause of hematuria. Even so, hematuria still mandates a referral to a urologist for a work-up to rule out cancer.
BPH develops in the transition zone of the prostate surrounding (and potentially obstructing) the urethra.
The initial evaluation of BPH should include a thorough history and physical, completion of an IPSS questionnaire, a urinalysis, and a voiding diary.
First-line medical therapy for BPH is an alpha-blocker which relaxes the prostatic smooth muscle. Dizziness is the most common side effect and may require discontinuation of the medication or reduction in its dose.
Finasteride (Proscar) is a 5-alpha reductase inhibitor which can reduce BPH-related symptoms by reducing the volume of the prostate.
Patients with BPH should be referred to a urologist if they fail medical therapy, have a potential neurologic cause of their symptoms, or are considering surgical therapy.
Transurethral resection of the prostate (TURP) is the gold-standard procedure for the treatment of BPH. Open radical prostatectomy is a cancer operation and is NOT indicated for benign prostatic obstruction.