BPH with lower urinary tract symptoms (LUTS), Prostatic Neoplasms (benign or malignant) vs. Prostatitis

For this week’s discussion I will discuss the case for topic number 3.  Mr. E.D. is a 63-year-old retired mail carrier who presents to his primary care provider for a routine follow up for his hypertension. He complains of a 4-day history of dysuria, increased urinary frequency, and nocturia. He states that he has been having fever and chills. Denies any recent sexual activity. On examination, his temperature is 99.5 F., pulse 75 and regular, respiratory rate 16 and unlabored, and blood pressure 135/85. He does not appear acutely ill and is in no apparent distress. Examination of the abdomen was normal. A digital rectal exam revealed a moderately enlarged, firm, non-tender prostate gland. He states that he has severe urgency and difficulty urinating.

• Review the onset, persistence, severity, duration, and exact location of the dysuria (Michels & Sands, 2015).  “Pain occurring at the start of urination may indicate urethral pathology; pain occurring at the end of urination is usually of bladder origin” (Michels & Sands, 2015, p. 779).
• Are you experiencing any testicular pain or pain in the perineal area, between the scrotum and anus?  “In addition to dysuria, men with prostatitis may have deep perineal pain and obstructive urinary symptoms, whereas those with epididymo-orchitis may have localized testicular pain” (Michels & Sands, 2015, p. 779).
• The patient indicated that is urinary frequency increased 4 days ago.  How long have you been experiencing urinary frequency?  How often do you have to urinate daily?  Do you feel like you are unable to completely empty your bladder when you urinate?
• Were you experiencing nocturia prior to the onset of dysuria 4 days ago?  If so how long have you been experiencing nocturia? On average how many times a night is your sleep interrupted because you have to get up to urinate?
• Did the symptoms of severe urgency and difficulty urinating start 4 days ago with the dysuria, or were you experiencing these symptoms before the onset of the dysuria?  If patient had started experiencing these symptoms prior to the dysuria, when did they start?
• Any incontinence, hematuria, or malodorous urine?
• Any fever, chills, nausea, or back or flank pain?  If patient indicates they have back or flank pain, inquire if the pain is unilateral or bilateral (Glass & Gunter, 2017).
• Any new symptoms of bone or back pain, loss of appetite, or weight loss (Glass & Gunter, 2017)?
• Any other symptoms such as genital lesions or penile discharge? (Glass & Gunter, 2017).
• Review the strength of the urinary flow, dribbling, hesitancy (Glass & Gunter, 2017)?
• Do you have a history of dysuria, urinary tract infections (UTIs), or sexually transmitted infections (Michels & Sands, 2015)?  Patient has denied any recent sexual encounters.  Inquiry in to recent sexual encounters or new sexual partners should be part of the history of present illness (HPI).
• Have you ever had any tests performed as part of a workup by a urologist?  If so why and what were the results?
• Surgical or procedural history? Any recent urologic instrumentation? Any history of trauma to bladder or urethra?
• History of prostatic disease, renal disease, renal infection, renal calculi, bladder disease, bladder dysfunction, sexual  dysfunction, diabetes mellitus, sickle cell disease, neurologic problems or trauma, cancer, or immunocompromised status?
• Do you have a history of smoking?
• What prescribed and OTC medications do you take, including cold and sinus medications, anticholinergic drugs (diphenhydramine), vitamins, herbal supplements, or minerals?
•   Do any of your hobbies include horseback riding or bicycling?
• Do you have a history of eye disease or cataracts?  This question is important if BPH is suspected, because tamsulosin (Flomax) and 5 other alpha 1 blockers are commonly used to treat the symptoms of BPH (Taylor-Woodbury, 2017).  Intraoperative floppy iris syndrome (IFIS) has been observed during cataract surgery in some patients treated with these medications (Taylor-Woodbury, 2017).  It is imperative that patients undergoing cataract surgery inform their ophthalmologist if they have ever taken these medications in order for the ophthalmologist to be prepared to modify their surgical technique should IFIS occur during the procedure (Taylor-Woodbury, 2017).
• Do you have a family history of benign prostatic hyperplasia (BPH) or prostate cancer?
• Ask the patient to complete the American Urological Association Symptom Score (AUASS) assessment tool.  This tool is used to assess the severity of symptoms of BPH (Glass & Gunter, 2017).  A symptom score of 1 to 7 indicates mild symptoms; a score of 8 – 19 indicates moderate symptoms; and a score of 20 – 35 indicates severe symptoms (Glass & Gunter, 2017).

Three Differential Diagnoses

Depending on the patient’s responses, several different differential diagnoses are possible. Based on the information given for the case the top 3 differential diagnoses I would consider are: BPH with lower urinary tract symptoms (LUTS). The BPH will be classified as mild, moderate, or severe using the AUASS assessment tool (Glass & Gunter, 2017); Prostatic neoplasms (benign or malignant); and prostatitis.  Other conditions that may be considered, dependent on the patient interview and physical exam findings, are urethral stricture, bladder cancer, bladder neck contracture, bladder stone, and cystitis.

Physical Examination

The physical examination, especially when a complicated UTI is a consideration, “should include vital signs, evaluation for costovertebral angle pain, palpation for abdominal mass or tenderness, and inspection for dermatologic conditions and acute joint effusions” (Michels & Sands, 2015, p. 779). A digital rectal exam should also be performed (Taylor-Woodbury, 2017).  ”A focused neurologic examination should be accomplished to rule out a neurogenic bladder” (Taylor-Woodbury, 2017, p. 451).

Diagnostics

Urinalysis by either dipstick or microscopic examinations to evaluate for hematuria or urinary tract infection (Taylor-Woodbury, 2017). If urinalysis indicates infection send for culture and sensitivity (Glass & Gunter, 2017). Patient’s with BPH are more susceptible to UTIs (Glass & Gunter, 2017). If urinalysis is positive for hematuria and patient has a smoking history obtain urine cytology to test for bladder cancer (Taylor-Woodbury, 2017). Consider testing for STIs.  Blood urea nitrogen (BUN) and creatinine levels are useful to rule out post renal insufficiency (Ferri, 2018). In men with symptomatic BPH, testing the total prostate specific antigen (PSA) level alone may not help to discriminate between BPH and prostate cancer because the total PSA will be elevated in BPH (Ferri, 2018). It is recommended that free PSA level be tested in men with BPH to assess for possible prostate cancer (Ferri, 2018). “A low free PSA percentage generally indicates a high grade cancer” (Ferri, 2018, p. 1076). Imaging studies are not routinely recommended for patients with BPH unless there is hematuria, elevated creatinine, or another indication (Glass & Gunter, 2017).

Evidence-Based Plan of Care

In men with complicated cystitis such as, febrile UTI, pyelonephritis, or prostatic involvement 2 weeks of antibiotic therapy based on microbe sensitivity should be completed (Wiser, 2017). “Treatment of concomitant prostatitis requires antimicrobial with good prostatic tissue and fluid penetration (fluroquinolones)” (Wiser, 2017, p. 1087).  Any patient with BPH scoring 8 or higher on the AUASS assessment tool, prostate cancer is suspected, detection of microscopic hematuria, complicated LUTS including history of prostate cancer, elevated PSA, urethral stricture, spinal cord injury, stroke, or recurrent/persistent UTI needs to be referred to an urologist to discuss treatment options (Glass & Gunter, 2017). Patients that are referred to urologist/specialist should be seen by their referring provider 2 to 3 weeks after seeing the specialist for further symptom evaluation (Glass & Gunter, 2017). Patients with mild symptoms of BPH should be evaluated every 3 to 6 months to monitor symptoms (Glass & Gunter, 2017). Prazosin (Minipress), a short acting alpha 1 antagonist, approved for the treatment of hypertension (HTN) would potentially be a good pharmacologic treatment for this patient due to his history of HTN and it also improves urine flow rates (Glass & Gunter, 2017).

Patients with enlarged prostates should be made aware of the following:  to always read labels to check for “Do not take if you have prostate enlargement.”; avoid taking OTC medications like cold medications, decongestants, antihistamines, and diarrhea medicines because they may worsen symptoms; double void to empty your bladder more completely; avoid spicy foods that irritate the bladder; caffeine and alcohol act as diuretics and increase the need to urinate (Glass & Gunter, 2017).

References

Ferri, F. F. (2018). Prostatic hyperplasia, benign. In F. F. Ferri (Ed.), 2018 Ferri’s clinical advisor (pp. 1075-1076). Philadelphia, PA: Elsevier.

Glass, C. A., & Gunter, D. (2017). Benign prostatic hypertrophy. In J. C. Cash & C. A. Glass (Eds.), Family practice guidelines (4th ed., pp. 339-342). New York, NY: Springer Publishing.

Glass, C. A., & Gunter, D. (2017). Urinary tract infection (acute cystitis). In J. C. Cash & C. A. Glass (Eds.), Family practice guidelines (4th ed., pp. 381-385). New York, NY: Springer Publishing.

Michels, T. C., & Sands, J. E. (2015). Dysuria: Evaluation and differential diagnosis in adults. American Family Physician, 92(9), 778-788. Retrieved from https://www.aafp.org

Taylor-Woodbury, J. N. (2017). Benign prostatic hyperplasia. In G. M. Collins-Bride, J. M. Saxe, K. G. Duderstadt, & R. Kaplan (Eds.), Clinical guidelines for advanced practice nursing: An interprofessional approach (3rd ed., pp. 449-455). Burlington, MA: Jones & Bartlett Learning.

Wiser, A. L. (2017). Urinary tract infection (UTI) in males. In F. J. Domino, R. A. Baldor, J. Golding, & M. B. Stephens (Eds.), The 5-minute clinical consult (25th ed., pp. 1086-1087). Philadelphia, PA: Wolters Kluwer.