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Toronto Notes 2019 Common Presenting Problems
Benign Prostatic Hyperplasia
• seeUrology,U8 Definition
• hyperplasiaofthestromaandepitheliumintheperiurethraltransitionzone
History and Physical
• includecurrent/pasthealth,surgeries,trauma,currentmedicationsincludingOTC
• specificurinarysymptoms
• physicalexammustincludeDREforsize,symmetry,nodularity,andtextureofprostate(prostateis
symmetrically enlarged, smooth, and rubbery in BPH)
Investigations
• urinalysistoexcludeUTIandformicroscopichematuria(commonsign) • serumPSA:proteinproducedbyprostatictissue
■ values
◆ <4.0 ng/mL: normal, but must take into account patient’s age and velocity of PSA increase ◆ 4-10 ng/mL: consider measuring free/total PSA
◆ >10 ng/mL: high likelihood of prostate pathology
■ PSA testing is inappropriate in men with a life expectancy less than 10 yr or patients with prostatitis, UTI
■ increased PSA in a younger man is more often due to cancer than other causes
■ abnormal DRE or PSA should trigger further assessment
■ discuss test with men at increased risk of prostate cancer (FHx, African ancestry) or who are
concerned about development of prostate cancer
■ decision to test PSA in an asymptomatic man should involve discussion about the risks and possible
benefits • othertests
■ Cr, BUN, post-void residual volume by ultrasound, urodynamic studies, renal ultrasound, patient voiding diary
• testsNOTrecommendedaspartofroutineinitialevaluationinclude:
■ cystoscopy, cytology, prostate ultrasound or biopsy, IVP, urodynamic studies
Family Medicine FM17
Table 10. Symptoms and Complications of BPH
Obstructive Symptoms
Hesitancy (difficulty starting urine flow)
Diminution in size and force of urinary stream
Stream interruption (double voiding)
Urinary retention (bladder does not feel completely empty) Post-void dribbling
Overflow incontinence
Nocturia
Management
Irritative Symptoms
Urgency Frequency Nocturia
Urge incontinence Dysuria
Late Complications
Hydronephrosis
Loss of renal concentrating ability Systemic acidosis
Renal failure
Self-Management Asthma and COPD Education and Written Action Plan
• Education is a key component in
management of asthma and COPD • Guided self-management combining
education, regular medical review, self- assessment, and written action plan have been shown to reduce hospitalizations, ER visits, and missed days at work or school.
• Sample action plans available online: http:// www.respiratoryguidelines.ca
• referraltourologistifmoderate/severesymptoms
• conservative:forpatientswithmildsymptomsormoderate/severesymptomsconsideredbythepatient
to be non-bothersome
■ fluid restriction (avoid alcohol and caffeine)
■ avoidance/monitoring of certain medications (e.g. antihistamines, diuretics, antidepressants,
decongestants)
■ pelvic floor/Kegel exercises
■ bladder retraining (scheduled voiding)
• pharmacological:formoderate/severesymptoms
■ α-receptor antagonists (e.g. terazosin [Hytrin®], doxazosin [Cardura®], tamsulosin [Flomax®],
alfuzosin [Xatral®])
◆ relax smooth muscle around the prostate and bladder neck
■ 5-α reductase inhibitors (e.g. finasteride [Proscar®])
◆ only for patients with demonstrated prostatic enlargement due to BPH
◆ inhibit the enzyme responsible for conversion of testosterone to dihydrotestosterone (DHT) thus
reducing growth of prostate
■ phytotherapy (e.g. saw palmetto berry extract, Pygeum africanum)
◆ more studies are required before it can be recommended as standard therapy (currently considered safe)
• surgical
■ TURP (transurethral resection of the prostate), TUIP (transurethral incision of the prostate, for
prostate <30 g)
■ absolute indications: failed medical therapy, intractable urinary retention, benign prostatic
obstruction leading to renal insufficiency
■ complications: impotence, incontinence, ejaculatory difficulties (retrograde ejaculation), decreased
Differential Diagnosis
• Prostate cancer
• Urethral obstruction
• Bladder neck obstruction • Neurogenic bladder
• Overactive bladder
• Cystitis
• Prostatitis
libido