New Urology Patient

Chief Complaint

The patient presents to the office to discuss:

1. Lower urinary tract symptoms (LUTS)
2. Microscopic hematuria
3. Erectile dysfunction

"HPI TODAY:" 10/24/2023:

Mr. Robert Vance is a 64-year-old male referred by his PCP for progressive LUTS over the past year and incidental microscopic hematuria. He reports weak urinary stream, hesitancy, and nocturia 3–4 times per night, stating, "I feel like I can never fully empty my bladder." His AUA symptom score today is 18, with a bother score of 4. He denies gross hematuria, dysuria, flank pain, or febrile UTIs. Additionally, he notes mild, progressive erectile dysfunction over the last 6 months, with an IIEF-5 score of 14; he maintains morning erections occasionally but struggles to maintain rigidity sufficient for penetration.

Renal and bladder ultrasound performed on 10/10/2023 at Metro Imaging Center demonstrated normal renal parenchyma bilaterally without hydronephrosis or nephrolithiasis, an estimated prostate volume of 48 mL, and a post-void residual (PVR) of 85 mL. I personally reviewed and independently interpreted the scan and agree with the findings.

Urinalysis from 10/02/2023 showed 8 RBC/HPF, negative leukocyte esterase, and negative nitrites, with a negative urine culture. Serum PSA on 10/02/2023 was 2.1 ng/mL, and serum creatinine was 0.9 mg/dL. Office uroflowmetry today revealed a Qmax of 9.5 mL/s with a voided volume of 210 mL, and repeat bladder scan PVR was 70 mL.

He works as a high school history teacher and enjoys woodworking and gardening in his free time.

PMH, PSH, Meds, Allergies, SH, and FH

• Information reviewed with the patient and in the EMR, with appropriate changes made.
• PMH: HTN, hyperlipidemia, GERD.
• PSH: Laparoscopic cholecystectomy (2015), right inguinal hernia repair (2019).
• Meds: Lisinopril 20 mg PO daily, atorvastatin (Lipitor®) 40 mg PO daily, omeprazole (Prilosec®) 20 mg PO daily.
• Allergies: Penicillin (maculopapular rash).
• SH: Former smoker (quit 15 years ago, 10 pack-year history); social alcohol (2–3 beers/week); married, lives with wife.
• FH: Father had BPH; no family history of prostate, bladder, or renal malignancy.

Physical Examination

Constitutional: Well-developed, well-nourished male in no acute distress. Alert and oriented x3.

Psychiatric: Mood and affect normal. Behavior appropriate. Judgment intact and thought content normal.

GU examination: Normal circumcised phallus without plaques or lesions; urethral meatus patent and orthotopic. Bilateral testes descended, normal size and consistency, without masses or tenderness; no hydrocele or varicocele. DRE reveals a symmetrically enlarged prostate (~45 g), smooth, firm, non-tender, without palpable nodules or induration. Normal rectal tone.

Assessment and Plan

64-year-old male presenting with moderate-to-severe obstructive and irritative LUTS secondary to BPH, asymptomatic microscopic hematuria (intermediate risk), and mild-to-moderate erectile dysfunction.

1. Benign prostatic hyperplasia with lower urinary tract symptoms (N40.1)

• Assessment: Moderate-to-severe symptoms (AUA 18) with reduced peak flow and moderate prostatomegaly on exam and ultrasound, without significant retention.
• Plan: Initiate tamsulosin (Flomax®) 0.4 mg PO daily, taken 30 minutes after the same meal each day.
• Counseling: Discussed the natural history of BPH, behavioral modifications (fluid restriction before bedtime, reducing caffeine/alcohol intake), and potential side effects of alpha-blockers including orthostatic hypotension, dizziness, and retrograde ejaculation.

2. Microscopic hematuria (R31.29)

• Assessment: Asymptomatic microhematuria (8 RBC/HPF) with negative infectious workup and normal upper tract ultrasound. Classified as intermediate risk per AUA guidelines due to age and smoking history.
• Plan: Schedule office flexible cystoscopy to evaluate the lower urinary tract mucosa.
• Counseling: Discussed AUA guideline recommendations for hematuria evaluation, explaining the small risk of underlying urothelial malignancy and the procedure details and risks of flexible cystoscopy (transient hematuria, dysuria, rare UTI).

3. Erectile dysfunction (N52.9)

• Assessment: Mild-to-moderate organic ED, likely vasculogenic given history of HTN and hyperlipidemia. No nitrate use noted.
• Plan: Start sildenafil (Viagra®) 50 mg PO PRN 1 hour prior to sexual activity (max once daily).
• Counseling: Reviewed mechanism of action of PDE5 inhibitors, importance of taking on an empty stomach for optimal absorption, and potential side effects (headache, flushing, dyspepsia, visual changes). Advised strict avoidance of nitrates.

Orders

• Medication: Tamsulosin (Flomax®) 0.4 mg PO daily (#90, 3 refills).
• Medication: Sildenafil (Viagra®) 50 mg PO PRN (#30, 3 refills).
• Procedure: Office flexible cystoscopy.

Follow Up

Return to clinic in 4 weeks for office flexible cystoscopy and to assess symptomatic response to tamsulosin and sildenafil, with a repeat PVR check at that visit.

Short Summary

64-year-old male seen for BPH with LUTS, microscopic hematuria, and ED. Started on tamsulosin and sildenafil, and scheduled for an office flexible cystoscopy in 4 weeks to complete his hematuria workup.