Urology Office Consult

Thank you for referring Arthur. We met today to discuss progressive lower urinary tract symptoms.

Reason for Referral

Evaluation and management of refractory lower urinary tract symptoms secondary to benign prostatic hyperplasia.

History of Present Illness

Arthur is a 68-year-old male presenting with a two-year history of progressively worsening lower urinary tract symptoms despite monotherapy with tamsulosin. His IPSS score today is 21, indicating severe symptoms, with a quality of life score of 4 (mostly dissatisfied).

He reports daytime voiding frequency every 1 to 2 hours, accompanied by significant urinary urgency and nocturia 3 to 4 times per night. Dysuria is absent. He notes a weak, intermittent urinary stream, requires straining to initiate micturition, and experiences a persistent sensation of incomplete bladder emptying.

He denies any suprapubic, flank, or perineal pain.

He reports one episode of self-limiting, painless gross hematuria two months ago, with no passage of clots.

He has no history of recurrent urinary tract infections.

Past Medical History

Hypertension, hyperlipidemia, type 2 diabetes mellitus, laparoscopic cholecystectomy (14/05/2015), right inguinal hernia repair (22/11/2019).

Medications

• tamsulosin (Flomax®) 0.4 mg PO daily
• ramipril (Altace®) 5 mg PO daily
• atorvastatin (Lipitor®) 20 mg PO daily
• metformin (Glucophage®) 500 mg PO BID
• saw palmetto 320 mg PO daily

Allergies

NKDA.

Social History

Former smoker with a 20 pack-year history, having quit 15 years ago. Consumes 2 to 3 alcoholic beverages per week. Retired civil engineer.

Family History

Father diagnosed with prostate cancer at age 74; paternal aunt had breast cancer at age 62. No family history of ovarian, pancreatic, colon, stomach, or endometrial malignancies.

Physical Examination

BP 134/82 mmHg, HR 72 bpm. Abdomen is soft, non-tender, and non-distended with no palpable bladder or flank masses. External genitalia are normal with a normal urethral meatus and bilateral descended testes without masses. Digital rectal examination reveals a symmetrically enlarged prostate estimated at 60 g, smooth, firm, non-tender, with no palpable nodules or induration and intact midline sulcus.

Investigations

• Urinalysis (10/10/2023): Negative for nitrites and leukocyte esterase; 3-5 RBC/HPF.
• Urine culture (10/10/2023): No growth.
• Serum Creatinine (10/10/2023): 88 µmol/L, eGFR 76 mL/min/1.73m².
• PSA (10/10/2023): 3.4 ng/mL (stable compared to 3.1 ng/mL on 15/09/2022).
• Renal and Bladder Ultrasound (18/10/2023): Normal kidneys bilaterally without hydronephrosis. Prostate volume measured at 65 mL. Pre-void volume 380 mL, post-void residual (PVR) volume 145 mL.
• Office Uroflowmetry (today): Qmax 8.2 mL/s, voided volume 210 mL, PVR 130 mL by bladder scan.

Assessment

Arthur is a 68-year-old male with severe lower urinary tract symptoms and elevated post-void residual secondary to benign prostatic hyperplasia, alongside a single episode of gross hematuria. Given his prostate volume of 65 mL and inadequate response to alpha-blocker monotherapy, we discussed adding a 5-alpha-reductase inhibitor versus proceeding directly to surgical intervention such as transurethral resection of the prostate (TURP). We reviewed the benefits of combination medical therapy in reducing prostate volume and long-term risk of acute urinary retention, weighed against potential adverse effects including erectile dysfunction, decreased libido, and ejaculatory disorders. He prefers to trial combination medical therapy prior to considering surgical options. Due to the episode of gross hematuria, flexible cystoscopy is indicated to rule out urothelial pathology.

Plan

1. Start dutasteride (Avodart®) 0.5 mg PO daily.
2. Continue tamsulosin (Flomax®) 0.4 mg PO daily.
3. Discontinue saw palmetto.
4. Schedule outpatient flexible cystoscopy and urine cytology.
5. Follow up in clinic in 6 months with a repeat PVR and IPSS assessment.