Renal and urology · Moderate
This case is fictional and exists for study. It describes no real patient.
67 years · male
A 67-year-old man presents to the general practice clinic complaining of a 9-month history of worsening lower urinary tract symptoms. He reports urinary hesitancy, a weak urinary stream, terminal dribbling, and nocturia occurring three to four times per night. He feels as though his bladder does not empty completely after voiding. He denies dysuria, gross haematuria, fever, or weight loss. On examination, his abdomen is soft and non-tender with no palpable bladder or flank masses. Digital rectal examination reveals a smoothly enlarged, firm, non-tender prostate with a well-defined median sulcus and no palpable nodules.
Vital signs
- HR
- 72 bpm
- BP
- 134/82 mmHg
- RR
- 14/min
- Temp
- 36.6 °C
- SpO₂
- 98%
Examination findings
- Digital rectal exam: Smoothly enlarged, firm, non-tender prostate with preserved median sulcus, no nodules
- Abdominal exam: Soft, non-tender, no dullness to percussion in the suprapubic area
Investigations
| Serum Creatinine | 88 µmol/L | reference: 60-110 |
| Prostate-Specific Antigen (PSA) | 2.4 ug/L | reference: 0.0-4.0 |
| Urine Dipstick | Negative N/A | reference: Negative for nitrites, leukocytes, protein, blood |
Question 1 of 3
Which of the following is the most likely diagnosis?
The clinical presentation of chronic voiding symptoms (hesitancy, weak stream, terminal dribbling, sensation of incomplete emptying) combined with a smooth, non-tender, symmetrically enlarged prostate on digital rectal examination (DRE) is classic for benign prostatic hyperplasia (BPH). Prostate adenocarcinoma typically presents with asymmetrical enlargement, hard nodules, or loss of the median sulcus. Acute bacterial prostatitis presents with systemic symptoms (fever, chills), severe dysuria, and a exquisitely tender, boggy prostate. Overactive bladder syndrome presents primarily with storage symptoms (urgency, urge incontinence) rather than voiding/obstructive symptoms.
Teaching point: Smooth, symmetrical, non-tender enlargement of the prostate with obstructive lower urinary tract symptoms in an older male is classic for benign prostatic hyperplasia.
Question 2 of 3
Which of the following is the most appropriate next non-invasive investigation to further characterize his symptoms before initiating treatment?
A frequency-volume chart (bladder diary) completed over at least 3 days is recommended as part of the initial assessment for lower urinary tract symptoms (LUTS). It helps distinguish between nocturnal polyuria, reduced bladder capacity, and primary voiding dysfunction, guiding appropriate therapy. Transrectal ultrasound biopsy is indicated if prostate cancer is suspected based on abnormal DRE or elevated PSA, neither of which is present here. Flexible cystoscopy is reserved for patients with haematuria, suspected urethral stricture, or prior failed treatments. CT abdomen and pelvis is not routinely indicated for uncomplicated LUTS/BPH.
Teaching point: A frequency-volume chart is a crucial non-invasive baseline assessment tool to evaluate urinary frequency, fluid intake, and voided volumes in LUTS.
Question 3 of 3
The patient scores 16 on the International Prostate Symptom Score (IPSS), indicating moderate symptoms, and requests medical treatment. Which of the following is the most appropriate initial pharmacological therapy?
Alpha-1 adrenergic receptor antagonists such as tamsulosin act quickly (within days) by relaxing smooth muscle in the prostate capsule and bladder neck, making them the first-line medical therapy for moderate-to-severe voiding LUTS secondary to BPH. 5-alpha-reductase inhibitors like finasteride reduce prostate size but take 3 to 6 months to demonstrate clinical efficacy; they are typically reserved for significantly enlarged prostates (>30g) or combined with alpha-blockers. Oxybutynin is an antimuscarinic useful for storage/overactive bladder symptoms, but can precipitate urinary retention if used alone in obstructive BPH. TURP is a surgical option reserved for severe symptoms, failure of medical management, or complications such as recurrent urinary retention.
Teaching point: Alpha-1 antagonists (e.g., tamsulosin) are the first-line medical treatment for rapid symptom relief in moderate benign prostatic hyperplasia.
Key learning points
- Benign prostatic hyperplasia (BPH) presents with voiding lower urinary tract symptoms and a smooth, non-tender enlarged prostate on DRE.
- Initial evaluation of LUTS includes urine dipstick, serum creatinine, PSA, and a frequency-volume chart.
- Alpha-1 antagonists (e.g., tamsulosin) are first-line for rapid symptom relief in moderate-to-severe BPH.
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