Clinical Geriatrics

Case Presentation
A 67-year-old male is seen in the Emergency Department for urinary retention. He has a history of moderate lower urinary tract obstructive and irritative symptoms consisting of frequency, urgency, poor force and caliber of his urinary stream, and nocturia. In the last few days prior to his admission to the hospital, he had dribbling of urination and lower abdominal pain. A physical exam revealed a bladder palpable above the pubic symphysis, the rectal exam revealed a markedly enlarged prostate gland, and a urinalysis revealed 5-7 white blood cells/high power field. The patient’s prostate-specific antigen (PSA) was 6.5 ng/mL. The blood urea nitrogen (BUN) was 40 mg/dL, and serum creatinine was 2.6 mg/dL. An abdominal ultrasound revealed hydroureteronephrosis with a markedly distended bladder. A Foley catheter was inserted, and he had approximately 900 cc of residual urine. He experienced a post-obstructive diuresis with normalization of his BUN and creatinine levels. A cystoscopy revealed coaptation of the lateral lobes of the prostate and grade 3 trabeculation of the bladder. The patient had GreenLight™ laser treatment of his outlet obstruction and used a catheter for 3 days after the procedure. He was able to void with a good stream and had less than 75 cc of post-void residual. Follow-up BUN and creatinine levels 3 weeks after the GreenLight laser procedure were 15 mg/dL and 1.7 mg/dL.

Discussion

Prevalence and Incidence of BPH
Benign prostatic hyperplasia (BPH) is the proliferation of nonmalignant stromal and epithelial cells in the prostate, which may lead to nodular formation in the periurethral area of the prostate and subsequent partial or complete obstruction of the urethra. Clinical BPH is a diagnosis of lower urinary tract symptoms (LUTS), urinary tract infections (UTIs), or acute urinary retention (AUR) due to the urethral obstruction. BPH progresses linearly with age. According to the National Institutes of Health, there are more than 7.8 million BPH diagnoses made and more than $1 billion in expenditures each year in the United States alone.¹

Histological evidence of BPH emerges after age 30, with a 50% prevalence in men age 50-61 and a 90% prevalence by age 90.² However, it is difficult to predict how many of these cases will progress to clinical BPH. The overall prevalence of clinical BPH (BPH with LUTS) is 10.3%, with a maximum prevalence of 24% by age 80. It is estimated that 45% of nonsymptomatic 46-year-old men with histological BPH will develop LUTS over the next 30 years.³ Other studies have shown that 40% of 55-74–year-old men with BPH have LUTS.⁴

Signs and Symptoms of BPH—Diagnosis
In most males, the prostate gland slowly begins to enlarge around the age of 30, but it is usually asymptomatic until age 50. An enlarged prostate can cause both obstructive (voiding) and irritative (holding) symptoms that decrease a patient’s quality of life. BPH may lead to UTIs and AUR, which may require surgical intervention, but these are often preceded by LUTS. Obstructive symptoms include decreased force of the urinary stream, straining to urinate and hesitancy to initiate urination, interruptions in flow, and the feeling of not emptying the bladder. Irritative symptoms include frequency, nocturia, dysuria, urgency, and urge incontinence.⁵ These symptoms may decrease a patient’s quality of life by interfering with his ability to perform his job, to travel, to attend social engagements, and to get a good night’s sleep. Depending on the individual, only some of these symptoms may be present, and to varying degrees of severity.

A digital rectal exam may reveal an enlarged prostate. An elevated PSA level may also signify an enlarged prostate, among other possible diagnoses, and should be followed by a free PSA determination.