A 56-year-Old-gentleman presented with urinary frequency, diminishing urinary flow and incomplete voiding. He also complained of increased nocturnal frequency. He was a non diabetic and non hypertensive. Routine haematological and biochemical parameters were within normal range. His PSA was normal, urine for routine test was normal. USG of abdomen revealed increased prostate size with a residual urinary volume of approximately 60 mi.
Diagnosis: Symptomatic benign prostatic hypertrophy
Lower urinary tract symptoms are quite common in men over 50 years and the commonest cause is benign prostatic hypertrophy. However other causes like urinary tract infection, cerebrovascular accident (urinary bladder is under inhibitory control from higher centers), heart failure (by redistribution of body fluid while recumbent) should also be excluded.
Lower urinary symptoms are a very common problem encountered by an internist or primary care physician.
While assessing such patient one has to differentiate uncomplicated from a complicated lower urinary tract symptoms. Presence of dysuria, haematuria, palpable urinary bladder, recurrent urinary tract infection, high urea creatinine, high PSA, usually indicate complicated urinary tract problem and should be referred to an urologist.
While treating such patients self-management techniques should be encouraged
These include:
Avoidance of caffeine containing drink.
Avoid diuretics in the evening.
Fluid restriction towards evening.
Double voiding of the bladder.
Drugs
Alpha blockers reduce the tone within the prostrate and bladder neck. They have no effect on prostate size. Commonly used alpha blockers are prazosin, terazosin and doxazocin and recently introduced more selective alpha blocker - tamsulosin and alfuzosin. They are equipotent in reducing symptoms of prostatism by around 30-45% and increasing flow rates by around 15-30%.
Postural hypotension is a common side effect and the dose titration should be done cautiously with the first dose taken at the bed time to prevent postural hypotension.
5 Alpha reductase inhibitors (Finasteride)
They inhibit conversion of testosterone to dehydrotestosterone leading to reduction of prostatic volume.
These drugs reduce lower urinary tract symptoms and reduce the rate of TURP and acute retention of urine. However they may take at least 6 months to produce symptomatic improvement. Usual dose of finasteride is 5 mg daily. These drugs should be used if the prostatic volume is more than 40 ml. One should remember that these groups of drugs reduce the PSA level by half and while on these drugs, PSA level should be interpreted accordingly.
Anti muscarine drugs
Commonly used drugs are oxybutinin and tolterodine. These drugs are particularly helpful in urge incontinence resulting from detrusor instability in patients with CVA. In patients with BPH these drugs may be used although there is theoretical risk of urinary retention. They are contraindicated in patients with significant outflow tract obstruction.
A 62-year-old gentleman presented with history of dull perineal pain, dysuria followed by urinary retention. He was admitted and catheterized and started on IV antibiotics for U. TI. U.S.G. showed evidence of enlarged prostate. In next 5 days time, the urinary catheter was withdrawn successfully. However, the family members were very concerned because of a very high PSA level (44 units, normal 0-4 units). He was given 4 weeks course of ofloxacin and a repeat PSA after 6 weeks was absolutely normal. This patient has prostatitis and UTI which caused his PSA to go high.
Causes of high PSA - other than carcinoma
1. Urinary tract infection
2. Prostatitis
3. Urinary tract instrumentation
4. Prostatic massage but not rectal examination.
If there is persistent elevation of PSA, one should go for prostatic biopsy and refer to an urologist.
Key Points
Lower urinary tract symptoms are very common in middle aged and elderly population.
BPH is the most common cause of such problem.
Patients with complicated symptoms should be referred to an urologist.
Alpha blockers improve symptoms without affecting the prostatic size.
5 alpha-reductase inhibitors reduce prostatic size but takes 6 months for symptomatic improvement.
5 alpha-reductase inhibitors reduce the PSA level by half and the PSA value has to be interpreted accordingly.
There are some non-malignant causes of raised PSA and PSA should be repeated after appropriately treating those conditions.
Persistently raised PSA needs an urgent urological referral for a prostatic biopsy