Benign Prostatic Hyperplasia

BPH Benign increase in

size of prostate Hyperplasia of

stromal and epithelial cells

Nodules

Patient W.M. 76 yo Recurrent UTIs Acute pyelonephritis Urinary frequency, urgency,

incontinence, and nocturia

Past Medical History Hypothyroidism COPD Obesity 1 ppd smoker Father – alcoholic Mother – DM type 2

Review of Symptoms Strain to initiate urination Urinary flow stops and then starts Post-void dribbling

Medications Ipratropium bromide Ibuprofen Levothyroxine Ferrous sulfate

Case Question 1:For what condition is the patient probably taking ipratroprium bromide?

Ipratropium bromide is used to relieve bronchial spasms

Anticholinergic

Answer:

COPD

Case Question 2:For what condition is the patient probably taking levothyroxine?

Synthetic thyroid hormone

Answer:

Hypothyroidsim

IPSS International Prostate Symptom Score 8 question survey Standardize patients

Case Question 3:Based on the patient’s IPSS, is his condition of prostatic enlargement considered mild, moderate or severe?

Case Question 4:Based on the patient’s BMI, is the patient technically overweight or obese?

BMI Measure of body fat

Underweight < 18.5 Normal weight = 18.5-24.9 Overweight = 25-29.9 Obesity > 30

Vital Signs

Patient’s BMI = 33.8%

BP 135/85 (R arm) 130/85 (L arm)

RR 16, unlabored HT 6’0”

P 80 and regular T 98.6 F WT 249 lbs

Physical Exam All normal Urinary Function Tests

Uroflowmetry Transabdominal ultrasound Pressure flow study

Case Question 5:Which urinary function test(s) is/are consistent with an enlarged prostate?

Uroflowmetry Normal: 10 – 21 mL/sec Patient: 7 mL/sec

Residual Urine Volume > 50 mL significant Patient: 110 mL

Bladder Voiding Pressure Weak < 100 cm H2O

Patient: 74 cm H2O

Case Question 6:Identify all abnormal results of this patient’s urinalysis

Color Straw

Bilirubin (-)

WBC 2/HPF

Appearance Clear Ketones (-)

RBC 2/HPF

SG 1.017

Blood (-)

Bacteria Trace

pH 6.4

Urobilinogen (-)

Crystals (-)

Glucose (-)

Nitrites (-)

Culture Not indicated

Blood Test ResultsNa 141 meq/L

MCHC 31.8 g/dL

LDH 219 IU/L

K 3.9 meq/L

Plt 282000/mm3

Bilirubin 1.2mg/dL

Cl 109 meq/L

WBC 8700/mm3

Protein 5.9mg/dL

HCO3 32 meq/L • Neutros 65%

Cholesterol 255mg/dL

BUN 15 mg/dL

• Lymphs 27%

Ca 8.7mg/dL

Cr .8 mg/dL

• Monos 5%

Mg 2.2mg/dL

Glu 119 mg/dL

• Eos 2%

PO4 2.8mg/dL

Hb 13.9 g/dL

• Basos 1%

Uric acid 6.3mg/dL

Hct 41%

AST 31 IU/L

T4 3.5µg/dL

MCV 97 fL

ALT 41 IU/L

TSH 107.9µU/mL

MCH 28.7 pg

Alk phos 52 IU/L

PSA* 5.2ng/mL

*PSA 13 months ago was 5.0 ng/mL

Case Question 7:Is the patient experiencing an electrolyte imbalance?

Na 141 meq/L

MCHC 31.8 g/dL

LDH 219 IU/L

K 3.9 meq/L

Plt 282000/mm3

Bilirubin 1.2mg/dL

Cl 109 meq/L

WBC 8700/mm3

Protein 5.9mg/dL

HCO3 32 meq/L • Neutros 65%

Cholesterol 255mg/dL

BUN 15 mg/dL

• Lymphs 27%

Ca 8.7mg/dL

Cr .8 mg/dL

• Monos 5%

Mg 2.2mg/dL

Glu 119 mg/dL

• Eos 2%

PO4 2.8mg/dL

Hb 13.9 g/dL

• Basos 1%

Uric acid 6.3mg/dL

Hct 41%

AST 31 IU/L

T4 3.5µg/dL

MCV 97 fL

ALT 41 IU/L

TSH 107.9µU/mL

MCH 28.7 pg

Alk phos 52 IU/L

PSA* 5.2ng/mL

*PSA 13 months ago was 5.0 ng/mL

8. Renal Function?Na 141 meq/L

MCHC 31.8 g/dL

LDH 219 IU/L

K 3.9 meq/L

Plt 282000/mm3

Bilirubin 1.2mg/dL

Cl 109 meq/L

WBC 8700/mm3

Protein 5.9mg/dL

HCO3 32 meq/L • Neutros 65%

Cholesterol 255mg/dL

BUN 15 mg/dL

• Lymphs 27%

Ca 8.7mg/dL

Cr .8 mg/dL

• Monos 5%

Mg 2.2mg/dL

Glu 119 mg/dL

• Eos 2%

PO4 2.8mg/dL

Hb 13.9 g/dL

• Basos 1%

Uric acid 6.3mg/dL

Hct 41%

AST 31 IU/L

T4 3.5µg/dL

MCV 97 fL

ALT 41 IU/L

TSH 107.9µU/mL

MCH 28.7 pg

Alk phos 52 IU/L

PSA* 5.2ng/mL

*PSA 13 months ago was 5.0 ng/mL

9. Hepatic Function?Na 141 meq/L

MCHC 31.8 g/dL

LDH 219 IU/L

K 3.9 meq/L

Plt 282000/mm3

Bilirubin 1.2mg/dL

Cl 109 meq/L

WBC 8700/mm3

Protein 5.9mg/dL

HCO3 32 meq/L • Neutros 65%

Cholesterol 255mg/dL

BUN 15 mg/dL

• Lymphs 27%

Ca 8.7mg/dL

Cr .8 mg/dL

• Monos 5%

Mg 2.2mg/dL

Glu 119 mg/dL

• Eos 2%

PO4 2.8mg/dL

Hb 13.9 g/dL

• Basos 1%

Uric acid 6.3mg/dL

Hct 41%

AST 31 IU/L

T4 3.5µg/dL

MCV 97 fL

ALT 41 IU/L

TSH 107.9µU/mL

MCH 28.7 pg

Alk phos 52 IU/L

PSA* 5.2ng/mL

*PSA 13 months ago was 5.0 ng/mL

10. Hb, Hct, MCV, MCH, MCHC?Na 141 meq/L

MCHC 31.8 g/dL

LDH 219 IU/L

K 3.9 meq/L

Plt 282000/mm3

Bilirubin 1.2mg/dL

Cl 109 meq/L

WBC 8700/mm3

Protein 5.9mg/dL

HCO3 32 meq/L • Neutros 65%

Cholesterol 255mg/dL

BUN 15 mg/dL

• Lymphs 27%

Ca 8.7mg/dL

Cr .8 mg/dL

• Monos 5%

Mg 2.2mg/dL

Glu 119 mg/dL

• Eos 2%

PO4 2.8mg/dL

Hb 13.9 g/dL

• Basos 1%

Uric acid 6.3mg/dL

Hct 41%

AST 31 IU/L

T4 3.5µg/dL

MCV 97 fL

ALT 41 IU/L

TSH 107.9µU/mL

MCH 28.7 pg

Alk phos 52 IU/L

PSA* 5.2ng/mL

*PSA 13 months ago was 5.0 ng/mL

11. T4 and TSH?Na 141 meq/L

MCHC 31.8 g/dL

LDH 219 IU/L

K 3.9 meq/L

Plt 282000/mm3

Bilirubin 1.2mg/dL

Cl 109 meq/L

WBC 8700/mm3

Protein 5.9mg/dL

HCO3 32 meq/L • Neutros 65%

Cholesterol 255mg/dL

BUN 15 mg/dL

• Lymphs 27%

Ca 8.7mg/dL

Cr .8 mg/dL

• Monos 5%

Mg 2.2mg/dL

Glu 119 mg/dL

• Eos 2%

PO4 2.8mg/dL

Hb 13.9 g/dL

• Basos 1%

Uric acid 6.3mg/dL

Hct 41%

AST 31 IU/L

T4 3.5µg/dL

MCV 97 fL

ALT 41 IU/L

TSH 107.9µU/mL

MCH 28.7 pg

Alk phos 52 IU/L

PSA* 5.2ng/mL

*PSA 13 months ago was 5.0 ng/mL

12. Single most significant result?Na 141 meq/L

MCHC 31.8 g/dL

LDH 219 IU/L

K 3.9 meq/L

Plt 282000/mm3

Bilirubin 1.2mg/dL

Cl 109 meq/L

WBC 8700/mm3

Protein 5.9mg/dL

HCO3 32 meq/L • Neutros 65%

Cholesterol 255mg/dL

BUN 15 mg/dL

• Lymphs 27%

Ca 8.7mg/dL

Cr .8 mg/dL

• Monos 5%

Mg 2.2mg/dL

Glu 119 mg/dL

• Eos 2%

PO4 2.8mg/dL

Hb 13.9 g/dL

• Basos 1%

Uric acid 6.3mg/dL

Hct 41%

AST 31 IU/L

T4 3.5µg/dL

MCV 97 fL

ALT 41 IU/L

TSH 107.9µU/mL

MCH 28.7 pg

Alk phos 52 IU/L

PSA* 5.2ng/mL

*PSA 13 months ago was 5.0 ng/mL

Case Question 13:Provide three strong lines of evidence that this patient does not have prostate cancer

1. Low PSA

1. Physical exam findings

1. Low WBC count

Case Question 14:Pharmacotherapy or surgery?

Case Question 15:When a patient with mild-to-moderate BPH does not respond to pharmacotherapy with 5α-reductase inhibitors or α1-blockers, what can be inferred?

the end