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 = Overweight = Obesity > 30
Vital Signs Patient’s BMI = 33.8% BP 135/85 (R arm) 130/85 (L arm) RR 16, unlaboredHT 6’0” P 80 and regularT 98.6 FWT 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 H 2 O Patient: 74 cm H 2 O
Case Question 6: Identify all abnormal results of this patient’s urinalysis
Color StrawBilirubin (-)WBC 2/HPF Appearance ClearKetones (-)RBC 2/HPF SG 1.017Blood (-)Bacteria Trace pH 6.4Urobilinogen (-)Crystals (-) Glucose (-)Nitrites (-)Culture Not indicated
Blood Test Results Na 141 meq/L MCHC 31.8 g/dLLDH 219 IU/L K 3.9 meq/L Plt /mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 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%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 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/dLLDH 219 IU/L K 3.9 meq/L Plt /mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 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%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 5.2ng/mL *PSA 13 months ago was 5.0 ng/mL
8. Renal Function? Na 141 meq/L MCHC 31.8 g/dLLDH 219 IU/L K 3.9 meq/L Plt /mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 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%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 5.2ng/mL *PSA 13 months ago was 5.0 ng/mL
9. Hepatic Function? Na 141 meq/L MCHC 31.8 g/dLLDH 219 IU/L K 3.9 meq/L Plt /mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 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%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 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/dLLDH 219 IU/L K 3.9 meq/L Plt /mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 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%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 5.2ng/mL *PSA 13 months ago was 5.0 ng/mL
11. T 4 and TSH? Na 141 meq/L MCHC 31.8 g/dLLDH 219 IU/L K 3.9 meq/L Plt /mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 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%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 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/dLLDH 219 IU/L K 3.9 meq/L Plt /mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 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%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 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