The 57-year-old patient noted urinary hesitancy and a decrease in the force of his urinarystream for several months. Both had progressively become worse. His physical examinationwas essentially negative except for an enlarged prostate, which was bulky and soft.Studies ResultsRoutine laboratory studies Within normal limits (WNL)Intravenous pyelogram (IVP) Mild indentation of the interior aspect of the bladder,indicating an enlarged prostateUroflowmetry with total voidedflow of 225 mL8 mL/sec (normal: >12 mL/sec)Cystometry Resting bladder pressure: 35 cm H2O (normal: <40 cm H2O)Peak bladder pressure: 50 cm H2O (normal: 40-90 cm H2O)Electromyography of the pelvicsphincter muscleNormal resting bladder with a positive tonus limbCystoscopy Benign prostatic hypertrophy (BPH)Prostatic acid phosphatase(PAP)0.5 units/L (normal: 0.11-0.60 units/L)Prostate specific antigen (PSA) 1.0 ng/mL (normal: <4 ng/mL)Prostate ultrasound Diffusely enlarged prostate; no localized tumorDiagnostic AnalysisBecause of the patient’s symptoms, bladder outlet obstruction was highly suspected. Physicalexamination indicated an enlarged prostate. IVP studies corroborated that finding. Thereduced urine flow rate indicated an obstruction distal to the urinary bladder. Because thepatient was found to have a normal total voided volume, one could not say that the reducedflow rate was the result of an inadequately distended bladder. Rather, the bladder wasappropriately distended, yet the flow rate was decreased. This indicated outlet obstruction.The cystogram indicated that the bladder was capable of mounting an effective pressure andwas not an atonic bladder compatible with neurologic disease. The tonus limb againindicated the bladder was able to contract. The peak bladder pressure of 50 cm H2O wasnormal, again indicating appropriate muscular function of the bladder. Based on thesestudies, the patient was diagnosed with a urinary outlet obstruction. The PAP and PSAindicated benign prostatic hypertrophy (BPH). The ultrasound supported that diagnosis.Cystoscopy documented that finding, and the patient was appropriately treated bytransurethral resection of the prostate (TURP). This patient did well postoperatively and hadno major problems.Critical Thinking Questions1. Does BPH predispose this patient to cancer?2. Why are patients with BPH at increased risk for urinary tract infections?3. What would you expect the patient’s PSA level to be after surgery?4. What is the recommended screening guidelines and treatment for BPH?5. What are some alternative treatments / natural homeopathic options for treatment?Note: I need you to have at least two to three bibliographic references and ask that they be updated, less than 5 years ago.

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