Benign prostatic hyperplasia / LUTS — KFP-style written assessment

KFP 1 (10 marks)

A 63-year-old accountant attends with six months of hesitancy, a weak stream, nocturia twice nightly and occasional urgency. He is otherwise well, takes no medication. His father had prostate surgery 'for his waterworks' at 70.^[24]

1. Outline your structured initial assessment of this man. (4) ^{[24] [1]}
2. He asks whether his prostate size predicts trouble ahead. Answer with data. (3) ^[9]
3. Which findings at this consultation would change your disposition immediately? (3) ^[24]

Model answers

1. Score symptoms with the IPSS (seven items, 0-35; he is likely moderate at 8-19) plus a separate bother question — bother drives therapy as much as score. Examine abdomen (palpable bladder), perform DRE (size, nodules, tone). Order urinalysis (infection, haematuria) and post-void residual; add renal function if impairment suspected. Given his storage symptoms and nocturia, issue a frequency-volume chart to separate nocturnal polyuria from small-capacity storage disease before committing to drugs. ^{[24] [1]}
2. Yes — gland size and PSA both predict retention: pooled from three placebo-controlled finasteride trials, two-year spontaneous acute urinary retention occurred in 4.2% of men with volume ≥40 mL versus 1.6% below, and in 3.9% of men with PSA ≥1.4 ng/mL versus 0.5%. Finasteride reduced retention incidence by 61% in larger glands — risk concentrates where the gland is big, and that is where disease-modifying therapy earns its place. ^[9]
3. Haematuria (cancer pathway, not BPH attribution), palpable bladder or large residual with renal impairment (obstructive uropathy — urgent imaging and referral), a hard or nodular DRE (prostate cancer investigation), fever with urinary infection (prostatitis/abscess), and new neurological signs suggesting neurogenic bladder. Any of these moves him off the routine LUTS pathway onto investigation or urgent referral. ^[24]