Jenna Peer Response

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• Peer response to Jenna
• The most plausible diagnosis presented in this case appears to be benign prostatic hypertrophy (BPH). While the HPI and PE lead directly to BPH, there are other diagnoses to consider to properly diagnose and treat this 65-year-old gentleman. The following diagnoses should be considered: cystitis, bladder calculi, and neurogenic bladder (Cash et al., 2021). The patient does not appear to be exhibiting signs of infection; however, it would be prudent to order a urinalysis to definitively rule out infection as the cause of the patient’s symptoms. Cystitis can be ruled out due to the patient not having any pain with urination, bladder discomfort, or ejaculatory pain (Clemens et al., 2022). The diagnosis of bladder calculi is also easily ruled out without the presence of hematuria, cramping or abdominal pain, nausea, fever, chills, and malaise (Ferreria Fontenelle & Dias Sarti, 2019). Lastly, neurogenic bladder can also be ruled out due any concern for a neurological condition causing neurogenic bladder. While the prompt does not provide a full detailed history of the patient, it can be assumed the patient is not experiencing these symptoms because of an associated neurological condition. Based off the frequent urination without burning, pain, hematuria, or difficulty voiding, there is high suspicion for an enlarged prostate obstructing or occluding the urethra in the case of benign prostatic hypertrophy.

           Multiple treatment modalities exist for BPH; however, a practitioner should always evaluate the severity of the condition and start modestly. The patient has already tried to initiate lifestyle modifications to improve his symptoms. The literature recommends limiting fluids through restriction, avoiding diuretics, and reducing trigger substances (Sandhu et al., 2024). In this case, lifestyle modifications have failed to improve symptoms. Treatment should progress to the inclusion of an alpha blocker such as terazosin, dozazosin, silodosin, Tamsulosin, or alfuzosin (Sandhu et al., 2024). The most common medication is Tamsulosin. The prescription would be Tamsulosin 0.4 mg orally once a day, a quantity total of 30 with 3 refills. The patient should follow up in two to three weeks to assess the improvement of symptoms and any need for medication adjustment (Cash et al., 2021).

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