doc649
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16. A 60-year-old man presents to the urologist
complaining of difficulty urinating. He states
that he frequently gets out of bed in the middle
of the night to go to the bathroom. Once he
gets to the bathroom he can’t urinate and must
“bear down” to do so. He denies any history of
sexually transmitted disease, trauma to the genitourinary
tract, or prior genitourinary instrumentation.
On rectal examination, the patient
has an enlarged prostate and one 1-cm area of
induration that is located on the middle posterior
aspect of the prostate. He has a prostatespecific
antigen level of 6 ng/mL (normal: 0–4
ng/mL), a blood urea nitrogen of 20 mg/L, and
a creatinine of 1.6 mg/L. The patient undergoes
a transrectal prostate biopsy, and no dysplasia
or atypia is present. Given the clinical
scenario and pathologic findings, what is the
most appropriate treatment?
(A) Brachytherapy
(B) Finasteride
(C) Radical retropubic prostatectomy
(D) Transurethral resection of the prostate
(E) Watchful waiting
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| gmc
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B. finasteride
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| nyimalay
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B
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| liliaeliz
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B
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| chemamr
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| hir
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D......pt is having creat-1.6mg/l, so towards obstructive nephropathy, so should remove prostate....?????
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| chemamr
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remove prostate?, not at this time, it's 60 yo, so Cr won't be normal, and with finasteride, this obstructive azotemia should improve.
any other opinion?
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| doc649
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hey guys..............only hir got the correct ans....
The correct answer is D. The patient has benign
prostatic hyperplasia. The biopsy revealed
a prostate that has undergone regular proliferation.
This disease can cause elevated levels of
PSA, as can prostate cancer. The nodule was
suspicious enough to warrant a biopsy that revealed
benign disease. This disease can be
managed expectantly, with medication, or with
surgery, depending on the severity of symptoms
and associated findings. The man presented
has renal failure secondary to the obstruction
and moderate to severe symptoms.
Thus, transurethral resection of the prostate is
the best treatment.
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| doc649
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Answer B is incorrect. Finasteride is a 5α-
reductase inhibitor that can be used to treat
benign prostatic hyperplasia. This is frequently
used in medical treatment of this condition.
The presence of renal disease (i.e., elevated
creatinine) would encourage more aggressive
steps to prevent further renal damage
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| doc649
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thanks for answering my Q...
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| nyimalay
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Thanks, Good questions.
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| chemamr
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it's a good question, I assumed the kidney failure was secondary to normal aging and CKD for some reason, we don't have his past medical history. I would be surprised if he is a 60yo american without HTN/DM/etc that can cause CKD and that Cr 1.6 be his baseline or even a better value for him (so, not new obstructive). But the question makes a point, and that's the important. Good 
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| Pioglitazone
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creatinine of 1.6 isn't renal failure by the way.
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| chemamr
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Creatinine of 1.6 might be renal failure. CKD definition is based on GFR, this patient could easily have GFR < 60. And as per RIFLE criteria for ARF a defined decrease in % of kidney function comparing with patient's baseline is also diagnostic. That's what I thought, am I wrong?
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| peter90036
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bun:crea ratio 20:1.6= 12.5
<10 = renal disease
10-20 = "normal" or post-renal
so... 12.5 .... towards the limit... but still... why not try medical tx ? - how long does it take to work ?
also, there was something of those 2 prostate drugs - one worked on the epithelial hypertrophy, the other on the muscular hypertrophy... what does finasteride work on? (epithelial?) ... how effective is it compared to muscular one?
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| Pioglitazone
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His BUN:Cr ratio and Creatinine levels are more consistent with OBSTRUCTIVE NEPHROPATHY (Post-Renal)
B is the best answer (my two cents)
Treatment options for BPH include lifestyle changes, "watchful waiting," drug therapy, non-surgical procedures and major surgery. The goals of treatment are to improve urinary flow and decrease the symptoms an individual may be experiencing. Treatment should also delay or prevent the progression of BPH. ......
Read the full text at: http://www.drugdigest.org/DD/HC/Treatment/0,4047,...
Options include:
1. Watchful waiting
2. Drug therapy
3. Surgery
Surgery is never resorted without first trying drugs. Exceptions include severe symptoms of BPH such as
1. recurrent urinary retention,
2. recurrent blood in the urine,
3. recurrent urinary tract infections or
4. bladder stones.
These symptoms indicate that surgery is most likely needed to correct the problem. In this case, the best option would be to try Finasteride and hence B would be the most appropriate choice.
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| Pioglitazone
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His Creatinine will come down once the gland regresses, relieveing the obstruction. That's what my reasoning is! Feel free to refute with a better reasoning! 
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| hir
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hey pioglitazone, u 'r right too..
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| Pioglitazone
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I'm sorry! I just found out there's a fifth indication for Sugery without resorting to medications - an elevated Cr due to obstruction. Here's the final list.
1. recurrent urinary retention,
2. recurrent blood in the urine,
3. recurrent urinary tract infections
4. bladder stones or
5. elevated serum creatinine concentration due to obstructive uropathy
So just like doc649 rightly said, it has to be D. I didn't know it would be me refuting myself 
take care.
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| hir
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good debate with yourself.... ............so finally, wots d answer???
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| Pioglitazone
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I believe you were right, it has to be D ! u got there without the long debate!
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| chemamr
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 , good discussion.
likely: B or D
finally, answer given: D
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| paheli
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Ok, I learnt something today.
Thanks everyone, it was fun to read as well!
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| inkspot
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good one !
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