Benign Prostatic Hyperplasia (ICD-10: N40.0 – Enlarged prostate without lower urinary tract
symptoms)
Clinical Scenario:
James presents for a routine annual exam. He mentions increasing difficulty initiating urination,
a weak urine stream, and waking up multiple times at night to urinate (nocturia). He denies pain,
blood in urine, or fever. He has no history of urinary tract infections or kidney stones.
Subjective:
Reports symptoms for the past 6 months
No dysuria or hematuria
No weight loss or fatigue
Feels frustrated by nocturia (2–3 times per night)
Denies family history of prostate cancer
Objective:
Vital signs: Stable
Digital Rectal Exam (DRE): Enlarged, smooth, non-tender prostate
Urinalysis: Normal, no infection
PSA: Mildly elevated at 3.5 ng/mL (age-adjusted borderline)
Bladder scan: No post-void residual
Assessment:
Benign Prostatic Hyperplasia (N40.0) with mild-to-moderate lower urinary tract symptoms.
Plan:
1. Lifestyle Modifications:
oLimit evening fluid intake and caffeine
oTimed voiding schedule
2. Pharmacologic Treatment:
oStart Tamsulosin 0.4 mg PO daily (alpha-blocker) to improve urinary flow
oDiscussed potential side effects (e.g., dizziness, retrograde ejaculation)
3. Monitoring:
oRecheck symptoms in 6–8 weeks
oRepeat PSA in 6 months if symptoms persist or worsen
