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BPH treatment plan with evidence based practice
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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: