Primary care

Prostatic symptoms

Andrew Farmer, honorary senior lecturer in general practice. 

Institute of Health Sciences, Oxford OX3 7LF

andrew.farmer{at}dphpc.ox.ac.uk

A 68 year old man has been urinating two or three times a night for the past six months and is worried because two friends have similar symptoms, and one has been told he has cancer and the other is due to have an operation, "though it isn't cancer".

	What issues you should cover

Top What issues you should... What you should do

• Discuss the cause of his symptoms. Show him a picture of where the prostate is and how it causes problems. He may be worried about cancer, so explain that usually the prostate simply enlarges but that in a small minority the symptoms are due to cancer. About 1 in 14 men will develop prostate cancer at some point in their life.
• Discuss plans for initial investigation, including the prostate specific antigen test. Tell him that if the test result is high then further tests will be needed, although cancer is not the only reason for an abnormal result.
• Explain the three main options if the test results are normal: (a) try to reduce symptoms by managing fluid intake and avoiding caffeine; (b) use medication, which often helps but sometimes has side effects (most people start by using an  blocker, which is likely to improve symptoms such as frequency, urgency, and poor streamit works quickly, but there is no evidence that it reduces long term complicationsbut finasteride is an alternative drug that takes up to six months to work); (c) consider surgery, which is usually very effective but occasionally leads to complications (surgery is usually reserved for those with severe symptoms and for those in whom medication has not worked).

	What you should do

Top What issues you should... What you should do

• Ask about urinary stream, urgency, and hesitancy. The international prostate symptom score (IPSS) is a useful way to quantify symptoms and monitor response to treatment (see box).
• Explore the impact of the symptoms on daily living. Are his activities constantly interrupted, for example, by "having to nip to the loo"? Would he consider treatment successful if he could return to normal activity?
• Ask about any worries he might have. As well as cancer, possible incontinence or impotence after prostate surgery are other common concerns.
• Examine him. Look particularly for signs of uraemia, enlargement of the bladder, kidneys, prostate, and palpable nodes.
• Arrange investigations: a midstream urine test to exclude urinary tract infection; serum creatinine test to rule out renal failure; and the prostate specific antigen test.
• Most men decide to try taking tablets, in anticipation that the test results will be normal.
• Check blood pressure. Avoid using  blockers in people prone to postural hypotension.
• Warn that common side effects of the drugs include dizziness. Unusual side effects are drowsiness, weakness, and dry mouth. Choose from alfuzosin, doxazosin, indoramin, prazosin, tamsulosin, and terazosin.
• To avoid hypotension, start some of these drugs at a low dose and increase at weekly intervals. Some drugs are available in starter packs.
• Follow up at one month to discuss results and treatment.

	Footnotes

The series is edited by Ann McPherson and Deborah Waller

The BMJ welcomes contributions from general practitioners to the series