Clinical Commander

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uro.bph.v1

Benign Prostatic Hyperplasia (BPH) — chronic LUTS in adult men

urologychronicadultgeriatricoutpatienttransition
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shard-3-neuro-sym Phase C wave-8 2026-05-15 — initial author at INTEGRATED with full §5.5 contract depth. 13 acuity / context phenotypes encoded as severity_triggers: mild_lower_urinary_tract_sx_IPSS_le7, moderate_IPSS_8_19, severe_IPSS_ge_20, acute_urinary_retention, recurrent_uti_secondary_to_bph, bladder_stone_complication, hematuria_workup_bph, hydronephrosis_renal_failure, 5alpha_reductase_eligible, refractory_to_medical, postop_bleeding, postop_stress_incontinence, postop_dry_orgasm_alpha_blocker. Pivot from sibling rows because per-phenotype dossiers do not exist (same engine, different management branch). 5 setting playbooks span the full journey: home (lifestyle + self-tracking) → outpatient (IPSS-driven α-blocker first-line; 5-ARI if >40 cc; combo for breakthrough) → ed (AUR + STAT Foley + α-blocker pre-TWOC) → inpatient (post-op recovery with CBI + Hb monitoring + Foley pull + trial void) → icu (RARE — only urosepsis with obstructive uropathy + AKI; SCC 2026 bundle + decompression). AUA 2021 ladder: lifestyle for mild → α1-blocker first-line for moderate-severe (uroselective tamsulosin 0.4 / alfuzosin 10 / silodosin 8 — minimal BP effect; doxazosin / terazosin if concurrent HTN) → add 5α-reductase inhibitor (finasteride 5 / dutasteride 0.5) if prostate >40 cc + breakthrough — 6 mo onset, reduces volume ~25%, DOUBLES PSA for screening interpretation → combination MTOPS / CombAT for moderate-severe + large gland → PDE5i (tadalafil 5 mg) overlay if concurrent ED → antimuscarinic (solifenacin) / β3 agonist (mirabegron) if storage-predominant + low PVR <250 mL → surgery (TURP ≤80 g, HoLEP / ThuLEP any size, GreenLight PVP anticoag-friendly, Urolift preserves ejaculation, Aquablation emerging, SP-RP / open very large) for refractory or complicated. IFIS doctrine — tamsulosin (and other α-blockers) cause Intra-operative Floppy Iris Syndrome during cataract surgery; tamsulosin highest risk; iris dilator atrophy is durable so discontinuation does NOT eliminate risk; ALWAYS document α-blocker history pre-cataract surgery for ophthalmologist (AUA BPH 2021). 5α-reductase inhibitor pearls — 6 mo onset; halves measured PSA (double for screening); sexual side effects + Post-Finasteride Syndrome (PFS) risk persistent after discontinuation in subset; FDA Black Box for possible increase in high-grade Gleason 8–10 (PCPT / REDUCE); TERATOGENIC (Pregnancy X) — women of childbearing potential must avoid handling crushed tablets. AUR + TWOC protocol — STAT Foley with slow decompression (clamp every 500 mL to avoid hematuria ex-vacuo); α-blocker started; TWOC at 24–72 h; success ~50% with α-blocker pre-treatment vs ~25% without; TWOC fail → urology + 5-ARI + surgical evaluation. AUA 2020 microhematuria doctrine — hematuria in BPH patient MUST exclude urothelial malignancy via AUA 2020 risk-stratified workup (CT urogram + cystoscopy for high-risk) BEFORE attribution to BPH. Schema-blocked downstream: calc.ipss, calc.pvr, protocol.aur_decompression_twoc, panel.uroflow, uro.prostate-cancer.v1, uro.cpps.v1, uro.overactive-bladder.v1 — none yet in clinical-tools-registry.ts. Tickets surfaced in depth brief §9. PubMed evidence anchors live-checked 2026-05-22; prior placeholder PMIDs were replaced with AUA Parts I/II, AUA 2023 amendment, MTOPS, CombAT, EAU LUTS/BPO, and UroLift L.I.F.T. anchors. Sibling pivots: uro.uti.complicated.v1 (recurrent UTI in men overlap), uro.urolithiasis.v1 (bladder stone complication), symptom.hematuria.v1 (mandatory AUA 2020 microhematuria workup before attribution) — all resolve to real engines in ALL_DOSSIERS. Dossier NOT registered in _registry.ts per shard scope (DO NOT TOUCH _registry.ts). Registration deferred to subsequent commit by shard-0 / cross-shard registry maintainer.

Entry points (7)

  • symptom
    Frequency / urgency / nocturia (storage) ± urge incontinence in adult man (AUA BPH 2021 PMID 34384237)
    luts_storage_predominant
  • symptom
    Weak stream / hesitancy / intermittency / incomplete emptying / straining (voiding) in adult man (AUA BPH 2021)
    luts_voiding_predominant
  • symptom
    Inability to void + palpable bladder + suprapubic pain — AUR (STAT decompression)
    acute_urinary_retention
  • symptom
    Post-void dribbling (post-micturition) in adult man (EAU BPH 2015)
    post_void_dribbling
  • lab_abnormality
    Elevated PSA found incidentally — workup BPH vs prostate cancer (USPSTF / AUA)
    elevated_psa
  • history
    Recurrent UTI in adult man → workup BPH + complicated UTI overlap
    recurrent_uti_in_man
  • problem_list
    Established BPH followup — IPSS retracking, dose adjustment, refractory consideration
    known_bph_followup

Required inputs (20)

  • sexrequired
    demographic • used at FRAME
    Engine scope is adult men; female LUTS routed to overactive-bladder / interstitial-cystitis engines (out of scope)
  • agerequired
    demographic • used at CONTEXT
    BPH prevalence rises with age; PSA screening window is 55–69 per USPSTF (shared decision-making); surgical risk increases with age
  • ipss_scorerequired
    symptom • used at RISK_STRATIFICATION
    International Prostate Symptom Score (0–35) — severity band drives initial therapy intensity (≤7 mild, 8–19 moderate, ≥20 severe) (AUA BPH 2021)
  • qol_bother_scorerequired
    symptom • used at RISK_STRATIFICATION
    IPSS bother / quality-of-life question (0–6) gates whether to escalate; not all moderate IPSS bother the patient (AUA BPH 2021)
  • current_medsrequired
    history • used at CONTEXT
    Anticholinergics + decongestants (pseudoephedrine) + opioids worsen LUTS; diuretics drive nocturia; α-blocker + tadalafil hypotension caution; cataract pending → IFIS flag (AUA BPH 2021)
  • cataract_surgery_pendingrequired
    history • used at CONTEXT
    Pending cataract surgery + α-blocker → IFIS risk; document for ophthalmologist; tamsulosin highest risk (AUA BPH 2021)
  • erectile_dysfunction
    history • used at CONTEXT
    Concurrent ED + LUTS → tadalafil 5 mg daily dual indication (FDA approved) (AUA BPH 2021)
  • hypertension
    history • used at CONTEXT
    Concurrent HTN → consider doxazosin / terazosin (also lower BP) vs uroselective tamsulosin / silodosin / alfuzosin (minimal BP effect) (AUA BPH 2021)
  • orthostatic_symptoms_or_falls
    history • used at CONTEXT
    Postural hypotension or fall history → uroselective α-blocker preferred; titrate cautiously (AUA BPH 2021)
  • family_history_prostate_cancer
    history • used at CONTEXT
    Family hx prostate cancer (especially first-degree, BRCA) → earlier PSA + urology shared decision-making (USPSTF)
  • prior_urologic_instrumentation
    history • used at CONTEXT
    Prior catheter / instrumentation → urethral stricture differential; cystoscopy may be warranted (EAU BPH 2015)
  • prior_bph_treatment_failure
    history • used at CONTEXT
    Breakthrough on max combination 6–12 mo → refractory phenotype → urology referral for surgical evaluation (AUA BPH 2021)
  • dre_examrequired
    imaging • used at INITIAL_WORKUP
    Digital rectal exam — size estimation (small <30 cc / medium 30–80 / large >80) + nodule check (firm asymmetric → cancer workup) (AUA BPH 2021)
  • post_void_residualrequired
    imaging • used at INITIAL_WORKUP
    Bladder ultrasound PVR — high (>250 mL) increases retention risk + antimuscarinic caution; gates AUR risk (AUA BPH 2021)
  • prostate_volume_us_or_mri
    imaging • used at INITIAL_WORKUP
    Prostate volume estimate (TRUS or MRI) — gates 5-ARI eligibility (>40 cc) and surgical option (TURP ≤80 g, HoLEP / open >80 g) (AUA BPH 2021)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Rule UTI / hematuria; persistent hematuria → AUA 2020 microhematuria workup before attribution to BPH (AUA BPH 2021)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Baseline renal function; obstructive uropathy workup if elevated; dose adjustment for some medications (AUA BPH 2021)
  • psa
    lab • used at INITIAL_WORKUP
    Counseled per USPSTF age 55–69 shared decision-making; elevated PSA → urology referral; BPH typically PSA <4 unless large gland; 5-ARI halves PSA — double measured value for screening (AUA BPH 2021)
  • sbprequired
    vital • used at TREATMENT
    Baseline BP — orthostatic / supine for α-blocker initiation; uroselective preferred if low baseline (AUA BPH 2021)
  • uroflowmetry
    lab • used at BRANCHING_WORKUP
    Optional — Qmax <10 mL/s favors obstruction; not routinely required for initial therapy but valuable before surgery (AUA BPH 2021)

12-phase flow (12)

  1. 1FRAME
    Adult man with LUTS (storage + voiding) — chronic BPH differential. Explicit pivots: acute prostatitis (fever + tender DRE) → uro.prostatitis.v1; prostate cancer (DRE nodule, elevated PSA velocity) → urology referral; female LUTS → out of scope (AUA BPH 2021)
    inputs: sex
    advance: engine scope confirmed
  2. 2ENTRY
    Storage (frequency / urgency / nocturia) + voiding (weak stream / hesitancy / incomplete emptying) symptoms — IPSS scoring (AUA BPH 2021 Foster PMID 34384237)
    inputs: age
    advance: entry captured + IPSS scored
  3. 3CONTEXT
    Comorbidities (HTN / ED / cataract pending / orthostatic risk / family hx prostate cancer), current meds (anticholinergics / decongestants / diuretics / α-blocker interactions), prior urologic history, prior treatment trials (AUA BPH 2021)
    inputs: current_meds, cataract_surgery_pending, erectile_dysfunction, hypertension, orthostatic_symptoms_or_falls, family_history_prostate_cancer, prior_urologic_instrumentation, prior_bph_treatment_failure
    advance: context complete
  4. 4RED_FLAGS
    AUR with palpable bladder → STAT Foley; gross hematuria → AUA 2020 microhematuria workup; obstructive AKI on labs → admit + urology + decompression; firm asymmetric nodule on DRE → urology + biopsy (AUA BPH 2021)
    inputs: acute_urinary_retention
    advance: no red flags OR routed
  5. 5INITIAL_WORKUP
    IPSS + QoL bother + DRE + UA + creatinine + PVR ± PSA per shared decision; bladder US for PVR; optional uroflowmetry / prostate volume by TRUS or MRI (AUA BPH 2021)
    inputs: ipss_score, qol_bother_score, dre_exam, post_void_residual, urinalysis, creatinine, psa
    actions: panel.renal, panel.ua
    advance: workup complete
  6. 6BRANCHING_WORKUP
    Hematuria → AUA 2020 microhematuria workup (route to symptom.hematuria.v1); elevated PSA → urology + MRI / biopsy; large prostate volume (>40 cc) → 5-ARI eligibility; complicated (recurrent UTI, stones, hydronephrosis, AUR) → urology referral; uroflowmetry + cystoscopy if surgery planned (AUA BPH 2021)
    inputs: prostate_volume_us_or_mri, uroflowmetry
    actions: workup.hematuria
    advance: branching diagnostics complete
  7. 7DIFFERENTIAL
    BPH vs prostate cancer (DRE nodule, elevated PSA velocity) vs prostatitis (fever + tender DRE) vs urethral stricture (history of instrumentation / STI) vs neurogenic bladder (CVA, DM, MS, cord injury) vs overactive bladder (storage-predominant without obstruction) vs polyuria (DI, DM, CHF diuresis) vs urethral cancer (AUA BPH 2021)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    IPSS band (≤7 mild / 8–19 moderate / ≥20 severe) + bother score gate therapy intensity; prostate volume + PSA gate 5-ARI eligibility; comorbidity overlay (ED / HTN / cataract / fall risk / storage vs voiding predominant); refractory tier on max combination (AUA BPH 2021)
    inputs: sbp
    advance: severity band + comorbidity overlay assigned
  9. 9TREATMENT
    Mild → lifestyle. Moderate → α-blocker first-line (uroselective tamsulosin 0.4 / alfuzosin 10 / silodosin 8; doxazosin / terazosin if HTN). Add 5-ARI if prostate >40 cc (finasteride 5 / dutasteride 0.5 — 6 mo onset). Combination MTOPS / CombAT if both indicated. PDE5i (tadalafil 5) if ED. Antimuscarinic / β3 if storage-predominant + low PVR. Surgery if refractory / complicated (AUA BPH 2021)
    inputs: current_meds
    advance: regimen prescribed
  10. 10DISPOSITION
    Outpatient primary; ED for AUR / hydronephrosis / AKI; admit for post-op complications or severe AUR with renal failure; urology referral for refractory / complicated / surgical (AUA BPH 2021)
    advance: disposition documented
  11. 11MONITORING
    IPSS re-score q3–6 mo on therapy; PSA q12 mo if on 5-ARI (double measured value for screening interpretation); BMP q6–12 mo; PVR if symptoms worsen; uroflowmetry if surgical evaluation (AUA BPH 2021)
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Annual IPSS + DRE; surgical referral if breakthrough on combination after 6–12 mo; counsel lifelong trajectory + IFIS (cataract surgery interaction) + retrograde ejaculation expectation + 5-ARI sexual / mood effects (AUA BPH 2021)
    advance: follow-up + counselling complete