Genitourinary Presentations in Primary Care: BPH, Overactive Bladder, Urethritis and When to Refer

Most genitourinary visits in primary care fall into three problems with three different guidelines. Lower urinary tract symptoms (LUTS) in an older man are evaluated with a history, examination, the International Prostate Symptom Score (IPSS) and a urinalysis under the AUA BPH guideline, then treated with an alpha blocker for bothersome symptoms, adding a 5-alpha reductase inhibitor (5-ARI) only when the prostate is enlarged. Overactive bladder (OAB) is managed under the 2024 AUA/SUFU guideline by shared decision-making rather than a rigid ladder, with bladder training offered to everyone and antimuscarinics or beta-3 agonists as the drug options. Urethritis is confirmed by objective signs, tested with nucleic acid amplification tests (NAAT), and treated empirically under the CDC 2021 STI guidelines.

BPH and male lower urinary tract symptoms

Assessment

The AUA guideline's first statement sets the initial evaluation: medical history, physical examination, the IPSS and a urinalysis.

• History: voiding symptoms (weak stream, hesitancy, straining, intermittency, incomplete emptying) and storage symptoms (frequency, urgency, nocturia). Ask about diuretics, decongestants, antihistamines, anticholinergics, evening fluids, caffeine and alcohol, diabetes, neurologic disease, prior urethral procedures and sexual function.
• Examination: a digital rectal examination for size, nodules and tenderness, a palpable bladder, and a focused neurologic examination.
• Urinalysis: cannot diagnose BPH but screens for glucosuria, proteinuria, hematuria and infection, each of which points away from simple BPH.
• IPSS: seven symptom questions scored 0 to 35, plus a separate quality-of-life question. Conventional bands are 0 to 7 mild, 8 to 19 moderate and 20 to 35 severe. Repeat it to measure response.
• PSA: useful as a surrogate for prostate size when choosing a 5-ARI. Prostate cancer screening is a separate shared decision for age-appropriate men.
• Post-void residual (PVR), uroflowmetry and imaging are recommended before procedures; PVR is also useful in primary care when retention is suspected or before adding an antimuscarinic.

Medical therapy

Points the guideline makes explicitly:

• Choose the alpha blocker by age, comorbidity and adverse-effect profile.
• Before starting an alpha blocker in a man with planned cataract surgery, inform him of the risk and ask him to discuss it with his ophthalmologist.
• Before starting a 5-ARI, discuss sexual side effects and the low risk of prostate cancer. Because PSA falls by about half, the measured value is doubled when interpreting it during treatment.
• Combination 5-ARI and alpha blocker therapy is only for men with demonstrable enlargement.

Follow-up

Reassess 4 to 12 weeks after starting treatment, sooner if adverse effects occur, with a repeat IPSS and, when indicated, PVR. Men who do not improve or cannot tolerate medication need re-evaluation and discussion of procedural options.

Acute urinary retention

For acute retention due to BPH, the AUA recommends starting an oral alpha blocker before a voiding trial, with at least 3 days of therapy before attempting catheter removal. Men who pass the trial remain at higher risk of recurrence.

Referral to urology

The AUA recommends surgery for:

• Renal insufficiency secondary to BPH.
• Refractory urinary retention.
• Recurrent urinary tract infections.
• Recurrent bladder stones or gross hematuria due to BPH.
• LUTS refractory to, or patient unwilling to use, other therapies.

Also refer for a nodule or asymmetry on rectal examination, an abnormal PSA, hematuria without another explanation, a neurologic cause, or a large or rising PVR.

Overactive bladder

OAB is urinary urgency, usually with frequency and nocturia, with or without urgency incontinence, in the absence of infection or another obvious cause.

Evaluation (AUA/SUFU 2024)

• History with a full assessment of bladder symptoms, physical examination, and a urinalysis to exclude microhematuria and infection.
• PVR may be obtained to exclude incomplete emptying or retention, especially with coexisting voiding symptoms.
• A symptom questionnaire or voiding diary may help with diagnosis, bother and response.
• Urodynamics, cystoscopy and urinary tract imaging are not routine in the initial evaluation; they are for diagnostic uncertainty or failed treatment.
• Assess comorbid contributors: constipation, obesity, pelvic floor dysfunction, poorly controlled diabetes with glucosuria (including SGLT2 inhibitor use), sleep apnea, evening fluid habits, diuretics and genitourinary syndrome of menopause.

Treatment

The 2024 guideline removed the old step-therapy model. Treatment is chosen with the patient, and options can be combined.

Antimuscarinic cautions in the 2024 guideline:

• Discuss the potential risk of dementia and cognitive impairment.
• Use with extreme caution in narrow-angle glaucoma, impaired gastric emptying or a history of urinary retention.
• Expect dry mouth and constipation, and treat constipation because it worsens OAB.

Beta-3 agonists avoid anticholinergic burden, which makes them attractive in older adults; mirabegron can raise blood pressure, so blood pressure is checked. Supplements and herbal remedies lack evidence for OAB. In postmenopausal women with genitourinary syndrome of menopause, the guideline's discussion notes that topical vaginal estrogen has been associated with improved urgency, frequency and urgency incontinence.

Men with BPH and bothersome OAB can be offered an antimuscarinic or beta-3 agonist alone, or added to an alpha blocker.

Urethritis

Diagnosis (CDC 2021)

Urethritis is confirmed by at least one objective sign:

• Mucoid, mucopurulent or purulent discharge on examination.
• Gram, methylene blue or gentian violet stain of urethral secretions showing 2 or more white cells per oil immersion field.
• Positive leukocyte esterase on first-void urine, or 10 or more white cells per high-power field in spun first-void urine sediment.

All men with suspected urethritis are tested for chlamydia and gonorrhea by NAAT (first-void urine is preferred) and should also be tested for HIV and syphilis. Gram-negative intracellular diplococci on stain indicate gonococcal infection.

Treatment

Follow-up and partners

• Abstain from sex until the patient and partners are treated: 7 days after single-dose therapy, or until a 7-day course is complete and symptoms resolve.
• Refer all partners from the previous 60 days for testing and treatment; expedited partner therapy is an option where permitted.
• Retest men diagnosed with chlamydia, gonorrhea or trichomoniasis about 3 months after treatment.
• Symptoms alone without objective signs do not justify retreatment.

Referral and emergency triggers

• Persistent urethritis after treatment for M. genitalium and Trichomonas: infectious disease or urology.
• Scrotal pain: epididymitis is treated empirically (ceftriaxone 500 mg once plus doxycycline 100 mg twice daily for 10 days when chlamydia and gonorrhea are likely), but sudden severe testicular pain needs emergency evaluation for torsion.
• Persistent pelvic or perineal pain: evaluate for chronic prostatitis or chronic pelvic pain syndrome.
• Signs of disseminated gonococcal infection: arthritis, tenosynovitis, pustular rash.

Patient and family education

• Tamsulosin works within days; finasteride and dutasteride take months, and stopping them reverses the benefit.
• Rise slowly from sitting or lying when starting an alpha blocker.
• Tell the eye surgeon about any alpha blocker before cataract surgery.
• Bladder training means gradually lengthening the time between voids; results take weeks.
• Limit caffeine and alcohol, and move fluids earlier in the day for nocturia.
• Report confusion or memory change on an antimuscarinic; caregivers often notice first.
• Inability to pass urine with a painful, full bladder is an emergency.
• For urethritis: finish every dose, avoid sex for the advised period, make sure partners are treated, and return in 3 months for retesting.

How the exam tests this

• 5-ARI for a small prostate. Finasteride for a man with a 25 g gland and PSA 0.8 is wrong; an alpha blocker is the answer.
• Forgetting PSA halving. A PSA of 1.4 after a year of finasteride corresponds to about 2.8.
• Missing the cataract question. Counseling about floppy iris syndrome is the expected answer before starting tamsulosin in a man scheduled for cataract surgery.
• Antimuscarinic with retention or narrow-angle glaucoma. A beta-3 agonist or nondrug therapy is safer.
• Urodynamics first for OAB. Not routine; history, examination and urinalysis come first.
• Outdated gonorrhea dosing. Ceftriaxone 250 mg plus azithromycin is the old regimen; 500 mg ceftriaxone alone, plus doxycycline if chlamydia is not excluded, is current.
• Azithromycin as preferred NGU therapy. Doxycycline for 7 days is the recommended regimen.
• Missing partner management and the 3-month retest.

Practice question

A 24-year-old man reports 3 days of dysuria and urethral discharge. He weighs 78 kg and has a new female partner. Examination shows purulent urethral discharge, and a Gram stain shows gram-negative intracellular diplococci. NAAT results are pending. He has no allergies. Which of the following is the most appropriate treatment?

• A. Ceftriaxone 500 mg IM once plus doxycycline 100 mg orally twice daily for 7 days
• B. Ceftriaxone 250 mg IM once plus azithromycin 1 g orally once
• C. Azithromycin 2 g orally once
• D. Ciprofloxacin 500 mg orally once

Answer: A. The Gram stain shows gonococcal urethritis, and CDC 2021 recommends ceftriaxone 500 mg IM for patients under 150 kg, with doxycycline for 7 days added because chlamydia has not been excluded while NAAT is pending. Option B is the superseded regimen, with an inadequate ceftriaxone dose. Option C, high-dose azithromycin monotherapy, is not recommended for gonorrhea because of resistance and gastrointestinal intolerance. Option D fails because widespread fluoroquinolone resistance means ciprofloxacin is no longer recommended for gonorrhea.

Key points

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