History Taking · Intermediate · Urology

Lower Urinary Tract Symptoms in a 68-Year-Old Man

Practise this PLAB 2 history taking station on Benign Prostatic Hyperplasia. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Fraser Hawkins, a 68-year-old man, has come to see you with lower urinary tract symptoms. He reports urinary frequency, nocturia, weak stream, and incomplete emptying. Recent urine dipstick shows nitrites and leukocytes. Please take a focused history to assess for urinary tract infection and benign prostatic hyperplasia, discuss investigations and management.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Mild osteoarthritis (knees/lower back), Appendicectomy

What this station tests

  • Classifying LUTS as obstructive versus irritative: framework for understanding BPH symptom pattern
  • Screening for prostate cancer red flags: haematuria, bone pain, weight loss, family history
  • PSA counselling: explaining what it means, its limitations, and that raised PSA does not equal cancer
  • Treating concurrent UTI before BPH assessment: UTI itself raises PSA and worsens symptoms
  • Alpha-blocker (tamsulosin) as first-line pharmacological treatment for moderate to severe LUTS

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Lower urinary tract symptoms in a man over 50 require the candidate to classify symptoms as obstructive or irritative, exclude prostate cancer through appropriate questioning, and address the patient's cancer anxiety. Mr Hawkins is 68, presenting with progressive urinary frequency, nocturia (4 to 5 times), weak stream, and incomplete emptying. Open with: 'Mr Hawkins, tell me about the urinary problems and how they are affecting your daily life, particularly your sleep.'

Core approach

Classify the symptoms. Obstructive: weak stream, hesitancy, straining, incomplete emptying, post-void dribbling, prolonged voiding time. Irritative: frequency (10 to 12 times daily), nocturia (4 to 5 times), urgency. He has both, which is typical of BPH. Use the IPSS (International Prostate Symptom Score) framework to quantify severity.

Screen for red flags suggesting prostate cancer. Any haematuria (blood in urine)? Any bone pain (metastatic disease)? Any weight loss? Any back pain with neurological symptoms (spinal cord compression)? Family history of prostate cancer? All absent, which is reassuring but does not exclude cancer.

Check for complications. Urinary retention: has he ever been unable to pass urine at all? UTI: urine dipstick shows nitrites and leukocytes (concurrent UTI likely). Renal impairment: recent bloods needed.

Impact: nocturia 4 to 5 times is severely affecting his sleep and his wife's sleep. He is tired during the day. He is embarrassed about discussing urinary symptoms and has delayed presenting. He is terrified this is prostate cancer.

Closing and safety netting

Address the cancer concern first: 'Mr Hawkins, the symptoms you describe are very typical of an enlarged prostate, which is a benign condition and not cancer. However, we should do some tests to confirm this.' Investigations: PSA (with counselling about what it means and its limitations), urine culture (treat the UTI), renal function, post-void residual volume (USS), DRE (digital rectal examination).

Treat the UTI first (antibiotics based on local sensitivities). Then address the BPH: alpha-blocker (tamsulosin) is first-line for moderate to severe LUTS, providing symptom relief within days to weeks. If prostate is significantly enlarged, 5-alpha reductase inhibitor (finasteride) can be added. Lifestyle: reduce caffeine and alcohol (especially evening), fluid management, bladder training.

PSA counselling: 'PSA is a blood test that can be raised in prostate cancer but also in BPH, UTI, and after certain activities. A raised PSA does not automatically mean cancer.' Safety net: 'If you are unable to pass urine at all, develop visible blood in your urine, or develop back pain with leg weakness, come in urgently.' Follow-up in 4 weeks with PSA result and UTI treatment response.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for benign prostatic hyperplasia. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: LUTS classified (obstructive and irritative). Severity quantified (IPSS framework). Cancer red flags screened. UTI identified. Complications checked (retention, renal impairment). Impact assessed (sleep, quality of life).

Costs marks: Not classifying symptoms. Not screening for cancer. Not identifying UTI. Not assessing impact.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: UTI treated first before PSA. PSA counselled appropriately. Alpha-blocker recommended. Lifestyle advice (caffeine, evening fluids). Retention safety netting. Follow-up planned.

Costs marks: PSA during UTI. No PSA counselling. No pharmacological treatment. No lifestyle advice. No safety netting.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Addressing cancer fear directly and early. Normalising BPH as extremely common. Acknowledging embarrassment about urinary symptoms. Addressing sleep impact on both patient and wife.

Costs marks: Not addressing cancer fear. Making him more embarrassed. Ignoring sleep impact.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Checking PSA without counselling about its limitations. PSA can be raised by BPH, UTI, ejaculation, and DRE, not just cancer. Candidates who order PSA without explaining this create unnecessary anxiety when a raised result returns.
  2. Checking PSA during active UTI. UTI raises PSA and creates a false positive. The UTI should be treated first, and PSA checked 4 to 6 weeks after treatment. Candidates who check PSA at this visit get an unreliable result.
  3. Not addressing the cancer fear. He is terrified of prostate cancer. Candidates who provide clinical information without directly addressing this fear leave him anxious regardless of the management plan.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this benign prostatic hyperplasia station?

Lower urinary tract symptoms in a man over 50 require the candidate to classify symptoms as obstructive or irritative, exclude prostate cancer through appropriate questioning, and address the patient's cancer anxiety. Mr Hawkins is 68, presenting with progressive urinary frequency, nocturia (4 to 5 times), weak stream, and incomplete emptying. Open with: 'Mr Hawkins, tell me about the urinary problems and how they are affecting your daily life, particularly your sleep.'

What does a strong performance look like to the examiner in this station?

Strong performances show: LUTS classified (obstructive and irritative). Severity quantified (IPSS framework). Cancer red flags screened. UTI identified. Complications checked (retention, renal impairment). Weak performances: Not classifying symptoms. Not screening for cancer. Not identifying UTI. Not assessing impact.

What is the biggest pitfall in this benign prostatic hyperplasia station?

Checking PSA without counselling about its limitations. PSA can be raised by BPH, UTI, ejaculation, and DRE, not just cancer. Candidates who order PSA without explaining this create unnecessary anxiety when a raised result returns.

How should I prepare for benign prostatic hyperplasia if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: Screening for prostate cancer red flags: haematuria, bone pain, weight loss, family history. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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