A 68-year-old retired businessman presents with frequency of micturition, urinary urgency, and hesitancy associated with a weak stream. Over the past several weeks, he has had a few episodes of hematuria and incontinence. In addition to his urologic symptoms, the patient is experiencing low-grade, constant back pain and bouts of constipation. His past medical history is unremarkable. Family history is noncontributory. Digital rectal examination (DRE) reveals that the patient has an enlarged prostate gland with several palpably discrete, hard, diffuse nodules.

The patient has a prostate-specific antigen (PSA) level of 95 ng/mL (a similar determination 6 years earlier was 1.5 ng/mL). His hemoglobin is 15 g/dL, hematocrit 43%, white blood cell count 7500 cells/µL, normal differential, platelet count 250,000 cells/µL, blood urea nitrogen 15 mg/dL, and creatinine 1.0 mg/dL. Alkaline phosphatase and liver function tests are all within normal range.