A 76-year-old man presents for an annual medical examination. His medical history is remarkable for chronic kidney disease that is managed with hemodialysis scheduled 3 times weekly. Since initiating hemodialysis, he has continued to produce small amounts of urine. He has no symptoms and is living independently at home with his wife. However, the patient's wife reports that, during the past year, he has become increasingly forgetful and occasionally exhibits aggressive behaviour, which is unusual for him.
Notably, he had an elevated PSA level 5 years previously, but findings on a subsequent prostate biopsy were negative for malignancy. Since that time, yearly PSA values, including that for last year, have been within normal limits. On physical examination, the patient appears quiet, reserved, and distracted. His prostate is smooth, non-tender, and symmetrically enlarged to about 50 cm…
