Asymptomatic PHPT is the most common presentation of PHPT seen in Europe and North America, and an increasingly common presentation in other parts of the world. Diagnosis depends on classical biochemical changes including increased serum calcium and PTH levels, with normal renal function and vitamin D sufficiency, and lack of symptoms related to the disorder. Some patients may have hypercalciuria, calcium-containing kidney stones, or osteoporosis, but not yet be symptomatic. The most recent guidelines recommend imaging for kidney stones or nephrocalcinosis, bone density testing of the lumbar spine, hips, and nondominant 1/3 distal radius, and measurement of 24-h urine calcium and creatinine to look for complications of the disorder in otherwise asymptomatic patients. As many as 25% of asymptomatic patients may develop indications for parathyroidectomy when followed over up to 15 years. Patients who remain asymptomatic should be monitored periodically for the development of complications that would justify surgery. Patients who become symptomatic should have surgery when recognized. Recent studies suggest that surgery may improve quality of life even in patients who remain asymptomatic. Medical options for therapy in patients with PHPT who cannot have or decline surgery are limited, with cinacalcet the only approved therapy at present.
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