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Case 6: Anthony

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Patient History

Anthony is a 55-year old lawyer.

He has been suffering from voiding complaints for several years, and for the past 5 years he has been treated with an α1-blocker for BPH.

Anthony recently experienced a urinary infection requiring antibiotics.

BPH = Benign Prostatic Hyperplasia

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What Typical Questions Do You Have for Anthony?

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1. Has your urine stream changed?

2. Do you have to get up at night to urinate?

3. Does it burn when you urinate?

4. Have you had a fever?

5. Has there been any blood in your urine?

6. Questions around irritative and obstructive symptoms

7. Questions examining possibility of diabetes

8. How much does your symptoms bother you?

9. Is there any history of prostate cancer in your family?

Some Possible Questions for Anthony

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Anthony’s response

Anthony says he is definitely getting worse

His nocturia is increased as well as day time voiding frequency

He is worried about prostate cancer, but there is no history of it in his family, to his knowledge

He is otherwise healthy and tries to exercise regularly

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In Your Practice, How Would You Determine the Severity of Anthony’s Symptoms

at this Stage?

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Use of Questionnaires:

1. IPSS (or AUA symptom score)2. Quality of life question

IPSS = International Prostate Symptom ScoreAUA = American Urological Association

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Discussion The IPSS and Quality of Life due to Urinary Symptoms

Questionnaires are requested of Anthony

You ask him to complete the forms before proceeding

Here are Anthony’s scores:

International Prostate Symptom Score (IPSS)

Patient name: Anthony

DOB: 05/05/50

ID: 0019-0026

Date of assessment: 29/06/05

Initial assessment (X)

Monitor: during __X__ therapy after _____therapy/surgery

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International Prostate Symptom Score

Not at all

Less than 1 timein 5

Less than half the time

About half the

time

More than half the time

Almost always

Anthony’s Results

1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?

0 1 2 3 4 5 5

2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

0 1 2 3 4 5 5

3. Over the past month, how often have you found you stopped and started again several times when you urinated?

0 1 2 3 4 5 1

4. Over the past month, how often have you found it difficult to postpone urinating?

0 1 2 3 4 5 4

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Not at all

Less than 1 timein 5

Less than half the time

About half the

time

More than half the time

Almost always

Anthony’s Results

5. Over the past month, how often have you had a weak urinary stream?

0 1 2 3 4 5 5

6. Over the past month, how often have you had to push or strain to begin urinating?

0 1 2 3 4 5 5

None 1 time 2 times 3 times 4 times5 or

more times

Anthony’s Results

7. Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

0 1 2 3 4 5 4

Total IPSS Score = 29

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Anthony’s QoL Score = 6 (Terrible)

Quality of Life Due to Urinary Symptoms

Delighted PleasedMostly

Satisfied

Mixed about equally

satisfied and dissatisfied

Mostly dissatis-

fiedUnhappy Terrible

1. If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?

0 1 2 3 4 5 6

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How Do You Interpret the Severity and Bother of Anthony’s Symptoms?

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Interpreting the IPSS and Bother Score

IPSS Values Indicate Symptom Severity:

Mild score: ≤ 7Moderate score: 8-19Severe score: ≥ 20

• Anthony’s IPSS = 29 (severe symptoms)

• Anthony’s Bother Score = 6 (terrible)

IPSS = International Prostate Symptom Score

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What Kind of Physical Exam Would You Perform on Anthony?

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Recommended

Examinations:

1. Abdominal exam

2. Genital exam

3. DRE

DRE = Digital Rectal Examination

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Results of the Physical Exam

On physical examination, Anthony appears healthy

Height 6 ft 1"

Weight 68 kg (150 lb)

Blood Pressure 120/80 mmHg

Abdominal Exam Negative

Genital Exam Negative

DRE:- Anus and rectal ampulla- Prostate

- Normal- Prostate clearly enlarged, painful

on both lobes

DRE = Digital Rectal Examination

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What Investigations Might You Consider for Anthony at this Stage?

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Urethral swab: negative

Blood/Glucose: negative

PSA: 3.6 ng/mL

Urinalysis: no abnormal findingsLab tests:

Lab Results

PSA = Prostate-Specific Antigen

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What Are the Possible Diagnoses You Are Considering for Anthony?

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Possible Diagnoses for Anthony

1. BPH

2. Prostate cancer

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Management Strategy

Anthony’s severe bother (QoL = 6) and high IPSS of 29 are indications of a need for further evaluation

Furthermore, his elevated PSA level of 3.6 ng/mL, while not extremely high, is worrisome for a 55 year old, and warrants referral to a urologist.

QoL = Quality of LifeIPSS = International Prostate Symptom ScorePSA = Prostate-Specific Antigen

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Urologist Consultation

Sextant prostate biopsies indicated no prostatic carcinoma.

Anthony is counseled by the urologist on pharmacotherapy and treatment options

He is not a candidate for surgery and is put on a 5α-reductase inhibitor

Anthony is still taking his α1-blocker

Anthony is referred back to his family physician

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Family Physician Follow-up

Anthony is now on combination therapy

After 12 months, his DRE is normal and his PSA is 1.2ng/ml

His bother score (QoL) is down to a 2

His IPSS is 18 (moderate symptoms)

DRE = Digital Rectal ExaminationQoL = Quality of LifePSA = Prostate-Specific AntigenIPSS = International Prostate Symptom Score

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How Would You Counsel Anthony?

If Anthony asked about his chances of prostate cancer, how would you respond?

What is his risk level?

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Counseling Anthony

Anthony has a low chance of having prostate cancer at this time.

The reduction in PSA is likely due to the 5α-reductase inhibitor and he should be monitored for symptoms, DRE and PSA.

In a large randomized study, 5α-reductase inhibitor therapy with finasteride reduced the risk of developing prostate cancer.

PSA = Prostate-Specific AntigenDRE = Digital Rectal Examination

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End of Case 6