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MODULE 5
Case 6: Anthony
2/26
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
MODULE 5
Case 6: Anthony
4/26
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
MODULE 5
Case 6: Anthony
5/26
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
MODULE 5
Case 6: Anthony
6/26
In Your Practice, How Would You Determine the Severity of Anthony’s Symptoms
at this Stage?
MODULE 5
Case 6: Anthony
7/26
Use of Questionnaires:
1. IPSS (or AUA symptom score)2. Quality of life question
IPSS = International Prostate Symptom ScoreAUA = American Urological Association
MODULE 5
Case 6: Anthony
8/26
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
MODULE 5
Case 6: Anthony
9/26
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
MODULE 5
Case 6: Anthony
10/26
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
MODULE 5
Case 6: Anthony
11/26
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
MODULE 5
Case 6: Anthony
13/26
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
MODULE 5
Case 6: Anthony
15/26
Recommended
Examinations:
1. Abdominal exam
2. Genital exam
3. DRE
DRE = Digital Rectal Examination
MODULE 5
Case 6: Anthony
16/26
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
MODULE 5
Case 6: Anthony
18/26
Urethral swab: negative
Blood/Glucose: negative
PSA: 3.6 ng/mL
Urinalysis: no abnormal findingsLab tests:
Lab Results
PSA = Prostate-Specific Antigen
MODULE 5
Case 6: Anthony
21/26
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
MODULE 5
Case 6: Anthony
22/26
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
MODULE 5
Case 6: Anthony
23/26
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
MODULE 5
Case 6: Anthony
24/26
How Would You Counsel Anthony?
If Anthony asked about his chances of prostate cancer, how would you respond?
What is his risk level?
MODULE 5
Case 6: Anthony
25/26
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