MODULE 5 1/38 Case 1: George. MODULE 5 Case 1: George 2/38 Patient History George is a 50 year old computer engineer and works in a busy software development

MODULE 5

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Case 1: George

MODULE 5Case 1: George

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Patient History

George is a 50 year old computer engineer and works in a busy software development company.

He comes to see you for a check-up and explains that his frequent trips to the bathroom at work are difficult to explain to his boss, who suspects George is skipping out of his duties!

George explains that his symptoms started about 3 years ago and have become more significant in the last few months.


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What Typical Questions Do You Have for George?


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1. Has your urine stream changed?

2. Do you think your are emptying your bladder?

3. Do you have to get up at night to urinate? How many times?

4. Do you have urinary frequency? Urgency void?

5. Do you have post void dribbling?

6. Does it burn when you urinate?

7. Has there been any blood in your urine?

8. Do your symptoms bother you?

9. Questions examining possibility of diabetes

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

Some Possible Questions for George


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Additional Patient History

George explains that he has a weak urine stream, with dribbling, but also reports some irritative symptoms, including mild nocturia.

He has no burning sensation on urination and no fever.

He doesn’t recall any blood in his urine and thinks he is free of STDs.

He was treated about 10 years ago for Chlamydia.

He hasn’t ever been tested for diabetes and feels otherwise healthy.

George seems very frustrated that he has problems with urinating and is concerned that he has cancer because that has been in the news lately.

He reports no family history of prostatic or bladder cancer.

STD = Sexually Transmitted Disease


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What Other Questions Will You Have for George at this Stage?


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Did George have any other medical history?

On further discussion George remembers a history of discharge and burning several years ago.

He explains that his treating physician told him he had urethritis.

Ask George if he has urethral discharge.

Possible Questions for George


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In Your Practice, How Would You Determine the Severity of George’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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Results of George’s IPSS & QoL Question

To validate the severity of George’s problem and get more information, you ask George to complete the IPSS and Quality of Life due to Urinary Symptoms Questionnaires.

Here are his results:

International Prostate Symptom Score (IPSS)

Patient name: George

DOB: 30/11/55

ID: 019-0021

Date of assessment: 04/12/05

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

George’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 1

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 2

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 2

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

0 1 2 3 4 5 2


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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

George’s Results

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

0 1 2 3 4 5 4

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

0 1 2 3 4 5 2

None 1 time 2 times 3 times 4 times5 or

more times

George’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 1

Total IPSS Score = 14


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George’s Bother Score = 5 (unhappy)

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 Associated with George’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

• George’s IPSS = 14 (moderate symptoms)

• George’s Bother Score = 5 (unhappy)

IPSS = International Prostate Symptom Score


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How Does George’s Age of 50 Years Factor Into Your Diagnosis?


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Discussion of Age as a Factor

At his age, it would be unusual for the effects of BPH to be as pronounced as George is experiencing but not impossible.

Thus the moderate severity of his symptom scores and high bother (unhappy quality of life score) suggest that he may be experiencing an unusual prostatic obstruction, possibly a urethral stricture or a bladder neck obstruction.

If he had been older, these same symptoms may have suggested BPH as the first possibility.

BPH = Benign Prostatic Hyperplasia


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What Kind of Physical Exam Would You Perform on George?


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Recommended Examinations:

1. Abdominal exam

2. Genital exam

3. DRE

4. Blood pressure

DRE = Digital Rectal Examination


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Results of the Physical Exam

On physical examination, George appears healthy.

Here are George’s results & findings of interest:

Height 5 ft 7"

Weight 68 kg (150 lb)

Blood Pressure 120/80 mmHg

Abdominal Exam Negative

Genital Exam Negative

DRE:- Anus and rectal ampulla- Prostate

- Normal- Feels normal

DRE = Digital Rectal Examination


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What Investigations Might You Consider for George at this Stage of the Consult?


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Lab tests: Urinalysis: no abnormal findings

PSA: 0.8 ng/mL

Blood/Glucose: negative

Urethral swab: negative

Serum creatinine (optional): 87 μmol/L (higher range of normal)

Lab Results

PSA = Prostate-Specific Antigen


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Discussion of Lab Results

Although George's symptoms are similar to those seen in BPH, differential diagnosis is important.

Urinalysis, serum creatinine and PSA levels were normal.

George’s PSA result is 0.8 ng/mL which is not suspicious of prostate cancer.

George’s other tests are negative, leaving the possibility of obstruction.

Note that some physicians may request an ultrasound for George, which is not recommended in the BPH guidelines, but is important if checking for bladder stones. It could also be of help in patients such as George who is young for significant BPH. An ultrasound could be used to estimate George’s residual urine volume.

BPH = Benign Prostatic HyperplasiaPSA = Prostate-Specific Antigen


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What Are the Possible Diagnoses You Are Considering for George?


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Possible Diagnoses for George

1. Benign Prostatic Hyperplasia (BPH)

2. Urethral stricture

3. Bladder calculus

4. Overactive bladder

5. Bladder neck hypertrophy

6. Urinary Infection

7. Prostatitis

8. Prostate cancer

9. Sexually Transmitted Disease (STD)


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What is the Most Likely Diagnosis for George?


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Diagnosis: Urethral stricture


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What Would Be Your Management Strategy for George?


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Management Strategy

Because of his younger age, normal prostate size and history of urethritis, George's symptoms of LUTS require further evaluation.

Urethral stricture is suspected, and George is referred to a urologist.

LUTS = Lower Urinary Tract Symptoms


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Urologist Consultation Letter

George sees the urologist and after several months returns to his familyphysician providing this letter from the urologist:

Dear Doctor:

An evaluation of the prostate was carried out with prostatic massage and examination of the prostatic fluid.

The results showed no evidence of prostatitis

A urinary flow and post void bladder scan confirmed urethral obstruction with a Qmax of 8 ml/sec (N > 15) with residual urine (R.U.) of 150 ml.

A cystoscopy confirmed a bulbo-urethral stricture which was incised endoscopically.


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Urologist Consultation Letter (Cont).

The patient should return to the urologist for follow-up including a repeat flow and bladder scan in 6 months.


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Long Term Management

How would you manage George in the long term?


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Monitor his symptoms closely (every 6 months for next 2 years).

If his stream subjectively deteriorates or patient has other voiding symptoms he should have ultrasound residual and be referred back to urologist.

DRE and PSA should be monitored as usual for his age.

DRE = Digital Rectal ExaminationPSA = Prostate-Specific Antigen


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What additional information should the specialist provide the family physician?


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Urethral stricture can recur

Refer to previous recommendations


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What would you do if George developed hematuria?


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Would require standard workup for gross hematuria including:

History

Physical Exam

Urinalysis

Culture

Cytology

Upper Tract Studies

Referral to Urologist for Cystoscopy


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End of Case 1

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MODULE 5 1/38 Case 1: George. MODULE 5 Case 1: George 2/38 Patient History George is a 50 year old computer engineer and works in a busy software development