MODULE 5 1/36 Case 4: Andy

MODULE 5 Case 4: Andy 2/36 History  You have known Andy as a patient for 15 years  Andy is 65 years of age and a retired bus driver  You have been treating him for BPH for 10 years  At his last office visit almost a year ago, his IPSS score was 21 and he reported mixed satisfaction/dissatisfaction with his QoL related to urinary condition  Today Andy has made an urgent request to see you and presents with symptoms of severe LUTS  He has just filled-in his IPSS and QoL questionnaires and is quite distressed BPH = Benign Prostatic Hyperplasia IPSS = International Prostate Symptom Score QoL = Quality of Life LUTS = Lower Urinary Tract Symptoms

MODULE 5 Case 4: Andy 3/36 What Questions Do You Have for Andy?

MODULE 5 Case 4: Andy 4/36 1.Has your urine stream changed? 2.How many times are you up at night to void? 3.Are you emptying your bladder 4.Does it burn when you urinate? 5.Has there been any blood in your urine? 6.Have you been sleeping properly? 7.Do you have any abdominal pain? 8.How much do these symptoms bother you? Some Possible Questions for Andy

MODULE 5 Case 4: Andy 5/36  Recognizing that Andy is distressed, you further inquire about his sleeping patterns and any outside stresses that could be affecting him.  You discover that he has to urinate at night so often that he is not getting any sleep  He has both severe irritative and obstructive symptoms  His wife is not speaking with him because she says he should have seen the Doctor sooner. He is now trying to get some sleep in the living room and has slept very poorly for the last 3 nights! Andy’s Response

MODULE 5 Case 4: Andy 6/36  Andy has previously been treated with α 1 -blocker therapy to which he has ceased to respond  Andy describes several similar acute episodes of pain over the past year, which got better after a few days. Andy’s Treatment History

MODULE 5 Case 4: Andy 7/36 How Would You Assess the Impact of Andy’s Urinary Problems on his Quality of Life?

MODULE 5 Case 4: Andy 8/36 Use of Questionnaires: 1.IPSS (or AUA symptom score) 2.Quality of life question IPSS = International Prostate Symptom Score AUA = American Urological Association

MODULE 5 Case 4: Andy 9/36 Discussion  The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of Andy  You ask him to complete the forms before proceeding  Here are Andy’s scores: International Prostate Symptom Score (IPSS) Patient name: Andy DOB: 06/08/40 ID: Date of assessment: 29/06/05 Initial assessment (X) Monitor: during __X__ therapyafter _____therapy/surgery

MODULE 5 Case 4: Andy 10/36 International Prostate Symptom Score Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Andy’s Results 1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Over the past month, how often have you found you stopped and started again several times when you urinated? Over the past month, how often have you found it difficult to postpone urinating?

MODULE 5 Case 4: Andy 11/36 Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Andy’s Results 5. Over the past month, how often have you had a weak urinary stream? Over the past month, how often have you had to push or strain to begin urinating? None1 time2 times3 times4 times 5 or more times Andy’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? Total IPSS Score = 32

MODULE 5 Case 4: Andy 12/36 Andy’s QoL Score = 6 (Terrible) Quality of Life Due to Urinary Symptoms DelightedPleased Mostly Satisfied Mixed about equally satisfied and dissatisfied Mostly dissatis- fied UnhappyTerrible 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?

MODULE 5 Case 4: Andy 13/36 How Do You Interpret the Severity and Bother of Andy’s Symptoms?

MODULE 5 Case 4: Andy 14/36 Interpreting the IPSS and Bother Score IPSS Values Indicate Symptom Severity: Mild score: ≤ 7 Moderate score: 8-19 Severe score: ≥ 20 Andy’s IPSS = 32 (severe symptoms) Andy’s Bother Score = 6 (terrible) IPSS = International Prostate Symptom Score

MODULE 5 Case 4: Andy 15/36 What Kind of Physical Examinations Would You Perform on Andy?

MODULE 5 Case 4: Andy 16/36 Necessary examinations: 1.Abdominal exam 2.Genital exam 3.DRE 4.Blood pressure 5.Pulse 6.Temperature DRE = Digital Rectal Examination

MODULE 5 Case 4: Andy 17/36 Results of the Physical Exam Height6 ft 0” Weight72 kg (158 lb) General appearanceHe appears pale, underweight and fatigued Abdominal exam  His bladder is palpable  No renal angle tenderness on both sides Genital examNo abnormal findings DRE: -Anus and rectal ampulla -Prostate - normal - markedly enlarged, firm and smooth Blood pressure128/82 mmHg PulseNormal Temperature36.5 °C DRE = Digital Rectal Examination

MODULE 5 Case 4: Andy 18/36  Andy has had severe burning when he voids but he has experienced no fever or chills  If he had fever or chills he should be admitted to the nearest emergency ward for monitoring and treatment in case of potential septicemia Note

MODULE 5 Case 4: Andy 19/36 What Are the Possible Diagnoses for Andy?

MODULE 5 Case 4: Andy 20/36 Possible Diagnoses for Andy 1.UTI complicating BPH 2.Gram negative urosepsis 3.Concomitant prostate cancer 4.Prostatitis 5.Acute urinary retention (with or without infection) UTI = Urinary Tract Infection BPH = Benign Prostatic Hyperplasia

MODULE 5 Case 4: Andy 21/36 What Other Investigations Might you Consider at this Stage?

MODULE 5 Case 4: Andy 22/36 Lab tests:Urinalysis: Colour: Unremarkable Turbidity: 8.0 NTU pH: 7.5 Specific gravity: Protein, Glucose, Ketones: Negative Leukocytes: 3+ Hemoglobin: 2+ WBC: Packed RBC: 1-5 Bacteria: Many CBC: normal except WBC 8.5 x 10 9 /L Midstream urinalysis for culture and sensitivity: Result reported in 72 hours showed 10 8 E. Coli Blood Cultures: Negative PSA Levels: never do a PSA in such a setting. Serum creatinine:110 μmol/L Patient needs urgent ultrasound PSA = Prostate-Specific Antigen WBC, RBC, CBC: (White, Red, Complete) Blood Count

MODULE 5 Case 4: Andy 23/36 Note  Never do PSA in acute settings PSA = Prostate-Specific Antigen

MODULE 5 Case 4: Andy 24/36 What is Your Diagnosis and Management for Andy?

MODULE 5 Case 4: Andy 25/36 Diagnosis: Acute urinary retention with UTI – acute prostatitis is also a possibility as part of UTI UTI = Urinary Tract Infection

MODULE 5 Case 4: Andy 26/36 Diagnosis, Continued  Clinically Andy has acute urinary retention with UTI. He must have residual urine checked by ultrasound or catheterization  Assessment of Andy’s renal function is determined by his age, weight and gender  His renal function is used to determine the acceptable dose for Ciprofloxacin  Andy’s Creatinine Clearance is 75 mL/min which is indicative of very mild renal failure UTI = Urinary Tract Infection

MODULE 5 Case 4: Andy 27/36 Treatment: When ultrasound confirms a residual urine of 500 mL, a foley catheter is inserted and ciprofloxacin hydrochloride prescribed: 500 mg BID for 14 days Treatment BID = Bis In Die (Twice Daily)

MODULE 5 Case 4: Andy 28/36 Discussion  Based on Andy’s history of severe BPH and his acute symptoms, acute urinary retention with urinary tract infection is suspected  He also has very mild renal failure  He needs an indwelling foley catheter and broad spectrum antibiotics while awaiting blood and urine results  A teleconference with the urologist is recommended  Andy needs to be watched very closely; he is in danger of extreme complications because he has untreated retention associated with renal failure  Andy should at least phone you the next day and confirm that he is feeling better. Even if he was feeling better, he might deteriorate again! BPH = Benign Prostatic Hyperplasia

MODULE 5 Case 4: Andy 29/36 What Would be your Next Steps and Follow-up Strategy?

MODULE 5 Case 4: Andy 30/36 Strategy:Referral to Urologist

MODULE 5 Case 4: Andy 31/36 Discussion & Follow-up  Because Andy’s treatment options have been optimized and the BPH progression is still having a profoundly negative effect on his quality of life, Andy is referred to his urologist for urgent consultation  Because he had such long standing severe obstructive and irritative voiding symptoms while on α 1 -blocker therapy, it is likely that he has chronic retention secondary to BPH and would likely fail a trial of voiding without a catheter. A catheter should remain in place until seen by a urologist. BPH = Benign Prostatic Hyperplasia

MODULE 5 32/36 What Options are Pursued by the Specialist?

MODULE 5 Case 4: Andy 33/36 Options Pursued by Specialist  Treatment of UTI / prostatitis and AUR as ordered  Initiate treatment again with α 1 -blockers for short term and 5α- reductase inhibitor for long term  Trial voiding without catheter. If this fails consider cystoscopy and TURP. UTI = Urinary Tract Infection AUR = Acute Urinary Retention TURP = Transurethral Resection of the Prostate

MODULE 5 34/36 At What Point will this Patient Return to his FP and What Should the Specialist Recommend to the FP in Terms of Long Term Follow up?

MODULE 5 Case 4: Andy 35/36 Family Physician Follow-up  FP can follow up after successful management of AUR (whether trial of voiding was successful or TURP was required) and can follow symptoms, DRE and PSA as per usual. AUR = Acute Urinary Retention TURP = Transurethral Resection of the Prostate DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen

MODULE 5 Case 4: Andy 36/36 End of Case 4