1. Case 7:John
Case 7: John
Understanding BPH From the Science to the Clinical Setting

2. Patient History John is a 64-year old retired school teacher.
You recently sent him to see his urologist for an assessment. He is quite worried because his recent PSA is 2.5 ng/mL, which is up from the last recorded value 1 year ago at 1.2 ng/mL.
John is now concerned that his mild lower urinary tract symptoms (LUTS) indicate that he has newly developed prostate cancer. His friend was recently diagnosed with prostate cancer.
PSA = Prostate-Specific Antigen

3. What Typical Questions Do You Have for John?

4. Some Possible Questions for John
Has your urine stream changed?
Do you have to get up at night to urinate?
Does it burn when you urinate?
Have you had a fever?
Has there been any blood in your urine?
Questions around irritative and obstructive symptoms
Questions examining possibility of diabetes
How much do your symptoms bother you?
Is there any history of prostate cancer in your family?

5. John’s Response John says his urine stream has changed
He now rises to void five times nightly and has moderate urgency during his working day.
His stream is slow but he has never had any episodes of urinary retention.

6. In Your Practice, How Would You Determine the Severity of John’s Symptoms at this Stage?

7. Use of Questionnaires: IPSS (or AUA symptom score)
Quality of life question
IPSS = International Prostate Symptom Score AUA = American Urological Association

8. International Prostate Symptom Score (IPSS)
Case 7:John
Discussion
The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of John
You ask him to complete the forms before proceeding
Here are John’s scores:
International Prostate Symptom Score (IPSS)
Patient name: John
DOB: 05/05/41
ID:
Date of assessment: 29/06/05
Initial assessment (X)
Monitor: during __X__ therapy after _____therapy/surgery
Understanding BPH From the Science to the Clinical Setting

9. International Prostate Symptom Score
Case 7:John
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
John’s Results
1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 1 2 3 4 5
2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating?
3. Over the past month, how often have you found you stopped and started again several times when you urinated?
4. Over the past month, how often have you found it difficult to postpone urinating?
Understanding BPH From the Science to the Clinical Setting

10. Total IPSS Score = 22 Case 7:John 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
John’s Results
5. Over the past month, how often have you had a weak urinary stream? 1 2 3 4 5
6. Over the past month, how often have you had to push or strain to begin urinating?
None
1 time
2 times
3 times
4 times
5 or more times
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 = 22
Understanding BPH From the Science to the Clinical Setting

11. Quality of Life Due to Urinary Symptoms
Delighted
Pleased
Mostly Satisfied
Mixed about equally satisfied and dissatisfied
Mostly dissatisfied
Unhappy
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? 1 2 3 4 5 6
John’s Bother Score = 3 (mixed bother)

12. How Do You Interpret the Severity and Bother of John’s Symptoms?
Case 7:John
How Do You Interpret the Severity and Bother of John’s Symptoms?
Understanding BPH From the Science to the Clinical Setting

13. Interpreting the IPSS and Bother Score
IPSS Values Indicate
Symptom Severity:
Mild score: ≤ 7
Moderate score: 8-19
Severe score: ≥ 20
John’s IPSS = 22 (severe symptoms)
John’s Bother Score = 3 (mixed bother)
IPSS = International Prostate Symptom Score

14. What Physical Examinations Do You Undertake on John?
Case 7:John
What Physical Examinations Do You Undertake on John?
Understanding BPH From the Science to the Clinical Setting

15. Recommended Examinations: Abdominal exam Genital exam DRE
Blood pressure
DRE = Digital Rectal Examination

16. Physical Examination HR 68 bpm Blood Pressure 115/75 mmHg Urinalysis
Clear Midstream specimen for culture show no growth
Abdominal Exam
Normal
Genital Exam
DRE
DRE reveals moderate sized smooth non-tender gland
DRE = Digital Rectal Examination

17. What Investigations Might You Consider for John at this Stage of the Consult?

18. Lab Results Lab tests: Urinalysis: no abnormal findings PSA: 2.5 ng/mL
Blood/Glucose: negative
Urethral swab: negative
PSA = Prostate-Specific Antigen

19. Management Strategy
John’s mixed bother and high IPSS are indications of a need for further evaluation
Furthermore, his elevated PSA level of 2.5 ng/mL, while not extremely high, warrants referral to a urologist.
IPSS = International Prostate Symptom Score PSA = Prostate-Specific Antigen

20. Urologist Feedback
John’s prostate size measurement via DRE is critical for monitoring his condition
Measurements (4.2 x 5.2 X 5.5 cm) give a calculated volume of 63 ml and technician observed that the bladder was not completely empty after voiding.
DRE = Digital Rectal Examination

21. Long Term Follow-up
John is placed on combination therapy of a 5α-reductase inhibitor and an α1-blocker
The PSA is expected to decrease by approximately 50% in the first months and then not rise appreciably while on 5α-reductase inhibitor.
He is monitored annually via DRE and PSA
DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen

22. Long Term Follow-up
Is there anything else the GP should do or discuss with this patient, besides annual monitoring of DRE and PSA?
DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen

23. Long Term Follow-up
This 64 year old gentleman with a PSA of 2.5, benign enlarged prostate gland should be reassured that his risk of clinically important prostate cancer is small.
He needs to have continued monitoring.
He is quite symptomatic and treatment with combination therapy has been initiated.
If his PSA starts to rise while on 5α-reductase inhibitor treatment then referral back to urologist is indicated.
He could be told that 5α-reductase inhibitor therapy with finasteride has been shown in a study to reduce the risk of future development of prostate cancer.
PSA = Prostate-Specific Antigen

24. End of Case 7