1. MODULE 5 1/30 Case 8: Craig

2. MODULE 5 Case 8: Craig 2/30 Patient History  Craig, a 56-year bank manager was recently referred to his urologist for consideration of progressive lower urinary tract symptoms (LUTS).  Craig’s current complaints include poor daytime stream, but otherwise normal nocturnal voiding two times per night.  No history of UTI, trauma or instrumentation to his genitourinary tract.  Craig experiences declining erectile function. He currently drinks approximately 2 units of alcohol a night, more on weekend. Craig also drinks a cup of tea every night before going to bed. He does not exercise. LUTS = Lower Urinary Tract Symptoms UTI = Urinary Tract Infection

3. MODULE 5 Case 8: Craig 3/30 What Typical Questions Do You Have for Craig?

4. MODULE 5 Case 8: Craig 4/30 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.Do you have post void dribbling or incontinence? 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 do your symptoms bother you? 9.Is there any history of prostate cancer in your family? 10.Specific questions about erectile dysfunction Some Possible Questions for Craig

5. MODULE 5 Case 8: Craig 5/30 In Your Practice, How Would You Determine the Severity of Craig’s Symptoms at this Stage?

6. MODULE 5 Case 8: Craig 6/30 Use of Questionnaires: 1.IPSS (or AUA symptom score) 2.Quality of life question 3.Sexual Function Questionnaire IPSS = International Prostate Symptom Score AUA = American Urological Association

7. MODULE 5 Case 8: Craig 7/30 Discussion  The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of Craig  You ask him to complete the forms before proceeding  Here are Craig’s scores: International Prostate Symptom Score (IPSS) Patient name: Craig DOB: 05/05/49 ID: 0019-0028 Date of assessment: 29/06/05 Initial assessment (X) Monitor: during __X__ therapyafter _____therapy/surgery

8. MODULE 5 Case 8: Craig 8/30 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 Craig’s Results 1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0123450 2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0123451 3. Over the past month, how often have you found you stopped and started again several times when you urinated? 0123452 4. Over the past month, how often have you found it difficult to postpone urinating? 0123451

9. MODULE 5 Case 8: Craig 9/30 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 Craig’s Results 5. Over the past month, how often have you had a weak urinary stream? 0123453 6. Over the past month, how often have you had to push or strain to begin urinating? 0123451 None1 time2 times3 times4 times 5 or more times Craig’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? 0123451 Total IPSS Score = 9

10. MODULE 5 Case 8: Craig 10/30 Craig’s Bother Score = 2 (Mostly Satisfied) 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? 0123456

11. MODULE 5 Case 8: Craig 11/30 How Do You Interpret the Severity and Bother of Craig’s Symptoms?

12. MODULE 5 Case 8: Craig 12/30 Interpreting the IPSS and Bother Score IPSS Values Indicate Symptom Severity: Mild score: ≤ 7 Moderate score: 8-19 Severe score: ≥ 20 Craig’s IPSS = 9 (moderate symptoms) Craig’s Bother Score = 2 (mostly satisfied) IPSS = International Prostate Symptom Score Sexual function: declining quality of erections

13. MODULE 5 Case 8: Craig 13/30 What Kind of Physical Exam Would You Perform on Craig?

14. MODULE 5 Case 8: Craig 14/30 Recommended Examinations: 1.Abdominal exam 2.Genital exam 3.DRE 4.Blood pressure DRE = Digital Rectal Examination

15. MODULE 5 Case 8: Craig 15/30 Physical Examination HR85 bpm Blood Pressure138/85 mmHg WeightSlightly Obese Abdominal ExamNormal Genital ExamNormal DRE Small size smooth non-tender gland DRE = Digital Rectal Examination

16. MODULE 5 Case 8: Craig 16/30 What Investigations Might You Consider for Craig at this Stage of the Consult?

17. MODULE 5 Case 8: Craig 17/30 Lab tests:Urinalysis: Clear PSA: 1.2 ng/mL (optional) Midstream specimen culture: No Growth Lab Tests PSA = Prostate-Specific Antigen

18. MODULE 5 Case 8: Craig 18/30 What Are the Possible Diagnoses You Are Considering for Craig?

19. MODULE 5 Case 8: Craig 19/30 Possible Diagnoses for Craig 1.BPH 2.Erectile dysfunction BPH = Benign Prostatic Hyperplasia

20. MODULE 5 Case 8: Craig 20/30 Management Strategy  Craig has moderate LUTS that is almost certainly related to BPH.  He consumed significant amounts of fluids in the evening including a bladder stimulant (tea).  Craig’s PSA is below the level that would usually be an indication for prostate biopsy.  Craig’s potential erectile dysfunction is a concomitant factor LUTS = Lower Urinary Tract Symptoms BPH = Benign Prostatic Hyperplasia PSA = Prostate-Specific Antigen

21. MODULE 5 Case 8: Craig 21/30 Management Strategy  Craig indicates that he wants treatment primarily for his frequent daytime voiding, and is informed about the availability of medication.  Craig indicates a desire for non-pharmacological treatment.

22. MODULE 5 Case 8: Craig 22/30 What are the Lifestyle Modifications You Recommend?

23. MODULE 5 Case 8: Craig 23/30 Lifestyle Modification  Avoid tea late at night  Avoid decongestants  Avoid alcohol

24. MODULE 5 Case 8: Craig 24/30 Follow-up  How should the GP manage Craig in the long term?  If his symptoms worsen, how should the GP counsel him?

25. MODULE 5 Case 8: Craig 25/30  Continue to promote conservative lifestyle changes and monitor symptoms, DRE and PSA.  If symptoms deteriorate in future, then medical therapy could be advised. Follow-up PSA = Prostate-Specific Antigen DRE = Digital Rectal Examination

26. MODULE 5 Case 8: Craig 26/30  How does his mild/moderate ED affect your choice of medical therapies? Follow-up ED = Erectile Dysfunction

27. MODULE 5 Case 8: Craig 27/30  Standard ED workup:  History  Physical  Medications  Drug history  If negative, and patient desires therapy then prescription of a PDE5 inhibitor such as Viagra® (sildenafil citrate), Levitra® (vardenafil HCI) or Cialis® (tadalafil) could be considered. Follow-up ED = Erectile Dysfunction PDE5 Inhibitor = Phosphodiesterase Type 5 Inhibitor

28. MODULE 5 28/30 If the patient with sexual dysfunction was also concomitantly taking testosterone therapy, how would the management of BPH differ?

29. MODULE 5 29/30 The management of BPH should not change in a patient on testosterone for BPH except for due diligence in following prostate cancer risk (periodic DRE and PSA in appropriate age groups) PSA = Prostate-Specific Antigen DRE = Digital Rectal Examination

30. MODULE 5 Case 8: Craig 30/30 End of Case 8