1. MODULE 5 1/33 Case 5: Sam

2. MODULE 5 Case 5: Sam 2/33 Patient History  Sam is a 66 year old retired painter & construction worker.  He is distressed by the development of urinary symptoms that began about 1 year ago.  Sam complains of reduced force in his urine stream, as well as waking in the middle of the night to urinate and frequently urinating during the day.  His father was a pulp mill operator who died in his 70's of prostate cancer and Sam fears he may face the same fate.  He is experiencing both obstructive and irritative symptoms. He has terminal dribbling and straining, and his nocturia, and day time voiding, are accompanied by extreme urgency.

3. MODULE 5 Case 5: Sam 3/33 What Additional Questions Do You Have for Sam?

4. MODULE 5 Case 5: Sam 4/33 In Your Practice How Would You Determine the Impact of Sam’s Symptoms on his Quality of Life?

5. MODULE 5 Case 5: Sam 5/33 Use of Questionnaires: 1.IPSS (or AUA symptom score) 2.Quality of life question IPSS = International Prostate Symptom Score AUA = American Urological Association

6. MODULE 5 Case 5: Sam 6/33 Discussion  The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of Sam  You ask him to complete the forms before proceeding  Here are Sam’s scores: International Prostate Symptom Score (IPSS) Patient name: Sam DOB: 05/05/39 ID: 0019-0025 Date of assessment: 29/06/05 Initial assessment (X) Monitor: during __X__ therapyafter _____therapy/surgery

7. MODULE 5 Case 5: Sam 7/33 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 Sam’s Results 1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0123451 2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0123452 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? 0123454

8. MODULE 5 Case 5: Sam 8/33 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 Sam’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? 0123452 None1 time2 times3 times4 times 5 or more times Sam’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? 0123453 Total IPSS Score = 17

9. MODULE 5 Case 5: Sam 9/33 Sam’s Bother Score = 5 (unhappy) 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

10. MODULE 5 Case 5: Sam 10/33 How Do You Interpret the Severity and Bother of Sam’s Symptoms?

11. MODULE 5 Case 5: Sam 11/33 Interpreting the IPSS and Bother Score IPSS Values Indicate Symptom Severity: Mild score: ≤ 7 Moderate score: 8-19 Severe score: ≥ 20 Sam’s IPSS = 17 (moderate symptoms) Sam’s Bother Score = 5 (unhappy) IPSS = International Prostate Symptom Score

12. MODULE 5 Case 5: Sam 12/33 What Physical Examinations Would You Undertake on Sam?

13. MODULE 5 Case 5: Sam 13/33 Recommended Examinations: 1.Abdominal exam 2.Genital exam 3.Prostate exam 4.Blood pressure

14. MODULE 5 Case 5: Sam 14/33 Physical Examination Height 6 ft 3" Weight77kg (170lb) Blood PressureNormal Abdominal ExamNormal Genital ExamNormal Prostate Asymmetrically enlarged with no areas of hardness.

15. MODULE 5 Case 5: Sam 15/33 What Are the Possible Diagnoses You Are Considering for Sam?

16. MODULE 5 Case 5: Sam 16/33 Possible Diagnoses for Sam 1.BPH 2.Prostate cancer 3.Co-existing condition BPH = Benign Prostatic Hyperplasia

17. MODULE 5 Case 5: Sam 17/33 What Investigations Might You Consider for Sam at this Stage?

18. MODULE 5 Case 5: Sam 18/33 Lab tests:Urinalysis: no abnormal findings PSA: 6.0 ng/mL Blood/Glucose: normal Lab Tests PSA = Prostate-Specific Antigen

19. MODULE 5 Case 5: Sam 19/33 Discussion of Lab Results  In men with voiding symptoms, particularly those with a DRE showing asymmetrical enlargement of the prostate, it is important to exclude a diagnosis of prostate cancer.  The PSA level for Sam is moderately elevated and requires further investigation. However, the PSA level can be elevated for other reasons.  The increased size of the prostate alone can be associated with an increased level of PSA. DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen

20. MODULE 5 Case 5: Sam 20/33 What Would be Your Management Strategy for Sam?

21. MODULE 5 Case 5: Sam 21/33 Management Strategy  Practitioners must rule out conditions such as infection, prostate cancer, stricture, hypotonic bladder or other neurogenic disorders that might mimic BPH before prescribing a 5-ARI.  In light of Sam’s recent PSA elevation, prostate cancer should also be ruled out before a 5-ARI is prescribed.  On the basis of his elevated PSA levels, and the suspicious findings on DRE as well as Sam’s family history, prostate cancer is suspected.  He is referred to a urologist. BPH = Benign Prostatic Hyperplasia ARI = Alpha Reductase Inhibitor PSA = Prostate-Specific Antigen DRE = Digital Rectal Examination

22. MODULE 5 Case 5: Sam 22/33 Management Strategy (cont).  Begin treatment with an α 1 -blocker. This would benefit the patient in that his voiding symptoms would likely improve quickly.  While it is possible that his PSA has become elevated as a result of BPH, it is important to rule out prostate cancer in men with elevated PSA. The transrectal ultrasound performed at the time of his biopsy can also be used to more accurately estimate the size of the prostate gland (large BPH gland could be the reason for Sam’s elevated PSA). PSA = Prostate-Specific Antigen BPH = Benign Prostatic Hyperplasia

23. MODULE 5 Case 5: Sam 23/33  Sam returns for follow-up with his family physician.  It has been 3 months since he saw the urologist.  His biopsy was negative for malignancy.  The urologist added a 5α-reductase inhibitor to his α 1 -blocker. Follow-up

24. MODULE 5 Case 5: Sam 24/33 What are Your Next Steps with Sam?

25. MODULE 5 Case 5: Sam 25/33 Next Steps & Discussion  Sam’s rectal examination shows a large prostate and the size by transrectal ultrasound is estimated to be 80 mL.  Sam’s PSA measurement is taken. It is now 4.1 ng/mL.  Urinalysis is normal. PSA = Prostate-Specific Antigen

26. MODULE 5 Case 5: Sam 26/33 How Do You interpret Sam’s Changes in PSA?  What is the normally expected change in PSA after 6 months on 5α- reductase inhibitor therapy?  At what stage, if ever, would you consider removal of Sam’s α 1 - blocker from his treatment regimen? PSA = Prostate-Specific Antigen

27. MODULE 5 Case 5: Sam 27/33 Urology Follow-up  Sam continues to follow-up with the urologist every 6 months who schedules another biopsy. The urologist expects Sam’s PSA to drop to 50% of its initial level after 6 months of 5-ARI treatment. When this does not happen, he knows that he may have missed prostate cancer on the first biopsy and recommends it be repeated.  The repeat biopsy is again negative for malignancy. PSA = Prostate-Specific Antigen ARI = Alpha Reductase Inhibitor

28. MODULE 5 Case 5: Sam 28/33 Long Term Management  How would you manage Sam over the next 2 to 3 years?

29. MODULE 5 Case 5: Sam 29/33 Long Term Management  Since the patient had symptomatic improvement and did not have prostate cancer on two biopsies, continuation of both the α 1 -blocker and the 5α-reductase inhibitor is an appropriate option.  However, it is also appropriate to consider discontinuation of the α 1 - blocker.  Many patients who begin with combination medical therapy can discontinue the α 1 -blocker after 12 months of therapy. The majority of patients will notice little, if any, difference in their symptoms.  From that point forward, they can be maintained on a 5-ARI over the long term.  The PSA must continue to be monitored. PSA = Prostate-Specific Antigen ARI = Alpha Reductase Inhibitor

30. MODULE 5 Case 5: Sam 30/33  What other long term follow up is important for this patient? Long Term Management

31. MODULE 5 Case 5: Sam 31/33  Although Sam has had two biopsies to rule out prostate cancer, he is still at risk for developing prostate cancer in the future.  He should be monitored for improvement in symptoms on combination medical therapy and if he is happy with his symptoms after 6 months, he can be kept on combination therapy on a long term basis  (could be considered for trial of discontinuing α 1 -blocker after a year to see if he still needs it). Long Term Management

32. MODULE 5 Case 5: Sam 32/33  His PSA should drop by approximately 50% (to about 3) over the next 6-12 months.  If it does not, then he needs to be reinvestigated for possibility of prostate cancer that was missed on the first set of biopsies.  If his PSA starts to climb during the long term follow up while on 5α-reductase inhibitor therapy, then again, consideration that he may be developing prostate cancer should be entertained and referral back to urologist is indicated. Long Term Management PSA = Prostate-Specific Antigen

33. MODULE 5 Case 5: Sam 33/33 End of Case 5