1. MODULE 5 1/26 Case 6: Anthony

2. MODULE 5 Case 6: Anthony 2/26 Patient History  Anthony is a 55-year old lawyer.  He has been suffering from voiding complaints for several years, and for the past 5 years he has been treated with an α 1 -blocker for BPH.  Anthony recently experienced a urinary infection requiring antibiotics. BPH = Benign Prostatic Hyperplasia

3. MODULE 5 Case 6: Anthony 3/26 What Typical Questions Do You Have for Anthony?

4. MODULE 5 Case 6: Anthony 4/26 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.Have you had a fever? 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 does your symptoms bother you? 9.Is there any history of prostate cancer in your family? Some Possible Questions for Anthony

5. MODULE 5 Case 6: Anthony 5/26 Anthony’s response  Anthony says he is definitely getting worse  His nocturia is increased as well as day time voiding frequency  He is worried about prostate cancer, but there is no history of it in his family, to his knowledge  He is otherwise healthy and tries to exercise regularly

6. MODULE 5 Case 6: Anthony 6/26 In Your Practice, How Would You Determine the Severity of Anthony’s Symptoms at this Stage?

7. MODULE 5 Case 6: Anthony 7/26 Use of Questionnaires: 1.IPSS (or AUA symptom score) 2.Quality of life question IPSS = International Prostate Symptom Score AUA = American Urological Association

8. MODULE 5 Case 6: Anthony 8/26 Discussion  The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of Anthony  You ask him to complete the forms before proceeding  Here are Anthony’s scores: International Prostate Symptom Score (IPSS) Patient name: Anthony DOB: 05/05/50 ID: 0019-0026 Date of assessment: 29/06/05 Initial assessment (X) Monitor: during __X__ therapyafter _____therapy/surgery

9. MODULE 5 Case 6: Anthony 9/26 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 Anthony’s Results 1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0123455 2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0123455 3. Over the past month, how often have you found you stopped and started again several times when you urinated? 0123451 4. Over the past month, how often have you found it difficult to postpone urinating? 0123454

10. MODULE 5 Case 6: Anthony 10/26 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 Anthony’s Results 5. Over the past month, how often have you had a weak urinary stream? 0123455 6. Over the past month, how often have you had to push or strain to begin urinating? 0123455 None1 time2 times3 times4 times 5 or more times Anthony’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? 0123454 Total IPSS Score = 29

11. MODULE 5 Case 6: Anthony 11/26 Anthony’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? 0123456

12. MODULE 5 Case 6: Anthony 12/26 How Do You Interpret the Severity and Bother of Anthony’s Symptoms?

13. MODULE 5 Case 6: Anthony 13/26 Interpreting the IPSS and Bother Score IPSS Values Indicate Symptom Severity: Mild score: ≤ 7 Moderate score: 8-19 Severe score: ≥ 20 Anthony’s IPSS = 29 (severe symptoms) Anthony’s Bother Score = 6 (terrible) IPSS = International Prostate Symptom Score

14. MODULE 5 Case 6: Anthony 14/26 What Kind of Physical Exam Would You Perform on Anthony?

15. MODULE 5 Case 6: Anthony 15/26 Recommended Examinations: 1.Abdominal exam 2.Genital exam 3.DRE DRE = Digital Rectal Examination

16. MODULE 5 Case 6: Anthony 16/26 Results of the Physical Exam  On physical examination, Anthony appears healthy Height6 ft 1" Weight68 kg (150 lb) Blood Pressure120/80 mmHg Abdominal ExamNegative Genital ExamNegative DRE: -Anus and rectal ampulla -Prostate - Normal - Prostate clearly enlarged, painful on both lobes DRE = Digital Rectal Examination

17. MODULE 5 Case 6: Anthony 17/26 What Investigations Might You Consider for Anthony at this Stage?

18. MODULE 5 Case 6: Anthony 18/26 Urethral swab: negative Blood/Glucose: negative PSA: 3.6 ng/mL Urinalysis: no abnormal findingsLab tests: Lab Results PSA = Prostate-Specific Antigen

19. MODULE 5 Case 6: Anthony 19/26 What Are the Possible Diagnoses You Are Considering for Anthony?

20. MODULE 5 Case 6: Anthony 20/26 Possible Diagnoses for Anthony 1.BPH 2.Prostate cancer

21. MODULE 5 Case 6: Anthony 21/26 Management Strategy  Anthony’s severe bother (QoL = 6) and high IPSS of 29 are indications of a need for further evaluation  Furthermore, his elevated PSA level of 3.6 ng/mL, while not extremely high, is worrisome for a 55 year old, and warrants referral to a urologist. QoL = Quality of Life IPSS = International Prostate Symptom Score PSA = Prostate-Specific Antigen

22. MODULE 5 Case 6: Anthony 22/26 Urologist Consultation  Sextant prostate biopsies indicated no prostatic carcinoma.  Anthony is counseled by the urologist on pharmacotherapy and treatment options  He is not a candidate for surgery and is put on a 5α-reductase inhibitor  Anthony is still taking his α 1 -blocker  Anthony is referred back to his family physician

23. MODULE 5 Case 6: Anthony 23/26 Family Physician Follow-up  Anthony is now on combination therapy  After 12 months, his DRE is normal and his PSA is 1.2ng/ml  His bother score (QoL) is down to a 2  His IPSS is 18 (moderate symptoms) DRE = Digital Rectal Examination QoL = Quality of Life PSA = Prostate-Specific Antigen IPSS = International Prostate Symptom Score

24. MODULE 5 Case 6: Anthony 24/26 How Would You Counsel Anthony?  If Anthony asked about his chances of prostate cancer, how would you respond?  What is his risk level?

25. MODULE 5 Case 6: Anthony 25/26 Counseling Anthony  Anthony has a low chance of having prostate cancer at this time.  The reduction in PSA is likely due to the 5α-reductase inhibitor and he should be monitored for symptoms, DRE and PSA.  In a large randomized study, 5α-reductase inhibitor therapy with finasteride reduced the risk of developing prostate cancer. PSA = Prostate-Specific Antigen DRE = Digital Rectal Examination

26. MODULE 5 Case 6: Anthony 26/26 End of Case 6