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Case 9: Pierre

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Case 9: Pierre

2/23

Patient History

Pierre is 65 years of age who has suffered with benign prostatic hyperplasia (BPH) for 10 years.

At his last GP visit almost a year ago, his IPSS score was 21 and he reported mixed satisfaction/dissatisfaction with his QoL related to urinary condition.

Today Pierre has made an urgent request to see his GP and presents with symptoms of severe LUTS. He has just filled his IPSS and QoL and is quite distressed.

IPSS = International Prostate Symptom ScoreQoL = Quality of LifeLUTS = Lower Urinary Tract Symptoms

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What Typical Questions Do You Have for Pierre?

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Case 9: Pierre

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Some Possible Questions for Pierre

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

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Case 9: Pierre

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Pierre’s Response

Pierre has previously been treated with α1-blocker therapy to which he has ceased to respond. He has been switched to a 5α-reductase inhibitor therapy in the last 3 years.

Because Pierre’s treatment options have been optimized and the BPH progression is still having a profoundly negative effect on his quality of life, Pierre is referred to his urologist for urgent consultation.

BPH = Benign Prostatic Hyperplasia

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Case 9: Pierre

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Use of Questionnaires:

1. IPSS (or AUA symptom score)2. Quality of life question

IPSS = International Prostate Symptom ScoreAUA = American Urological Association

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Case 9: Pierre

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Discussion The IPSS and Quality of Life due to Urinary Symptoms

Questionnaires are requested of Pierre

You ask him to complete the forms before proceeding

Here are Pierre’s scores:

International Prostate Symptom Score (IPSS)

Patient name: Pierre

DOB: 05/05/40

ID: 0019-0029

Date of assessment: 29/06/05

Initial assessment (X)

Monitor: during __X__ therapy after _____therapy/surgery

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Case 9: Pierre

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International Prostate Symptom Score

Not at all

Less than 1 timein 5

Less than half the time

About half the

time

More than half the time

Almost always

Pierre’s Results

1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?

0 1 2 3 4 5 5

2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

0 1 2 3 4 5 3

3. Over the past month, how often have you found you stopped and started again several times when you urinated?

0 1 2 3 4 5 5

4. Over the past month, how often have you found it difficult to postpone urinating?

0 1 2 3 4 5 3

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Not at all

Less than 1 timein 5

Less than half the time

About half the

time

More than half the time

Almost always

Pierre’s Results

5. Over the past month, how often have you had a weak urinary stream?

0 1 2 3 4 5 4

6. Over the past month, how often have you had to push or strain to begin urinating?

0 1 2 3 4 5 5

None 1 time 2 times 3 times 4 times5 or

more times

Pierre’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?

0 1 2 3 4 5 5

Total IPSS Score = 30

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Pierre’s Bother Score = 6 (terrible)

Quality of Life Due to Urinary Symptoms

Delighted PleasedMostly

Satisfied

Mixed about equally

satisfied and dissatisfied

Mostly dissatis-

fiedUnhappy 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?

0 1 2 3 4 5 6

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Case 9: Pierre

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How Do You Interpret the Severity and Bother of Pierre’s Symptoms?

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Case 9: Pierre

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Interpreting the IPSS and Bother Score

IPSS Values Indicate Symptom Severity:

Mild score: ≤ 7Moderate score: 8-19Severe score: ≥ 20

• Pierre’s IPSS = 30 (severe symptoms)

IPSS = International Prostate Symptom Score

• Pierre’s Bother Score = 6 (terrible)

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Case 9: Pierre

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What Physical Examinations Do You Undertake on Pierre?

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Case 9: Pierre

14/23

Physical Examination Height 6 ft 0”

Weight 72 kg (158 lb)

Blood Pressure 128/82 mmHg

Pulse Normal

Temperature 36.5°C

General appearance He appears pale, underweight and fatigued

Abdominal ExamHis bladder is palpable

No renal angle tenderness on both sides

Genital Exam No abnormal findings

DRE:-Anus and rectal ampulla-Prostate

-Normal-Markedly enlarged, firm and smooth

DRE = Digital Rectal Examination

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Case 9: Pierre

15/23

Possible Diagnoses for Pierre

1. Severe BPH

2. Acute urinary retention

3. Concomitant prostate cancer

4. Prostatitis

BPH = Benign Prostatic Hyperplasia

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Case 9: Pierre

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Referral to Urologist

Because he has failed medical therapy with both α1-blockers and 5-ARIs, Pierre is a possible candidate for surgery

Pierre is referred to his urologist

ARI = Alpha Reductase Inhibitor

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Case 9: Pierre

17/23

Urologist Consult LetterDear Doctor,

Pierre was referred to me for his severe BPH, after several years of medical treatment with both 5-ARIs and α1-blockers.

He had a PSA of 2.5 ng/mL, a large benign prostate, and a residual urine of 280 mL.

On cystoscopy, he had trilobar obstructive hyperplasia with bladder evidence of long standing outlet obstruction. He was subsequently treated with TURP and his symptoms have now subsided.

He reports no more nocturia and is generally quite happy with the procedure. His pathology was benign.

Pierre should resume his regular annual checkups and be monitored for any future LUTS.

BPH = Benign Prostatic HyperplasiaARI = Alpha Reductase InhibitorPSA = Prostate-Specific AntigenTURP = Transurethral Resection of the ProstateLUTS = Lower Urinary Tract Symptoms

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Long Term Follow-up

Discussion of risk of TURP surgery

Specialist perspective

Family Physician perspective

Let patient know that he still have to be monitored for prostate cancer even though he has had a TURP

TURP = Transurethral Resection of the Prostate

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Long Term Follow-up

What are the key issues for the GP in terms of long term management of this patient?

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Long Term Follow-up

Approximately 20% of patients with a successful TURP will have recurrence of symptoms over the next decade secondary to regrowth of prostate, development of prostate cancer, development of urethral or bladder neck stricture or development of aging hypotonic bladder.

The GP can follow-up by monitoring symptoms (and PSA if indicated based on age and co-morbidities or because of recurrence of symptoms, change in DRE etc)

TURP = Transurethral Resection of the ProstateDRE = Digital Rectal ExaminationPSA = Prostate-Specific Antigen

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Long Term Follow-up

Should the patient still be monitored for prostate cancer?

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Long Term Follow-up

If the urologist states that pathology was negative for cancer at the time of TURP, the GP must continue to monitor for future development of prostate cancer with DRE and PSA as per the usual standard routine (based on age and co-morbities).

TURP = Transurethral Resection of the ProstateDRE = Digital Rectal ExaminationPSA = Prostate-Specific Antigen

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End of Case 9