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Case 7: John

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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

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What Typical Questions Do You Have for John?

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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 do your symptoms bother you?

9. Is there any history of prostate cancer in your family?

Some Possible Questions for John

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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.

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In Your Practice, How Would You Determine the Severity of John’s Symptoms

at this Stage?

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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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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: 0019-0027

Date of assessment: 29/06/05

Initial assessment (X)

Monitor: during __X__ therapy after _____therapy/surgery

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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

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?

0 1 2 3 4 5 3

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 1

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

0 1 2 3 4 5 4

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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

John’s Results

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

0 1 2 3 4 5 3

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

0 1 2 3 4 5 4

None 1 time 2 times 3 times 4 times5 or

more times

John’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 4

Total IPSS Score = 22

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John’s Bother Score = 3 (mixed bother)

Quality of Life Due to Urinary Symptoms

Delighted PleasedMostly

Satisfied

Mixed about equally

satisfied and dissatisfied

Mostly dissatisfi

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

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Interpreting the IPSS and Bother Score

IPSS Values Indicate Symptom Severity:

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

• John’s IPSS = 22 (severe symptoms)

• John’s Bother Score = 3 (mixed bother)

IPSS = International Prostate Symptom Score

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What Physical Examinations Do You Undertake on John?

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Recommended Examinations:

1. Abdominal exam

2. Genital exam

3. DRE

4. Blood pressure

DRE = Digital Rectal Examination

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Physical Examination HR 68 bpm

Blood Pressure 115/75 mmHg

UrinalysisClear

Midstream specimen for culture show no growth

Abdominal Exam Normal

Genital Exam Normal

DRE DRE reveals moderate sized smooth non-tender gland

DRE = Digital Rectal Examination

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

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Urethral swab: negative

Blood/Glucose: negative

PSA: 2.5 ng/mL

Urinalysis: no abnormal findingsLab tests:

Lab Results

PSA = Prostate-Specific Antigen

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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 ScorePSA = Prostate-Specific Antigen

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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

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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 6-12 months and then not rise appreciably while on 5α-reductase inhibitor.

He is monitored annually via DRE and PSA

DRE = Digital Rectal ExaminationPSA = Prostate-Specific Antigen

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Is there anything else the GP should do or discuss with this patient, besides annual monitoring of DRE and PSA?

Long Term Follow-up

DRE = Digital Rectal ExaminationPSA = Prostate-Specific Antigen

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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.

Long Term Follow-up

PSA = Prostate-Specific Antigen

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End of Case 7