1. Case 1: George Case 1: George
Understanding BPH From the Science to the Clinical Setting

2. Patient History
George is a 50 year old computer engineer and works in a busy software development company.
He comes to see you for a check-up and explains that his frequent trips to the bathroom at work are difficult to explain to his boss, who suspects George is skipping out of his duties!
George explains that his symptoms started about 3 years ago and have become more significant in the last few months.

3. What Typical Questions Do You Have for George?

4. Some Possible Questions for George
Has your urine stream changed?
Do you think your are emptying your bladder?
Do you have to get up at night to urinate? How many times?
Do you have urinary frequency? Urgency void?
Do you have post void dribbling?
Does it burn when you urinate?
Has there been any blood in your urine?
Do your symptoms bother you?
Questions examining possibility of diabetes
Is there any history of prostate cancer in your family?

5. Additional Patient History
George explains that he has a weak urine stream, with dribbling, but also reports some irritative symptoms, including mild nocturia.
He has no burning sensation on urination and no fever.
He doesn’t recall any blood in his urine and thinks he is free of STDs.
He was treated about 10 years ago for Chlamydia.
He hasn’t ever been tested for diabetes and feels otherwise healthy.
George seems very frustrated that he has problems with urinating and is concerned that he has cancer because that has been in the news lately.
He reports no family history of prostatic or bladder cancer.
STD = Sexually Transmitted Disease

6. What Other Questions Will You Have for George at this Stage?

7. Possible Questions for George
Did George have any other medical history?
On further discussion George remembers a history of discharge and burning several years ago.
He explains that his treating physician told him he had urethritis.
Ask George if he has urethral discharge.

8. Case 1: George
In Your Practice, How Would You Determine the Severity of George’s Symptoms at this Stage?
Understanding BPH From the Science to the Clinical Setting

9. Use of Questionnaires: IPSS (or AUA symptom score)
Quality of life question
IPSS = International Prostate Symptom Score AUA = American Urological Association

10. Results of George’s IPSS & QoL Question
Case 1: George
Results of George’s IPSS & QoL Question
To validate the severity of George’s problem and get more information, you ask George to complete the IPSS and Quality of Life due to Urinary Symptoms Questionnaires.
Here are his results:
International Prostate Symptom Score (IPSS)
Patient name: George
DOB: 30/11/55
ID:
Date of assessment: 04/12/05
Initial assessment (X)
Monitor: during __X__ therapy after _____therapy/surgery
Understanding BPH From the Science to the Clinical Setting

11. International Prostate Symptom Score
Case 1: George
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
George’s Results
1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 1 2 3 4 5
2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating?
3. Over the past month, how often have you found you stopped and started again several times when you urinated?
4. Over the past month, how often have you found it difficult to postpone urinating?
Understanding BPH From the Science to the Clinical Setting

12. Total IPSS Score = 14 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
George’s Results
5. Over the past month, how often have you had a weak urinary stream? 1 2 3 4 5
6. Over the past month, how often have you had to push or strain to begin urinating?
None
1 time
2 times
3 times
4 times
5 or more times
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?
Total IPSS Score = 14

13. Quality of Life Due to Urinary Symptoms
Delighted
Pleased
Mostly Satisfied
Mixed about equally satisfied and dissatisfied
Mostly dissatis-fied
Unhappy
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? 1 2 3 4 5 6
George’s Bother Score = 5 (unhappy)

14. How Do You Interpret the Severity and Bother Associated with George’s Symptoms?

15. Interpreting the IPSS and Bother Score
IPSS Values Indicate
Symptom Severity:
Mild score: ≤ 7
Moderate score: 8-19
Severe score: ≥ 20
George’s IPSS = 14 (moderate symptoms)
George’s Bother Score = 5 (unhappy)
IPSS = International Prostate Symptom Score

16. How Does George’s Age of 50 Years Factor Into Your Diagnosis?

17. Discussion of Age as a Factor
At his age, it would be unusual for the effects of BPH to be as pronounced as George is experiencing but not impossible.
Thus the moderate severity of his symptom scores and high bother (unhappy quality of life score) suggest that he may be experiencing an unusual prostatic obstruction, possibly a urethral stricture or a bladder neck obstruction.
If he had been older, these same symptoms may have suggested BPH as the first possibility.
BPH = Benign Prostatic Hyperplasia

18. What Kind of Physical Exam Would You Perform on George?

19. Recommended Examinations: Abdominal exam Genital exam DRE
Blood pressure
DRE = Digital Rectal Examination

20. Results of the Physical Exam
On physical examination, George appears healthy.
Here are George’s results & findings of interest:
Height
5 ft 7"
Weight
68 kg (150 lb)
Blood Pressure
120/80 mmHg
Abdominal Exam
Negative
Genital Exam
DRE:
Anus and rectal ampulla
Prostate
- Normal
- Feels normal
DRE = Digital Rectal Examination

21. What Investigations Might You Consider for George at this Stage of the Consult?

22. Lab Results Lab tests: Urinalysis: no abnormal findings PSA: 0.8 ng/mL
Blood/Glucose: negative
Urethral swab: negative
Serum creatinine (optional): 87 μmol/L (higher range of normal)
PSA = Prostate-Specific Antigen

23. Discussion of Lab Results
Although George's symptoms are similar to those seen in BPH, differential diagnosis is important.
Urinalysis, serum creatinine and PSA levels were normal.
George’s PSA result is 0.8 ng/mL which is not suspicious of prostate cancer.
George’s other tests are negative, leaving the possibility of obstruction.
Note that some physicians may request an ultrasound for George, which is not recommended in the BPH guidelines, but is important if checking for bladder stones. It could also be of help in patients such as George who is young for significant BPH. An ultrasound could be used to estimate George’s residual urine volume.
BPH = Benign Prostatic Hyperplasia PSA = Prostate-Specific Antigen

24. What Are the Possible Diagnoses You Are Considering for George?

25. Possible Diagnoses for George
Case 1: George
Possible Diagnoses for George
Benign Prostatic Hyperplasia (BPH)
Urethral stricture
Bladder calculus
Overactive bladder
Bladder neck hypertrophy
Urinary Infection
Prostatitis
Prostate cancer
Sexually Transmitted Disease (STD)
Understanding BPH From the Science to the Clinical Setting

26. What is the Most Likely Diagnosis for George?

27. Diagnosis:
Urethral stricture

28. What Would Be Your Management Strategy for George?

29. Management Strategy
Because of his younger age, normal prostate size and history of urethritis, George's symptoms of LUTS require further evaluation.
Urethral stricture is suspected, and George is referred to a urologist.
LUTS = Lower Urinary Tract Symptoms

30. Urologist Consultation Letter
George sees the urologist and after several months returns to his family
physician providing this letter from the urologist:
Dear Doctor:
An evaluation of the prostate was carried out with prostatic massage and examination of the prostatic fluid.
The results showed no evidence of prostatitis
A urinary flow and post void bladder scan confirmed urethral obstruction with a Qmax of 8 ml/sec (N > 15) with residual urine (R.U.) of 150 ml.
A cystoscopy confirmed a bulbo-urethral stricture which was incised endoscopically.

31. Urologist Consultation Letter (Cont).
The patient should return to the urologist for follow-up including a repeat flow and bladder scan in 6 months.

32. Long Term Management
How would you manage George in the long term?

33. Long Term Management
Monitor his symptoms closely (every 6 months for next 2 years).
If his stream subjectively deteriorates or patient has other voiding symptoms he should have ultrasound residual and be referred back to urologist.
DRE and PSA should be monitored as usual for his age.
DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen

34. Long Term Management
What additional information should the specialist provide the family physician?

35. Long Term Management Urethral stricture can recur
Refer to previous recommendations

36. Long Term Management
What would you do if George developed hematuria?

37. Long Term Management
Would require standard workup for gross hematuria including:
History
Physical Exam
Urinalysis
Culture
Cytology
Upper Tract Studies
Referral to Urologist for Cystoscopy

38. End of Case 1