Presentation on theme: "Case 7:John Case 7: John Understanding BPH From the Science to the Clinical Setting."— Presentation transcript:
1Case 7:JohnCase 7: JohnUnderstanding BPH From the Science to the Clinical Setting
2Patient 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
4Some Possible Questions for John Has your urine stream changed?Do you have to get up at night to urinate?Does it burn when you urinate?Have you had a fever?Has there been any blood in your urine?Questions around irritative and obstructive symptomsQuestions examining possibility of diabetesHow much do your symptoms bother you?Is there any history of prostate cancer in your family?
5John’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.
6In Your Practice, How Would You Determine the Severity of John’s Symptoms at this Stage?
7Use of Questionnaires: IPSS (or AUA symptom score) Quality of life questionIPSS = International Prostate Symptom Score AUA = American Urological Association
8International Prostate Symptom Score (IPSS) Case 7:JohnDiscussionThe IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of JohnYou ask him to complete the forms before proceedingHere are John’s scores:International Prostate Symptom Score (IPSS)Patient name: JohnDOB: 05/05/41ID:Date of assessment: 29/06/05Initial assessment (X)Monitor: during __X__ therapy after _____therapy/surgeryUnderstanding BPH From the Science to the Clinical Setting
9International Prostate Symptom Score Case 7:JohnInternational Prostate Symptom ScoreNot at allLess than 1 timein 5Less than half the timeAbout half the timeMore than half the timeAlmost alwaysJohn’s Results1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?123452. 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
10Total IPSS Score = 22 Case 7:John Not at all Less than 1 time in 5 Less than half the timeAbout half the timeMore than half the timeAlmost alwaysJohn’s Results5. Over the past month, how often have you had a weak urinary stream?123456. Over the past month, how often have you had to push or strain to begin urinating?None1 time2 times3 times4 times5 or more times7. 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 = 22Understanding BPH From the Science to the Clinical Setting
11Quality of Life Due to Urinary Symptoms DelightedPleasedMostly SatisfiedMixed about equally satisfied and dissatisfiedMostly dissatisfiedUnhappyTerrible1. 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?123456John’s Bother Score = 3 (mixed bother)
12How Do You Interpret the Severity and Bother of John’s Symptoms? Case 7:JohnHow Do You Interpret the Severity and Bother of John’s Symptoms?Understanding BPH From the Science to the Clinical Setting
19Management StrategyJohn’s mixed bother and high IPSS are indications of a need for further evaluationFurthermore, his elevated PSA level of 2.5 ng/mL, while not extremely high, warrants referral to a urologist.IPSS = International Prostate Symptom Score PSA = Prostate-Specific Antigen
20Urologist FeedbackJohn’s prostate size measurement via DRE is critical for monitoring his conditionMeasurements (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
21Long Term Follow-upJohn is placed on combination therapy of a 5α-reductase inhibitor and an α1-blockerThe PSA is expected to decrease by approximately 50% in the first months and then not rise appreciably while on 5α-reductase inhibitor.He is monitored annually via DRE and PSADRE = Digital Rectal Examination PSA = Prostate-Specific Antigen
22Long Term Follow-upIs there anything else the GP should do or discuss with this patient, besides annual monitoring of DRE and PSA?DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen
23Long Term Follow-upThis 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.PSA = Prostate-Specific Antigen