Presentation on theme: "Case 1: George Case 1: George"— Presentation transcript:
1 Case 1: George Case 1: George Understanding BPH From the Science to the Clinical Setting
2 Patient HistoryGeorge 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.
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 diabetesIs 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: GeorgeIn 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 questionIPSS = International Prostate Symptom Score AUA = American Urological Association
10 Results of George’s IPSS & QoL Question Case 1: GeorgeResults of George’s IPSS & QoL QuestionTo 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: GeorgeDOB: 30/11/55ID:Date of assessment: 04/12/05Initial assessment (X)Monitor: during __X__ therapy after _____therapy/surgeryUnderstanding BPH From the Science to the Clinical Setting
11 International Prostate Symptom Score Case 1: GeorgeInternational Prostate Symptom ScoreNot at allLess than 1 timein 5Less than half the timeAbout half the timeMore than half the timeAlmost alwaysGeorge’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
12 Total IPSS Score = 14 Not at all Less than 1 time in 5 Less than half the timeAbout half the timeMore than half the timeAlmost alwaysGeorge’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 = 14
13 Quality of Life Due to Urinary Symptoms DelightedPleasedMostly SatisfiedMixed about equally satisfied and dissatisfiedMostly dissatis-fiedUnhappyTerrible1. 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?123456George’s Bother Score = 5 (unhappy)
14 How Do You Interpret the Severity and Bother Associated with George’s Symptoms?
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 pressureDRE = Digital Rectal Examination
20 Results of the Physical Exam On physical examination, George appears healthy.Here are George’s results & findings of interest:Height5 ft 7"Weight68 kg (150 lb)Blood Pressure120/80 mmHgAbdominal ExamNegativeGenital ExamDRE:Anus and rectal ampullaProstate- Normal- Feels normalDRE = 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: negativeUrethral swab: negativeSerum 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: GeorgePossible Diagnoses for GeorgeBenign Prostatic Hyperplasia (BPH)Urethral strictureBladder calculusOveractive bladderBladder neck hypertrophyUrinary InfectionProstatitisProstate cancerSexually Transmitted Disease (STD)Understanding BPH From the Science to the Clinical Setting
28 What Would Be Your Management Strategy for George?
29 Management StrategyBecause 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 familyphysician 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 prostatitisA 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 ManagementHow would you manage George in the long term?
33 Long Term ManagementMonitor 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 ManagementWhat additional information should the specialist provide the family physician?
35 Long Term Management Urethral stricture can recur Refer to previous recommendations
36 Long Term ManagementWhat would you do if George developed hematuria?
37 Long Term ManagementWould require standard workup for gross hematuria including:HistoryPhysical ExamUrinalysisCultureCytologyUpper Tract StudiesReferral to Urologist for Cystoscopy