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MODULE 5 1/38 Case 1: George. MODULE 5 Case 1: George 2/38 Patient History  George is a 50 year old computer engineer and works in a busy software development.

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Presentation on theme: "MODULE 5 1/38 Case 1: George. MODULE 5 Case 1: George 2/38 Patient History  George is a 50 year old computer engineer and works in a busy software development."— Presentation transcript:

1 MODULE 5 1/38 Case 1: George

2 MODULE 5 Case 1: George 2/38 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 MODULE 5 Case 1: George 3/38 What Typical Questions Do You Have for George?

4 MODULE 5 Case 1: George 4/38 1.Has your urine stream changed? 2.Do you think your are emptying your bladder? 3.Do you have to get up at night to urinate? How many times? 4.Do you have urinary frequency? Urgency void? 5.Do you have post void dribbling? 6.Does it burn when you urinate? 7.Has there been any blood in your urine? 8.Do your symptoms bother you? 9.Questions examining possibility of diabetes 10.Is there any history of prostate cancer in your family? Some Possible Questions for George

5 MODULE 5 Case 1: George 5/38 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 MODULE 5 Case 1: George 6/38 What Other Questions Will You Have for George at this Stage?

7 MODULE 5 Case 1: George 7/38  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. Possible Questions for George

8 MODULE 5 Case 1: George 8/38 In Your Practice, How Would You Determine the Severity of George’s Symptoms at this Stage?

9 MODULE 5 Case 1: George 9/38 Use of Questionnaires: 1.IPSS (or AUA symptom score) 2.Quality of life question IPSS = International Prostate Symptom Score AUA = American Urological Association

10 MODULE 5 Case 1: George 10/38 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__ therapyafter _____therapy/surgery

11 MODULE 5 Case 1: George 11/38 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? Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Over the past month, how often have you found you stopped and started again several times when you urinated? Over the past month, how often have you found it difficult to postpone urinating?

12 MODULE 5 Case 1: George 12/38 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? Over the past month, how often have you had to push or strain to begin urinating? None1 time2 times3 times4 times 5 or more times George’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? Total IPSS Score = 14

13 MODULE 5 Case 1: George 13/38 George’s Bother Score = 5 (unhappy) Quality of Life Due to Urinary Symptoms DelightedPleased Mostly Satisfied Mixed about equally satisfied and dissatisfied Mostly dissatis- fied UnhappyTerrible 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?

14 MODULE 5 Case 1: George 14/38 How Do You Interpret the Severity and Bother Associated with George’s Symptoms?

15 MODULE 5 Case 1: George 15/38 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 MODULE 5 Case 1: George 16/38 How Does George’s Age of 50 Years Factor Into Your Diagnosis?

17 MODULE 5 Case 1: George 17/38 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 MODULE 5 Case 1: George 18/38 What Kind of Physical Exam Would You Perform on George?

19 MODULE 5 Case 1: George 19/38 Recommended Examinations: 1.Abdominal exam 2.Genital exam 3.DRE 4.Blood pressure DRE = Digital Rectal Examination

20 MODULE 5 Case 1: George 20/38 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 mmHg Abdominal ExamNegative Genital ExamNegative DRE: -Anus and rectal ampulla -Prostate - Normal - Feels normal DRE = Digital Rectal Examination

21 MODULE 5 Case 1: George 21/38 What Investigations Might You Consider for George at this Stage of the Consult?

22 MODULE 5 Case 1: George 22/38 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) Lab Results PSA = Prostate-Specific Antigen

23 MODULE 5 Case 1: George 23/38 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 MODULE 5 Case 1: George 24/38 What Are the Possible Diagnoses You Are Considering for George?

25 MODULE 5 Case 1: George 25/38 Possible Diagnoses for George 1.Benign Prostatic Hyperplasia (BPH) 2.Urethral stricture 3.Bladder calculus 4.Overactive bladder 5.Bladder neck hypertrophy 6.Urinary Infection 7.Prostatitis 8.Prostate cancer 9.Sexually Transmitted Disease (STD)

26 MODULE 5 Case 1: George 26/38 What is the Most Likely Diagnosis for George?

27 MODULE 5 Case 1: George 27/38 Diagnosis:Urethral stricture

28 MODULE 5 Case 1: George 28/38 What Would Be Your Management Strategy for George?

29 MODULE 5 Case 1: George 29/38 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 MODULE 5 Case 1: George 30/38 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 MODULE 5 Case 1: George 31/38 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 MODULE 5 Case 1: George 32/38 Long Term Management  How would you manage George in the long term?

33 MODULE 5 Case 1: George 33/38 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 MODULE 5 Case 1: George 34/38 Long Term Management  What additional information should the specialist provide the family physician?

35 MODULE 5 Case 1: George 35/38 Long Term Management  Urethral stricture can recur  Refer to previous recommendations

36 MODULE 5 Case 1: George 36/38 Long Term Management  What would you do if George developed hematuria?

37 MODULE 5 Case 1: George 37/38 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 MODULE 5 Case 1: George 38/38 End of Case 1


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