1. MODULE 5 1/23 Case 9: Pierre

2. MODULE 5 Case 9: Pierre 2/23 Patient History  Pierre is 65 years of age who has suffered with benign prostatic hyperplasia (BPH) for 10 years.  At his last GP visit almost a year ago, his IPSS score was 21 and he reported mixed satisfaction/dissatisfaction with his QoL related to urinary condition.  Today Pierre has made an urgent request to see his GP and presents with symptoms of severe LUTS. He has just filled his IPSS and QoL and is quite distressed. IPSS = International Prostate Symptom Score QoL = Quality of Life LUTS = Lower Urinary Tract Symptoms

3. MODULE 5 3/23 What Typical Questions Do You Have for Pierre?

4. MODULE 5 Case 9: Pierre 4/23 Some Possible Questions for Pierre 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. Do you have post void dribbling or incontinence? 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? 10. Specific questions about erectile dysfunction

5. MODULE 5 Case 9: Pierre 5/23 Pierre’s Response  Pierre has previously been treated with α 1 -blocker therapy to which he has ceased to respond. He has been switched to a 5α-reductase inhibitor therapy in the last 3 years.  Because Pierre’s treatment options have been optimized and the BPH progression is still having a profoundly negative effect on his quality of life, Pierre is referred to his urologist for urgent consultation. BPH = Benign Prostatic Hyperplasia

6. MODULE 5 Case 9: Pierre 6/23 Use of Questionnaires: 1.IPSS (or AUA symptom score) 2.Quality of life question IPSS = International Prostate Symptom Score AUA = American Urological Association

7. MODULE 5 Case 9: Pierre 7/23 Discussion  The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of Pierre  You ask him to complete the forms before proceeding  Here are Pierre’s scores: International Prostate Symptom Score (IPSS) Patient name: Pierre DOB: 05/05/40 ID: 0019-0029 Date of assessment: 29/06/05 Initial assessment (X) Monitor: during __X__ therapyafter _____therapy/surgery

8. MODULE 5 Case 9: Pierre 8/23 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 Pierre’s Results 1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0123455 2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0123453 3. Over the past month, how often have you found you stopped and started again several times when you urinated? 0123455 4. Over the past month, how often have you found it difficult to postpone urinating? 0123453

9. MODULE 5 Case 9: Pierre 9/23 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 Pierre’s Results 5. Over the past month, how often have you had a weak urinary stream? 0123454 6. Over the past month, how often have you had to push or strain to begin urinating? 0123455 None1 time2 times3 times4 times 5 or more times Pierre’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? 0123455 Total IPSS Score = 30

10. MODULE 5 Case 9: Pierre 10/23 Pierre’s Bother Score = 6 (terrible) 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? 0123456

11. MODULE 5 Case 9: Pierre 11/23 How Do You Interpret the Severity and Bother of Pierre’s Symptoms?

12. MODULE 5 Case 9: Pierre 12/23 Interpreting the IPSS and Bother Score IPSS Values Indicate Symptom Severity: Mild score: ≤ 7 Moderate score: 8-19 Severe score: ≥ 20 Pierre’s IPSS = 30 (severe symptoms) IPSS = International Prostate Symptom Score Pierre’s Bother Score = 6 (terrible)

13. MODULE 5 Case 9: Pierre 13/23 What Physical Examinations Do You Undertake on Pierre?

14. MODULE 5 Case 9: Pierre 14/23 Physical Examination Height6 ft 0” Weight72 kg (158 lb) Blood Pressure128/82 mmHg PulseNormal Temperature36.5°C General appearanceHe appears pale, underweight and fatigued Abdominal Exam His bladder is palpable No renal angle tenderness on both sides Genital ExamNo abnormal findings DRE: - Anus and rectal ampulla -Prostate -Normal -Markedly enlarged, firm and smooth DRE = Digital Rectal Examination

15. MODULE 5 Case 9: Pierre 15/23 Possible Diagnoses for Pierre 1.Severe BPH 2.Acute urinary retention 3.Concomitant prostate cancer 4.Prostatitis BPH = Benign Prostatic Hyperplasia

16. MODULE 5 Case 9: Pierre 16/23 Referral to Urologist  Because he has failed medical therapy with both α 1 -blockers and 5-ARIs, Pierre is a possible candidate for surgery  Pierre is referred to his urologist ARI = Alpha Reductase Inhibitor

17. MODULE 5 Case 9: Pierre 17/23 Urologist Consult Letter Dear Doctor, Pierre was referred to me for his severe BPH, after several years of medical treatment with both 5-ARIs and α 1 -blockers. He had a PSA of 2.5 ng/mL, a large benign prostate, and a residual urine of 280 mL. On cystoscopy, he had trilobar obstructive hyperplasia with bladder evidence of long standing outlet obstruction. He was subsequently treated with TURP and his symptoms have now subsided. He reports no more nocturia and is generally quite happy with the procedure. His pathology was benign. Pierre should resume his regular annual checkups and be monitored for any future LUTS. BPH = Benign Prostatic Hyperplasia ARI = Alpha Reductase Inhibitor PSA = Prostate-Specific Antigen TURP = Transurethral Resection of the Prostate LUTS = Lower Urinary Tract Symptoms

18. MODULE 5 Case 9: Pierre 18/23 Long Term Follow-up  Discussion of risk of TURP surgery  Specialist perspective  Family Physician perspective  Let patient know that he still have to be monitored for prostate cancer even though he has had a TURP TURP = Transurethral Resection of the Prostate

19. MODULE 5 Case 9: Pierre 19/23 Long Term Follow-up  What are the key issues for the GP in terms of long term management of this patient?

20. MODULE 5 Case 9: Pierre 20/23 Long Term Follow-up  Approximately 20% of patients with a successful TURP will have recurrence of symptoms over the next decade secondary to regrowth of prostate, development of prostate cancer, development of urethral or bladder neck stricture or development of aging hypotonic bladder.  The GP can follow-up by monitoring symptoms (and PSA if indicated based on age and co-morbidities or because of recurrence of symptoms, change in DRE etc) TURP = Transurethral Resection of the Prostate DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen

21. MODULE 5 Case 9: Pierre 21/23 Long Term Follow-up  Should the patient still be monitored for prostate cancer?

22. MODULE 5 Case 9: Pierre 22/23 Long Term Follow-up  If the urologist states that pathology was negative for cancer at the time of TURP, the GP must continue to monitor for future development of prostate cancer with DRE and PSA as per the usual standard routine (based on age and co- morbities). TURP = Transurethral Resection of the Prostate DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen

23. MODULE 5 Case 9: Pierre 23/23 End of Case 9