1. MODULE 5 1/46 Case 2: Troy

2. MODULE 5 Case 2: Troy 2/46 Patient History  Troy is a 59 year old retired school teacher who comes to you for his annual physical  He is overweight and during routine questioning, you ask Troy if he has any urinary problems  Troy says his body is not what it used to be and now that you mention it, he has been meaning to ask about the frequency of his urination, which seems a bit abnormal, but maybe its just part of getting old!

3. MODULE 5 Case 2: Troy 3/46 What Questions Do You Have About Troy’s History?

4. MODULE 5 Case 2: Troy 4/46 1.What is the frequency of your urination per day? 2.How many times are you up to void at night? 3.Have you experienced any recent weight gain? 4.Do you have a family history of diabetes? 5.Is your stream strong and forceful? 6.Is there is any blood in your urine? 7.Do you have any problems with your erections, interest in sex, ejaculation? 8.Do you have the urgent need to void? Are you able to empty your bladder well? 9.Ask questions pertaining to signs of infection  i.e. Burning sensation when voiding Possible Questions

5. MODULE 5 Case 2: Troy 5/46 Troy’s Response  Troy reports he has to void 2 to 4 times per night, as well as sporadic lower back pain, especially when driving  He thinks the problem is aggravated by red meat consumption and caffeine intake (he still is in the habit of drinking 2 to 3 cups of coffee a day)  He thinks the problem started a while ago, but he has really noticed it over the past 6 months

6. MODULE 5 Case 2: Troy 6/46 Obstructive Symptoms of LUTS  Further questioning of Troy reveals obstructive symptoms of LUTS, including a weak stream and a sensation of incomplete voiding  In addition, Troy has some urinary frequency and urgency  When asked about physical activity, Troy says he doesn’t do much and even though he feels he needs to go on a diet, he hasn’t had much luck losing weight since he quit smoking 15 years ago LUTS = Lower Urinary Tract Symptoms

7. MODULE 5 Case 2: Troy 7/46 How Would You Assess the Impact of Troy’s Urinary Problems on his Quality of Life?

8. MODULE 5 Case 2: Troy 8/46 Use of Questionnaires: 1.IPSS (or AUA symptom score) 2.Quality of life question IPSS = International Prostate Symptom Score AUA = American Urological Association

9. MODULE 5 Case 2: Troy 9/46 Discussion  The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of Troy  You ask him to complete the forms before proceeding  Here are Troy’s scores: International Prostate Symptom Score (IPSS) Patient name: Troy DOB: 05/05/46 ID: 0019-0022 Date of assessment: 29/06/05 Initial assessment (X) Monitor: during __X__ therapyafter _____therapy/surgery

10. MODULE 5 Case 2: Troy 10/46 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 Troy’s Results 1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0123453 2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0123454 3. Over the past month, how often have you found you stopped and started again several times when you urinated? 0123451 4. Over the past month, how often have you found it difficult to postpone urinating? 0123454

11. MODULE 5 Case 2: Troy 11/46 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 Troy’s Results 5. Over the past month, how often have you had a weak urinary stream? 0123452 6. Over the past month, how often have you had to push or strain to begin urinating? 0123451 None1 time2 times3 times4 times 5 or more times Troy’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? 0123452 Total IPSS Score = 17

12. MODULE 5 Case 2: Troy 12/46 Troy’s QoL Score = 4 (Mostly Dissatisfied) 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

13. MODULE 5 Case 2: Troy 13/46 How Do You Interpret the Severity and Bother Associated with Troy’s Symptoms?

14. MODULE 5 Case 2: Troy 14/46 Interpreting the IPSS and Bother Score IPSS Values Indicate Symptom Severity: Mild score: ≤ 7 Moderate score: 8-19 Severe score: ≥ 20 Troy’s IPSS = 17 (moderate symptoms) Troy’s Bother Score = 4 (mostly dissatisfied) IPSS = International Prostate Symptom Score

15. MODULE 5 Case 2: Troy 15/46 Discussion  The IPSS revealed a score of 17  This is a score of moderate severity and perhaps explains why Troy has been somewhat reluctant to seek treatment  He scores a 4 on the quality of life question, being mostly dissatisfied with his condition IPSS = International Prostate Symptom Score

16. MODULE 5 Case 2: Troy 16/46 What Physical Examinations Would You Undertake on Troy?

17. MODULE 5 Case 2: Troy 17/46 Recommended Examinations: 1.Abdominal exam 2.Genital exam 3.DRE DRE = Digital Rectal Examination

18. MODULE 5 Case 2: Troy 18/46 Physical Examination Results Height5 ft 6" Weight100 kg (220 lb) Blood Pressure122/80 mmHg Abdominal ExamNormal Genital ExamNormal DRE: - Anus & Rectal Ampulla -Prostate - Normal - Moderately enlarged, firm and smooth but has no nodules DRE = Digital Rectal Examination

19. MODULE 5 Case 2: Troy 19/46 What Are the Possible Diagnoses You Are Considering for Troy?

20. MODULE 5 Case 2: Troy 20/46 Possible Diagnoses 1.BPH 2.Prostate cancer 3.Prostatitis 4.Diabetes 5.Neurogenic bladder 6.Bladder outlet obstruction 7.Urethral stricture 8.Urinary tract infection 9.Bladder cancer 10.Bladder stone BPH = Benign Prostatic Hyperplasia

21. MODULE 5 Case 2: Troy 21/46 What Investigations Might You Consider for Troy at this Stage?

22. MODULE 5 Case 2: Troy 22/46 Lab tests:Urinalysis: no abnormal findings Serum creatinine: 72 μmol/L PSA: 1.8 ng/mL Blood/Glucose: normal Midstream urine for C & S (culture and sensitivity): normal Lab Results PSA = Prostate-Specific Antigen

23. MODULE 5 Case 2: Troy 23/46 Discussion of Lab Results  Troy appears to have moderate symptoms of BPH  Urinalysis shows no evidence of pyuria or bacteria, ruling out infectious syndromes  The serum creatinine is also normal  Troy’s PSA level is normal BPH = Benign Prostatic Hyperplasia PSA = Prostate-Specific Antigen

24. MODULE 5 Case 2: Troy 24/46 What is the Most Likely Diagnosis for Troy?

25. MODULE 5 Case 2: Troy 25/46 Diagnosis  On the basis of the normal lab results, his symptoms, and the smooth, firm enlargement of his prostate, Troy is diagnosed with BPH  Before any treatment strategies are initiated Troy is counseled about this diagnosis  He is reassured that it is a benign disease but that it may progress, or symptoms may stay the same or improve  Surgery is not recommended to Troy Diagnosis:BPH BPH = Benign Prostatic Hyperplasia

26. MODULE 5 Case 2: Troy 26/46 What Would be Your Management Strategy for Troy?

27. MODULE 5 Case 2: Troy 27/46 Management Strategy  Troy is offered the options of either watchful waiting or pharmacological treatment  Troy elects pharmacologic treatment:  Troy is prescribed combination therapy with a 5α–reductase inhibitor and an α 1 -blocker  This combination should relieve the obstructive symptoms, as well as shrink his prostate  A moderate exercise regime is recommended for Troy, as well as cutting back on his red meat and caffeine intake  Troy says he is relieved to know that his problem is not likely to be related to cancer because he has a friend who recently died from that disease

28. MODULE 5 Case 2: Troy 28/46 Note:  Combination therapy results in more symptom amelioration than either medication alone  In addition it has the best possibility of preventing BPH progression (prevents future deterioration of symptoms, acute urinary retention and eventual surgery) Troy’s TreatmentRationale Combination Therapy: 1.5α – reductase inhibitor AND 2.α 1 - blocker Shrink the gland AND Relieve the obstructive symptoms Treatment Strategy BPH = Benign Prostatic Hyperplasia

29. MODULE 5 Case 2: Troy 29/46 Discussion  α 1 -blockers work quickly to reduce symptoms while 5α-reductase inhibitors slowly reduce the size of the prostate and eventually reduce symptoms  It is the reduction in size of the prostate and prevention of growth that results in prevention of BPH progression BPH = Benign Prostatic Hyperplasia

30. MODULE 5 Case 2: Troy 30/46 When Would You Expect Troy’s Treatment Options to Show Some Effect?

31. MODULE 5 Case 2: Troy 31/46 Time to Effect Time to take effect: α 1 -blocker: a few days – 1 week 5α-reductase inhibitor : up to six months

32. MODULE 5 Case 2: Troy 32/46 Troy Asks About Phytotherapy for BPH. What Do You Tell Him? BPH = Benign Prostatic Hyperplasia

33. MODULE 5 Case 2: Troy 33/46 Would You Do Anything Different if Troy had High Blood Pressure and was Taking Antihypertensive Medication?

34. MODULE 5 Case 2: Troy 34/46 Discussion Regarding Thiazide Diuretics  If Troy was taking a thiazide diuretic:  Non-selective α 1 - blockers, such as terazosin and doxazosin, may cause postural hypotension in patients already receiving antihypertensives  Non selective α 1 - blockers are no longer indicated as first line agents for the treatment of hypertension because of adverse outcomes (see Canadian Hypertension Guidelines - http://www.hypertension.ca)  Non-selective α 1 - blockers by themselves are not a good choice for monotherapy to treat BPH and hypertension  The selective α 1 - blockers, tamsulosin and alfuzosin do not tend to cause clinically significant hypotension and can be used in conjunction with thiazide diuretics BPH = Benign Prostatic Hyperplasia

35. MODULE 5 Case 2: Troy 35/46 What Would Be Your Follow-up Strategy For Troy?

36. MODULE 5 Case 2: Troy 36/46 Follow-up Strategy  Following your instructions, Troy will make sure he requests an IPSS and QoL questionnaire from the receptionist each time he arrives for his follow up appointments  He will come about 10 minutes early for his appointment so he can fill it out in the waiting room before he sees you IPSS = International Prostate Symptom Score QoL = Quality of Life

37. MODULE 5 Case 2: Troy 37/46 Follow-up Appointments for Troy What Would your Likely Course of Action be at Each Visit?

38. MODULE 5 Case 2: Troy 38/46 Follow-up Appointments for Troy 2 weeks  If a non-selective agent has been chosen the dose must be titrated upward balancing effectiveness against hypotension  Selective α 1 -blockers do not need titration and we might expect some improvement of symptoms at this stage  Maintain the 5α-reductase inhibitor 4-6 weeks  Troy reports mild relief of his urinary symptoms  The dose of selective α 1 -blocker is maintained  The dose of the non-selective α 1 -blocker may need to be titrated depending on his extent of symptom relief  Maintain the 5α-reductase inhibitor 3 months  Moderate symptom relief is reported  The dose of non-selective or selective α 1 -blockers is maintained  Maintain the 5α-reductase inhibitor

39. MODULE 5 Case 2: Troy 39/46 6 months  He reports moderate relief of irritative and obstructive symptoms  His score on the IPSS has dropped from 17 to 12  He answers 3 to the quality of life question (less bother)  The dose of α 1 -blocker is maintained  Maintain the 5α-reductase inhibitor 9 months  If Troy’s 6 month visit is promising, this visit can be skipped  Monitor Troy’s urinary symptoms  The dose of α 1 -blocker is maintained  Maintain the 5α-reductase inhibitor IPSS = International Prostate Symptom Score

40. MODULE 5 Case 2: Troy 40/46 Discussion  What do you expect Troy’s PSA value to be at 12 months?  How frequently would you perform the DRE?  What examinations and tests would you perform at 1 year?  When, if ever, would you consider changing his therapy? PSA = Prostate-Specific Antigen DRE = Digital Rectal Examination

41. MODULE 5 Case 2: Troy 41/46 12 months  Troy’s IPSS is now 10 and he has greatly improved  His quality of life has improved (no bother)  Perform a physical exam including DRE, urinalysis, and PSA, and serum creatinine is optional  The dose of α 1 -blocker is maintained  Maintain the 5α-reductase inhibitor  His PSA is 0.8ng/ml  DRE: Normal 1 - 2 years  An option is to remove Troy from the α 1 -blocker and see if he still requires it for symptom relief  Maintain the 5α-reductase inhibitor Yearly follow-ups  Unless Troy experiences increased severity of symptoms, a yearly DRE and PSA is recommended as well as IPSS and QoL  Note: Troy’s DRE is normal and his PSA levels have reduced and there is no need to refer him to a urologist IPSS = International Prostate Symptom Score PSA = Prostate-Specific Antigen DRE = Digital Rectal Examination QoL = Quality of Life

42. MODULE 5 Case 2: Troy 42/46 Long Term Management  How would you manage Troy after 2 or 3 years if he no longer has any bothersome symptoms based on his IPSS and QoL? IPSS = International Prostate Symptom Score QoL = Quality of Life

43. MODULE 5 Case 2: Troy 43/46 Long Term Management  Consider stopping the α 1 -blocker and see if he still needs it.  Continue to monitor DRE and PSA as usual routine. DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen

44. MODULE 5 Case 2: Troy 44/46 Long Term Management  What kind of lifestyle options would you counsel Troy on, to help with his symptoms?

45. MODULE 5 Case 2: Troy 45/46 Long Term Management  If he wants to take multivitamins, consider vitamin E and selenium and perhaps lycopenes since they may be shown in future studies to be important for prevention of prostate cancer.  He no longer has any bothersome symptoms so no direct advice other than:  Good diet  Exercise  Avoidance of anything that causes recurrence of his symptoms

46. MODULE 5 Case 2: Troy 46/46 End of Case 2