MODULE 5 1/46 Case 2: Troy. MODULE 5 Case 2: Troy 2/46 Patient History Troy is a 59 year old...

MODULE 5

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Case 2: Troy

MODULE 5Case 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!


3/46

What Questions Do You Have About Troy’s History?


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


5/46

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


6/46

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


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How Would You Assess the Impact of Troy’s Urinary Problems on his Quality of Life?


8/46

Use of Questionnaires:

1. IPSS (or AUA symptom score)2. Quality of life question

IPSS = International Prostate Symptom ScoreAUA = American Urological Association


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__ therapy after _____therapy/surgery


10/46

International Prostate Symptom Score

Not at all

Less than 1 timein 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?

0 1 2 3 4 5 3

2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

0 1 2 3 4 5 4

3. Over the past month, how often have you found you stopped and started again several times when you urinated?

0 1 2 3 4 5 1

4. Over the past month, how often have you found it difficult to postpone urinating?

0 1 2 3 4 5 4


11/46

Not at all

Less than 1 timein 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?

0 1 2 3 4 5 2

6. Over the past month, how often have you had to push or strain to begin urinating?

0 1 2 3 4 5 1

None 1 time 2 times 3 times 4 times5 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?

0 1 2 3 4 5 2

Total IPSS Score = 17


12/46

Troy’s QoL Score = 4 (Mostly Dissatisfied)

Quality of Life Due to Urinary Symptoms

Delighted PleasedMostly

Satisfied

Mixed about equally

satisfied and dissatisfied

Mostly dissatis-

fiedUnhappy Terrible

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?

0 1 2 3 4 5 6


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How Do You Interpret the Severity and Bother Associated with Troy’s Symptoms?


14/46

Interpreting the IPSS and Bother Score

IPSS Values Indicate Symptom Severity:

Mild score: ≤ 7Moderate score: 8-19Severe score: ≥ 20

• Troy’s IPSS = 17 (moderate symptoms)

• Troy’s Bother Score = 4 (mostly dissatisfied)

IPSS = International Prostate Symptom Score


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



16/46

What Physical Examinations Would You Undertake on Troy?


17/46

Recommended

Examinations:

1. Abdominal exam

2. Genital exam

3. DRE

DRE = Digital Rectal Examination


18/46

Physical Examination Results

Height 5 ft 6"

Weight 100 kg (220 lb)

Blood Pressure 122/80 mmHg

Abdominal Exam Normal

Genital Exam Normal

DRE:- Anus & Rectal Ampulla- Prostate

- Normal

- Moderately enlarged, firm and smooth but has no nodules

DRE = Digital Rectal Examination


19/46

What Are the Possible Diagnoses You Are Considering for 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


21/46

What Investigations Might You Consider for Troy at this Stage?


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


23/46

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 HyperplasiaPSA = Prostate-Specific Antigen


24/46

What is the Most Likely Diagnosis for 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



26/46

What Would be Your Management Strategy for 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 α1-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


28/46

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 Treatment Rationale

Combination Therapy:

1. 5α – reductase inhibitor

AND

2. α1- blocker

Shrink the gland

AND

Relieve theobstructive symptoms

Treatment Strategy



29/46

Discussion

α1-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



30/46

When Would You Expect Troy’s Treatment Options to Show Some Effect?


31/46

Time to Effect

Time to take effect: α1-blocker: a few days – 1 week

5α-reductase inhibitor : up to six months


32/46

Troy Asks About Phytotherapy for BPH. What Do You Tell Him?



33/46

Would You Do Anything Different if Troy had High Blood Pressure and was Taking

Antihypertensive Medication?


34/46

Discussion Regarding Thiazide Diuretics

If Troy was taking a thiazide diuretic:

Non-selective α1- blockers, such as terazosin and doxazosin, may cause postural hypotension in patients already receiving antihypertensives

Non selective α1- 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 α1- blockers by themselves are not a good choice for monotherapy to treat BPH and hypertension

The selective α1- blockers, tamsulosin and alfuzosin do not tend to cause clinically significant hypotension and can be used in conjunction with thiazide diuretics



35/46

What Would Be Your Follow-up Strategy For 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 ScoreQoL = Quality of Life


37/46

Follow-up Appointments for Troy

What Would your Likely Course of Action be at Each Visit?


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 α1-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 α1-blocker is maintained The dose of the non-selective α1-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 α1-blockers is maintained Maintain the 5α-reductase inhibitor


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 α1-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 α1-blocker is maintained Maintain the 5α-reductase inhibitor



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 AntigenDRE = Digital Rectal Examination


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 α1-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 α1-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 ScorePSA = Prostate-Specific AntigenDRE = Digital Rectal ExaminationQoL = Quality of Life


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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 ScoreQoL = Quality of Life


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Consider stopping the α1-blocker and see if he still needs it.

Continue to monitor DRE and PSA as usual routine.

DRE = Digital Rectal ExaminationPSA = Prostate-Specific Antigen


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What kind of lifestyle options would you counsel Troy on, to help with his symptoms?


45/46


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


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End of Case 2

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MODULE 5 1/46 Case 2: Troy. MODULE 5 Case 2: Troy 2/46 Patient History Troy is a 59 year old...

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