Case 6: Anthony

1. Case 6: Anthony

2. Patient History • Anthony is a 55-year old lawyer. • He has been suffering from voiding complaints for several years, and for the past 5 years he has been treated with an α1-blocker for BPH. • Anthony recently experienced a urinary infection requiring antibiotics. BPH = Benign Prostatic Hyperplasia

3. What Typical Questions Do You Have for Anthony?

4. Some Possible Questions for Anthony

5. Anthony’s response • Anthony says he is definitely getting worse • His nocturia is increased as well as day time voiding frequency • He is worried about prostate cancer, but there is no history of it in his family, to his knowledge • He is otherwise healthy and tries to exercise regularly

6. In Your Practice, How Would You Determine the Severity of Anthony’s Symptoms at this Stage?

7. IPSS = International Prostate Symptom ScoreAUA = American Urological Association

8. Discussion • The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of Anthony • You ask him to complete the forms before proceeding • Here are Anthony’s scores: International Prostate Symptom Score (IPSS) Patient name: Anthony DOB: 05/05/50 ID: 0019-0026 Date of assessment: 29/06/05 Initial assessment (X) Monitor: during __X__ therapy after _____therapy/surgery

10. Total IPSS Score = 29

11. Anthony’s QoL Score = 6 (Terrible)

12. How Do You Interpret the Severity and Bother of Anthony’s Symptoms?

13. Interpreting the IPSS and Bother Score • Anthony’s IPSS = 29 (severe symptoms) • Anthony’s Bother Score = 6 (terrible) IPSS = International Prostate Symptom Score

14. What Kind of Physical Exam Would You Perform on Anthony?

15. DRE = Digital Rectal Examination

16. Results of the Physical Exam • On physical examination, Anthony appears healthy DRE = Digital Rectal Examination

17. What Investigations Might You Consider for Anthony at this Stage?

18. Lab Results Lab tests: Urinalysis: no abnormal findings PSA: 3.6 ng/mL Blood/Glucose: negative Urethral swab: negative PSA = Prostate-Specific Antigen

19. What Are the Possible Diagnoses You Are Considering for Anthony?

20. Possible Diagnoses for Anthony

21. Management Strategy • Anthony’s severe bother (QoL = 6) and high IPSS of 29 are indications of a need for further evaluation • Furthermore, his elevated PSA level of 3.6 ng/mL, while not extremely high, is worrisome for a 55 year old, and warrants referral to a urologist. QoL = Quality of LifeIPSS = International Prostate Symptom ScorePSA = Prostate-Specific Antigen

22. Urologist Consultation • Sextant prostate biopsies indicated no prostatic carcinoma. • Anthony is counseled by the urologist on pharmacotherapy and treatment options • He is not a candidate for surgery and is put on a 5α-reductase inhibitor • Anthony is still taking his α1-blocker • Anthony is referred back to his family physician

23. Family Physician Follow-up • Anthony is now on combination therapy • After 12 months, his DRE is normal and his PSA is 1.2ng/ml • His bother score (QoL) is down to a 2 • His IPSS is 18 (moderate symptoms) DRE = Digital Rectal ExaminationQoL = Quality of LifePSA = Prostate-Specific AntigenIPSS = International Prostate Symptom Score

24. How Would You Counsel Anthony? • If Anthony asked about his chances of prostate cancer, how would you respond? • What is his risk level?

25. Counseling Anthony • Anthony has a low chance of having prostate cancer at this time. • The reduction in PSA is likely due to the 5α-reductase inhibitor and he should be monitored for symptoms, DRE and PSA. • In a large randomized study, 5α-reductase inhibitor therapy with finasteride reduced the risk of developing prostate cancer. PSA = Prostate-Specific AntigenDRE = Digital Rectal Examination

26. End of Case 6