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Case 1: George

Case 1: George. Patient History. George is a 50 year old computer engineer and works in a busy software development company.

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Case 1: George

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  1. Case 1: George

  2. 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. What Typical Questions Do You Have for George?

  4. Some Possible Questions for George

  5. 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. What Other Questions Will You Have for George at this Stage?

  7. Possible Questions for George • 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.

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

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

  10. 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: 019-0021 Date of assessment: 04/12/05 Initial assessment (X) Monitor: during __X__ therapy after _____therapy/surgery

  11. Total IPSS Score = 14

  12. George’s Bother Score = 5 (unhappy)

  13. How Do You Interpret the Severity and Bother Associated with George’s Symptoms?

  14. Interpreting the IPSS and Bother Score • George’s IPSS = 14 (moderate symptoms) • George’s Bother Score = 5 (unhappy) IPSS = International Prostate Symptom Score

  15. How Does George’s Age of 50 Years Factor Into Your Diagnosis?

  16. 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

  17. What Kind of Physical Exam Would You Perform on George?

  18. DRE = Digital Rectal Examination

  19. Results of the Physical Exam • On physical examination, George appears healthy. • Here are George’s results & findings of interest: DRE = Digital Rectal Examination

  20. What Investigations Might You Consider for George at this Stage of the Consult?

  21. Lab Results PSA = Prostate-Specific Antigen

  22. 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 HyperplasiaPSA = Prostate-Specific Antigen

  23. What Are the Possible Diagnoses You Are Considering for George?

  24. Possible Diagnoses for George

  25. What is the Most Likely Diagnosis for George?

  26. What Would Be Your Management Strategy for George?

  27. 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

  28. 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.

  29. Urologist Consultation Letter (Cont). • The patient should return to the urologist for follow-up including a repeat flow and bladder scan in 6 months.

  30. Long Term Management • How would you manage George in the long term?

  31. 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 ExaminationPSA = Prostate-Specific Antigen

  32. Long Term Management • What additional information should the specialist provide the family physician?

  33. Long Term Management • Urethral stricture can recur • Refer to previous recommendations

  34. Long Term Management • What would you do if George developed hematuria?

  35. 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

  36. End of Case 1

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