Case 2: Troy

1. Case 2: Troy

2. 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. What Questions Do You Have About Troy’s History?

4. Possible Questions

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

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

9. 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

11. Total IPSS Score = 17

12. Troy’s QoL Score = 4 (Mostly Dissatisfied)

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

14. Interpreting the IPSS and Bother Score • Troy’s IPSS = 17 (moderate symptoms) • Troy’s Bother Score = 4 (mostly dissatisfied) IPSS = International Prostate Symptom Score

15. 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. What Physical Examinations Would You Undertake on Troy?

17. DRE = Digital Rectal Examination

18. Physical Examination Results DRE = Digital Rectal Examination

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

20. Possible Diagnoses BPH = Benign Prostatic Hyperplasia

21. What Investigations Might You Consider for Troy at this Stage?

22. Lab Results PSA = Prostate-Specific Antigen

23. 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. What is the Most Likely Diagnosis for Troy?

25. 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 BPH = Benign Prostatic Hyperplasia

26. What Would be Your Management Strategy for Troy?

27. 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. Treatment Strategy 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) BPH = Benign Prostatic Hyperplasia

29. 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 BPH = Benign Prostatic Hyperplasia

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

31. Time to Effect

32. Troy Asks About Phytotherapy for BPH. What Do You Tell Him? BPH = Benign Prostatic Hyperplasia

33. Would You Do Anything Different if Troy had High Blood Pressure and was Taking Antihypertensive Medication?

34. 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 BPH = Benign Prostatic Hyperplasia

35. What Would Be Your Follow-up Strategy For Troy?

36. 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. Follow-up Appointments for Troy What Would your Likely Course of Action be at Each Visit?

38. Follow-up Appointments for Troy

39. IPSS = International Prostate Symptom Score

40. 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. 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

42. 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

43. Long Term Management • 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

44. Long Term Management • What kind of lifestyle options would you counsel Troy on, to help with his symptoms?

45. 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. End of Case 2