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Case 5: Sam

Case 5: Sam. Patient History. Sam is a 66 year old retired painter & construction worker. He is distressed by the development of urinary symptoms that began about 1 year ago.

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Case 5: Sam

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  1. Case 5: Sam

  2. Patient History • Sam is a 66 year old retired painter & construction worker. • He is distressed by the development of urinary symptoms that began about 1 year ago. • Sam complains of reduced force in his urine stream, as well as waking in the middle of the night to urinate and frequently urinating during the day. • His father was a pulp mill operator who died in his 70's of prostate cancer and Sam fears he may face the same fate. • He is experiencing both obstructive and irritative symptoms. He has terminal dribbling and straining, and his nocturia, and day time voiding, are accompanied by extreme urgency.

  3. What Additional Questions Do You Have for Sam?

  4. In Your Practice How Would You Determine the Impact of Sam’s Symptoms on his Quality of Life?

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

  6. Discussion • The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of Sam • You ask him to complete the forms before proceeding • Here are Sam’s scores: International Prostate Symptom Score (IPSS) Patient name: Sam DOB: 05/05/39 ID: 0019-0025 Date of assessment: 29/06/05 Initial assessment (X) Monitor: during __X__ therapy after _____therapy/surgery

  7. Total IPSS Score = 17

  8. Sam’s Bother Score = 5 (unhappy)

  9. How Do You Interpret the Severity and Bother of Sam’s Symptoms?

  10. Interpreting the IPSS and Bother Score • Sam’s IPSS = 17 (moderate symptoms) • Sam’s Bother Score = 5 (unhappy) IPSS = International Prostate Symptom Score

  11. What Physical Examinations Would You Undertake on Sam?

  12. Physical Examination

  13. What Are the Possible Diagnoses You Are Considering for Sam?

  14. Possible Diagnoses for Sam BPH = Benign Prostatic Hyperplasia

  15. What Investigations Might You Consider for Sam at this Stage?

  16. Lab Tests PSA = Prostate-Specific Antigen

  17. Discussion of Lab Results • In men with voiding symptoms, particularly those with a DRE showing asymmetrical enlargement of the prostate, it is important to exclude a diagnosis of prostate cancer. • The PSA level for Sam is moderately elevated and requires further investigation. However, the PSA level can be elevated for other reasons. • The increased size of the prostate alone can be associated with an increased level of PSA. DRE = Digital Rectal ExaminationPSA = Prostate-Specific Antigen

  18. What Would be Your Management Strategy for Sam?

  19. Management Strategy • Practitioners must rule out conditions such as infection, prostate cancer, stricture, hypotonic bladder or other neurogenic disorders that might mimic BPH before prescribing a 5-ARI. • In light of Sam’s recent PSA elevation, prostate cancer should also be ruled out before a 5-ARI is prescribed. • On the basis of his elevated PSA levels, and the suspicious findings on DRE as well as Sam’s family history, prostate cancer is suspected. • He is referred to a urologist. BPH = Benign Prostatic Hyperplasia ARI = Alpha Reductase Inhibitor PSA = Prostate-Specific AntigenDRE = Digital Rectal Examination

  20. Management Strategy (cont). • Begin treatment with an α1-blocker. This would benefit the patient in that his voiding symptoms would likely improve quickly. • While it is possible that his PSA has become elevated as a result of BPH, it is important to rule out prostate cancer in men with elevated PSA. The transrectal ultrasound performed at the time of his biopsy can also be used to more accurately estimate the size of the prostate gland (large BPH gland could be the reason for Sam’s elevated PSA). PSA = Prostate-Specific Antigen BPH = Benign Prostatic Hyperplasia

  21. Follow-up • Sam returns for follow-up with his family physician. • It has been 3 months since he saw the urologist. • His biopsy was negative for malignancy. • The urologist added a 5α-reductase inhibitor to his α1-blocker.

  22. What are Your Next Steps with Sam?

  23. Next Steps & Discussion • Sam’s rectal examination shows a large prostate and the size by transrectal ultrasound is estimated to be 80 mL. • Sam’s PSA measurement is taken. It is now 4.1 ng/mL. • Urinalysis is normal. PSA = Prostate-Specific Antigen

  24. How Do You interpret Sam’s Changes in PSA? • What is the normally expected change in PSA after 6 months on 5α- reductase inhibitor therapy? • At what stage, if ever, would you consider removal of Sam’s α1-blocker from his treatment regimen? PSA = Prostate-Specific Antigen

  25. Urology Follow-up • Sam continues to follow-up with the urologist every 6 months who schedules another biopsy. The urologist expects Sam’s PSA to drop to 50% of its initial level after 6 months of 5-ARI treatment. When this does not happen, he knows that he may have missed prostate cancer on the first biopsy and recommends it be repeated. • The repeat biopsy is again negative for malignancy. PSA = Prostate-Specific Antigen ARI = Alpha Reductase Inhibitor

  26. Long Term Management • How would you manage Sam over the next 2 to 3 years?

  27. Long Term Management • Since the patient had symptomatic improvement and did not have prostate cancer on two biopsies, continuation of both the α1-blocker and the 5α-reductase inhibitor is an appropriate option. • However, it is also appropriate to consider discontinuation of the α1-blocker. • Many patients who begin with combination medical therapy can discontinue the α1-blocker after 12 months of therapy. The majority of patients will notice little, if any, difference in their symptoms. • From that point forward, they can be maintained on a 5-ARI over the long term. • The PSA must continue to be monitored. PSA = Prostate-Specific Antigen ARI = Alpha Reductase Inhibitor

  28. Long Term Management • What other long term follow up is important for this patient?

  29. Long Term Management • Although Sam has had two biopsies to rule out prostate cancer, he is still at risk for developing prostate cancer in the future. • He should be monitored for improvement in symptoms on combination medical therapy and if he is happy with his symptoms after 6 months, he can be kept on combination therapy on a long term basis • (could be considered for trial of discontinuing α1-blocker after a year to see if he still needs it).

  30. Long Term Management • His PSA should drop by approximately 50% (to about 3) over the next 6-12 months. • If it does not, then he needs to be reinvestigated for possibility of prostate cancer that was missed on the first set of biopsies. • If his PSA starts to climb during the long term follow up while on 5α-reductase inhibitor therapy, then again, consideration that he may be developing prostate cancer should be entertained and referral back to urologist is indicated. PSA = Prostate-Specific Antigen

  31. End of Case 5

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