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Case 9: Pierre

Case 9: Pierre. Patient History. Pierre is 65 years of age who has suffered with benign prostatic hyperplasia (BPH) for 10 years. At his last GP visit almost a year ago, his IPSS score was 21 and he reported mixed satisfaction/dissatisfaction with his QoL related to urinary condition.

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Case 9: Pierre

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  1. Case 9: Pierre

  2. Patient History • Pierre is 65 years of age who has suffered with benign prostatic hyperplasia (BPH) for 10 years. • At his last GP visit almost a year ago, his IPSS score was 21 and he reported mixed satisfaction/dissatisfaction with his QoL related to urinary condition. • Today Pierre has made an urgent request to see his GP and presents with symptoms of severe LUTS. He has just filled his IPSS and QoL and is quite distressed. IPSS = International Prostate Symptom Score QoL = Quality of LifeLUTS = Lower Urinary Tract Symptoms

  3. What Typical Questions Do You Have for Pierre?

  4. Some Possible Questions for Pierre • Has your urine stream changed? • Do you have to get up at night to urinate? • Does it burn when you urinate? • Do you have post void dribbling or incontinence? • Has there been any blood in your urine? • Questions around irritative and obstructive symptoms • Questions examining possibility of diabetes • How much do your symptoms bother you? • Is there any history of prostate cancer in your family? • Specific questions about erectile dysfunction

  5. Pierre’s Response • Pierre has previously been treated with α1-blocker therapy to which he has ceased to respond. He has been switched to a 5α-reductase inhibitor therapy in the last 3 years. • Because Pierre’s treatment options have been optimized and the BPH progression is still having a profoundly negative effect on his quality of life, Pierre is referred to his urologist for urgent consultation. BPH = Benign Prostatic Hyperplasia

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

  7. Discussion • The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of Pierre • You ask him to complete the forms before proceeding • Here are Pierre’s scores: International Prostate Symptom Score (IPSS) Patient name: Pierre DOB: 05/05/40 ID: 0019-0029 Date of assessment: 29/06/05 Initial assessment (X) Monitor: during __X__ therapy after _____therapy/surgery

  8. Total IPSS Score = 30

  9. Pierre’s Bother Score = 6 (terrible)

  10. How Do You Interpret the Severity and Bother of Pierre’s Symptoms?

  11. Interpreting the IPSS and Bother Score • Pierre’s IPSS = 30 (severe symptoms) • Pierre’s Bother Score = 6 (terrible) IPSS = International Prostate Symptom Score

  12. What Physical Examinations Do You Undertake on Pierre?

  13. Physical Examination DRE = Digital Rectal Examination

  14. Possible Diagnoses for Pierre BPH = Benign Prostatic Hyperplasia

  15. Referral to Urologist • Because he has failed medical therapy with both α1-blockers and 5-ARIs, Pierre is a possible candidate for surgery • Pierre is referred to his urologist ARI = Alpha Reductase Inhibitor

  16. Urologist Consult Letter Dear Doctor, Pierre was referred to me for his severe BPH, after several years of medical treatment with both 5-ARIs and α1-blockers. He had a PSA of 2.5 ng/mL, a large benign prostate, and a residual urine of 280 mL. On cystoscopy, he had trilobar obstructive hyperplasia with bladder evidence of long standing outlet obstruction. He was subsequently treated with TURP and his symptoms have now subsided. He reports no more nocturia and is generally quite happy with the procedure. His pathology was benign. Pierre should resume his regular annual checkups and be monitored for any future LUTS. BPH = Benign Prostatic HyperplasiaARI = Alpha Reductase InhibitorPSA = Prostate-Specific AntigenTURP = Transurethral Resection of the Prostate LUTS = Lower Urinary Tract Symptoms

  17. Long Term Follow-up • Discussion of risk of TURP surgery • Specialist perspective • Family Physician perspective • Let patient know that he still have to be monitored for prostate cancer even though he has had a TURP TURP = Transurethral Resection of the Prostate

  18. Long Term Follow-up • What are the key issues for the GP in terms of long term management of this patient?

  19. Long Term Follow-up • Approximately 20% of patients with a successful TURP will have recurrence of symptoms over the next decade secondary to regrowth of prostate, development of prostate cancer, development of urethral or bladder neck stricture or development of aging hypotonic bladder. • The GP can follow-up by monitoring symptoms (and PSA if indicated based on age and co-morbidities or because of recurrence of symptoms, change in DRE etc) TURP = Transurethral Resection of the Prostate DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen

  20. Long Term Follow-up • Should the patient still be monitored for prostate cancer?

  21. Long Term Follow-up • If the urologist states that pathology was negative for cancer at the time of TURP, the GP must continue to monitor for future development of prostate cancer with DRE and PSA as per the usual standard routine (based on age and co-morbities). TURP = Transurethral Resection of the Prostate DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen

  22. End of Case 9

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