Case 7: John

1. Case 7: John

2. Patient History • John is a 64-year old retired school teacher. • You recently sent him to see his urologist for an assessment. He is quite worried because his recent PSA is 2.5 ng/mL, which is up from the last recorded value 1 year ago at 1.2 ng/mL. • John is now concerned that his mild lower urinary tract symptoms (LUTS) indicate that he has newly developed prostate cancer. His friend was recently diagnosed with prostate cancer. PSA = Prostate-Specific Antigen

3. What Typical Questions Do You Have for John?

4. Some Possible Questions for John

5. John’s Response • John says his urine stream has changed • He now rises to void five times nightly and has moderate urgency during his working day. • His stream is slow but he has never had any episodes of urinary retention.

6. In Your Practice, How Would You Determine the Severity of John’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 John • You ask him to complete the forms before proceeding • Here are John’s scores: International Prostate Symptom Score (IPSS) Patient name: John DOB: 05/05/41 ID: 0019-0027 Date of assessment: 29/06/05 Initial assessment (X) Monitor: during __X__ therapy after _____therapy/surgery

10. Total IPSS Score = 22

11. John’s Bother Score = 3 (mixed bother)

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

13. Interpreting the IPSS and Bother Score • John’s IPSS = 22 (severe symptoms) • John’s Bother Score = 3 (mixed bother) IPSS = International Prostate Symptom Score

14. What Physical Examinations Do You Undertake on John?

15. DRE = Digital Rectal Examination

16. Physical Examination DRE = Digital Rectal Examination

17. What Investigations Might You Consider for John at this Stage of the Consult?

18. Lab Results Lab tests: Urinalysis: no abnormal findings PSA: 2.5 ng/mL Blood/Glucose: negative Urethral swab: negative PSA = Prostate-Specific Antigen

19. Management Strategy • John’s mixed bother and high IPSS are indications of a need for further evaluation • Furthermore, his elevated PSA level of 2.5 ng/mL, while not extremely high, warrants referral to a urologist. IPSS = International Prostate Symptom ScorePSA = Prostate-Specific Antigen

20. Urologist Feedback • John’s prostate size measurement via DRE is critical for monitoring his condition • Measurements (4.2 x 5.2 X 5.5 cm) give a calculated volume of 63 ml and technician observed that the bladder was not completely empty after voiding. DRE = Digital Rectal Examination

21. Long Term Follow-up • John is placed on combination therapy of a 5α-reductase inhibitor and an α1-blocker • The PSA is expected to decrease by approximately 50% in the first 6-12 months and then not rise appreciably while on 5α-reductase inhibitor. • He is monitored annually via DRE and PSA DRE = Digital Rectal ExaminationPSA = Prostate-Specific Antigen

22. Long Term Follow-up • Is there anything else the GP should do or discuss with this patient, besides annual monitoring of DRE and PSA? DRE = Digital Rectal ExaminationPSA = Prostate-Specific Antigen

23. Long Term Follow-up • This 64 year old gentleman with a PSA of 2.5, benign enlarged prostate gland should be reassured that his risk of clinically important prostate cancer is small. • He needs to have continued monitoring. • He is quite symptomatic and treatment with combination therapy has been initiated. • If his PSA starts to rise while on 5α-reductase inhibitor treatment then referral back to urologist is indicated. • He could be told that 5α-reductase inhibitor therapy with finasteride has been shown in a study to reduce the risk of future development of prostate cancer. PSA = Prostate-Specific Antigen

24. End of Case 7