Case 6 anthony
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Case 6: Anthony. Patient History. Anthony is a 55-year old lawyer. He has been suffering from voiding complaints for several years, and for the past 5 years he has been treated with an α 1 -blocker for BPH. Anthony recently experienced a urinary infection requiring antibiotics.

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Case 6: Anthony

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Case 6: Anthony


Patient History

  • Anthony is a 55-year old lawyer.

  • He has been suffering from voiding complaints for several years, and for the past 5 years he has been treated with an α1-blocker for BPH.

  • Anthony recently experienced a urinary infection requiring antibiotics.

BPH = Benign Prostatic Hyperplasia


What Typical Questions Do You Have for Anthony?


Some Possible Questions for Anthony


Anthony’s response

  • Anthony says he is definitely getting worse

  • His nocturia is increased as well as day time voiding frequency

  • He is worried about prostate cancer, but there is no history of it in his family, to his knowledge

  • He is otherwise healthy and tries to exercise regularly


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


IPSS = International Prostate Symptom ScoreAUA = American Urological Association


Discussion

  • The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of Anthony

  • You ask him to complete the forms before proceeding

  • Here are Anthony’s scores:

International Prostate Symptom Score (IPSS)

Patient name: Anthony

DOB: 05/05/50

ID: 0019-0026

Date of assessment: 29/06/05

Initial assessment (X)

Monitor: during __X__ therapyafter _____therapy/surgery


Total IPSS Score = 29


Anthony’s QoL Score = 6 (Terrible)


How Do You Interpret the Severity and Bother of Anthony’s Symptoms?


Interpreting the IPSS and Bother Score

  • Anthony’s IPSS = 29 (severe symptoms)

  • Anthony’s Bother Score = 6 (terrible)

IPSS = International Prostate Symptom Score


What Kind of Physical Exam Would You Perform on Anthony?


DRE = Digital Rectal Examination


Results of the Physical Exam

  • On physical examination, Anthony appears healthy

DRE = Digital Rectal Examination


What Investigations Might You Consider for Anthony at this Stage?


Lab Results

Lab tests:

Urinalysis: no abnormal findings

PSA: 3.6 ng/mL

Blood/Glucose: negative

Urethral swab: negative

PSA = Prostate-Specific Antigen


What Are the Possible Diagnoses You Are Considering for Anthony?


Possible Diagnoses for Anthony


Management Strategy

  • Anthony’s severe bother (QoL = 6) and high IPSS of 29 are indications of a need for further evaluation

  • Furthermore, his elevated PSA level of 3.6 ng/mL, while not extremely high, is worrisome for a 55 year old, and warrants referral to a urologist.

QoL = Quality of LifeIPSS = International Prostate Symptom ScorePSA = Prostate-Specific Antigen


Urologist Consultation

  • Sextant prostate biopsies indicated no prostatic carcinoma.

  • Anthony is counseled by the urologist on pharmacotherapy and treatment options

  • He is not a candidate for surgery and is put on a 5α-reductase inhibitor

  • Anthony is still taking his α1-blocker

  • Anthony is referred back to his family physician


Family Physician Follow-up

  • Anthony is now on combination therapy

  • After 12 months, his DRE is normal and his PSA is 1.2ng/ml

  • His bother score (QoL) is down to a 2

  • His IPSS is 18 (moderate symptoms)

DRE = Digital Rectal ExaminationQoL = Quality of LifePSA = Prostate-Specific AntigenIPSS = International Prostate Symptom Score


How Would You Counsel Anthony?

  • If Anthony asked about his chances of prostate cancer, how would you respond?

  • What is his risk level?


Counseling Anthony

  • Anthony has a low chance of having prostate cancer at this time.

  • The reduction in PSA is likely due to the 5α-reductase inhibitor and he should be monitored for symptoms, DRE and PSA.

  • In a large randomized study, 5α-reductase inhibitor therapy with finasteride reduced the risk of developing prostate cancer.

PSA = Prostate-Specific AntigenDRE = Digital Rectal Examination


End of Case 6


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