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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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Patient history
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

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

Case 6 anthony

IPSS = International Prostate Symptom ScoreAUA = American Urological Association


  • 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__ therapy after _____therapy/surgery

Case 6 anthony

Interpreting the IPSS and Bother Score Symptoms?

  • 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
What Kind of Physical Exam Would You Symptoms?Perform on Anthony?

Results of the physical exam
Results of the Physical Exam Symptoms?

  • On physical examination, Anthony appears healthy

DRE = Digital Rectal Examination

What investigations might you consider for anthony at this stage
What Investigations Might You Symptoms?Consider for Anthony at this Stage?

Case 6 anthony

Lab Results Symptoms?

Lab tests:

Urinalysis: no abnormal findings

PSA: 3.6 ng/mL

Blood/Glucose: negative

Urethral swab: negative

PSA = Prostate-Specific Antigen

Management strategy
Management Strategy Anthony?

  • 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
Urologist Consultation Anthony?

  • 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
Family Physician Follow-up Anthony?

  • 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
How Would You Counsel Anthony? Anthony?

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

  • What is his risk level?

Counseling anthony
Counseling Anthony 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

Case 6 anthony

End of Case 6 Anthony?