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Case 8: Craig

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Patient History

Craig, a 56-year bank manager was recently referred to his urologist for consideration of progressive lower urinary tract symptoms (LUTS).

Craig’s current complaints include poor daytime stream, but otherwise normal nocturnal voiding two times per night.

No history of UTI, trauma or instrumentation to his genitourinary tract.

Craig experiences declining erectile function. He currently drinks approximately 2 units of alcohol a night, more on weekend. Craig also drinks a cup of tea every night before going to bed. He does not exercise.

LUTS = Lower Urinary Tract SymptomsUTI = Urinary Tract Infection

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What Typical Questions Do You Have for Craig?

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1. Has your urine stream changed?

2. Do you have to get up at night to urinate?

3. Does it burn when you urinate?

4. Do you have post void dribbling or incontinence?

5. Has there been any blood in your urine?

6. Questions around irritative and obstructive symptoms

7. Questions examining possibility of diabetes

8. How much do your symptoms bother you?

9. Is there any history of prostate cancer in your family?

10. Specific questions about erectile dysfunction

Some Possible Questions for Craig

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In Your Practice, How Would You Determine the Severity of Craig’s Symptoms

at this Stage?

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Use of Questionnaires:

1. IPSS (or AUA symptom score)2. Quality of life question3. Sexual Function Questionnaire

IPSS = International Prostate Symptom ScoreAUA = American Urological Association

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Discussion The IPSS and Quality of Life due to Urinary Symptoms

Questionnaires are requested of Craig

You ask him to complete the forms before proceeding

Here are Craig’s scores:

International Prostate Symptom Score (IPSS)

Patient name: Craig

DOB: 05/05/49

ID: 0019-0028

Date of assessment: 29/06/05

Initial assessment (X)

Monitor: during __X__ therapy after _____therapy/surgery

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International Prostate Symptom Score

Not at all

Less than 1 timein 5

Less than half the time

About half the

time

More than half the time

Almost always

Craig’s Results

1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?

0 1 2 3 4 5 0

2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

0 1 2 3 4 5 1

3. Over the past month, how often have you found you stopped and started again several times when you urinated?

0 1 2 3 4 5 2

4. Over the past month, how often have you found it difficult to postpone urinating?

0 1 2 3 4 5 1

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Not at all

Less than 1 timein 5

Less than half the time

About half the

time

More than half the time

Almost always

Craig’s Results

5. Over the past month, how often have you had a weak urinary stream?

0 1 2 3 4 5 3

6. Over the past month, how often have you had to push or strain to begin urinating?

0 1 2 3 4 5 1

None 1 time 2 times 3 times 4 times5 or

more times

Craig’s Results

7. Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

0 1 2 3 4 5 1

Total IPSS Score = 9

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Craig’s Bother Score = 2 (Mostly Satisfied)

Quality of Life Due to Urinary Symptoms

Delighted PleasedMostly

Satisfied

Mixed about equally

satisfied and dissatisfied

Mostly dissatis-

fiedUnhappy Terrible

1. If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?

0 1 2 3 4 5 6

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

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Interpreting the IPSS and Bother Score

IPSS Values Indicate Symptom Severity:

Mild score: ≤ 7Moderate score: 8-19Severe score: ≥ 20

• Craig’s IPSS = 9 (moderate symptoms)

• Craig’s Bother Score = 2 (mostly satisfied)

IPSS = International Prostate Symptom Score

• Sexual function: declining quality of erections

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What Kind of Physical Exam Would You Perform on Craig?

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Recommended Examinations:

1. Abdominal exam

2. Genital exam

3. DRE

4. Blood pressure

DRE = Digital Rectal Examination

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Physical Examination HR 85 bpm

Blood Pressure 138/85 mmHg

Weight Slightly Obese

Abdominal Exam Normal

Genital Exam Normal

DRE Small size smooth non-tender gland

DRE = Digital Rectal Examination

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What Investigations Might You Consider for Craig at this Stage of the Consult?

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Lab tests: Urinalysis: Clear

PSA: 1.2 ng/mL (optional)

Midstream specimen culture: No Growth

Lab Tests

PSA = Prostate-Specific Antigen

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What Are the Possible Diagnoses You Are Considering for Craig?

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Possible Diagnoses for Craig

1. BPH

2. Erectile dysfunction

BPH = Benign Prostatic Hyperplasia

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Management Strategy

Craig has moderate LUTS that is almost certainly related to BPH.

He consumed significant amounts of fluids in the evening including a bladder stimulant (tea).

Craig’s PSA is below the level that would usually be an indication for prostate biopsy.

Craig’s potential erectile dysfunction is a concomitant factor

LUTS = Lower Urinary Tract SymptomsBPH = Benign Prostatic HyperplasiaPSA = Prostate-Specific Antigen

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Management Strategy

Craig indicates that he wants treatment primarily for his frequent daytime voiding, and is informed about the availability of medication.

Craig indicates a desire for non-pharmacological treatment.

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What are the Lifestyle Modifications You Recommend?

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Lifestyle Modification

Avoid tea late at night

Avoid decongestants

Avoid alcohol

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Follow-up

How should the GP manage Craig in the long term?

If his symptoms worsen, how should the GP counsel him?

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Continue to promote conservative lifestyle changes and monitor symptoms, DRE and PSA.

If symptoms deteriorate in future, then medical therapy could be advised.

Follow-up

PSA = Prostate-Specific AntigenDRE = Digital Rectal Examination

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How does his mild/moderate ED affect your choice of medical therapies?

Follow-up

ED = Erectile Dysfunction

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Standard ED workup:

History

Physical

Medications

Drug history

If negative, and patient desires therapy then prescription of a PDE5 inhibitor such as Viagra® (sildenafil citrate), Levitra® (vardenafil HCI) or Cialis® (tadalafil) could be considered.

Follow-up

ED = Erectile DysfunctionPDE5 Inhibitor = Phosphodiesterase Type 5 Inhibitor

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If the patient with sexual dysfunction was also concomitantly taking testosterone therapy, how

would the management of BPH differ?

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The management of BPH should not change in a patient on testosterone for BPH except for due

diligence in following prostate cancer risk (periodic DRE and PSA in appropriate age groups)

PSA = Prostate-Specific AntigenDRE = Digital Rectal Examination

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End of Case 8