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Case 4: Andy

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History

You have known Andy as a patient for 15 years

Andy is 65 years of age and a retired bus driver

You have been treating him for BPH for 10 years

At his last office visit almost a year ago, his IPSS score was 21 and he reported mixed satisfaction/dissatisfaction with his QoL related to urinary condition

Today Andy has made an urgent request to see you and presents with symptoms of severe LUTS

He has just filled-in his IPSS and QoL questionnaires and is quite distressed

BPH = Benign Prostatic HyperplasiaIPSS = International Prostate Symptom ScoreQoL = Quality of LifeLUTS = Lower Urinary Tract Symptoms

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What Questions Do You Have for Andy?

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1. Has your urine stream changed?

2. How many times are you up at night to void?

3. Are you emptying your bladder

4. Does it burn when you urinate?

5. Has there been any blood in your urine?

6. Have you been sleeping properly?

7. Do you have any abdominal pain?

8. How much do these symptoms bother you?

Some Possible Questions for Andy

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Recognizing that Andy is distressed, you further inquire about his sleeping patterns and any outside stresses that could be affecting him.

You discover that he has to urinate at night so often that he is not getting any sleep

He has both severe irritative and obstructive symptoms

His wife is not speaking with him because she says he should have seen the Doctor sooner. He is now trying to get some sleep in the living room and has slept very poorly for the last 3 nights!

Andy’s Response

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Andy has previously been treated with α1-blocker therapy to which he has ceased to respond

Andy describes several similar acute episodes of pain over the past year, which got better after a few days.

Andy’s Treatment History

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How Would You Assess the Impact of Andy’s Urinary Problems on his Quality of Life?

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Use of Questionnaires:

1. IPSS (or AUA symptom score)2. Quality of life question

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 Andy

You ask him to complete the forms before proceeding

Here are Andy’s scores:

International Prostate Symptom Score (IPSS)

Patient name: Andy

DOB: 06/08/40

ID: 0019-0024

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

Andy’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 5

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 5

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 5

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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

Andy’s Results

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

0 1 2 3 4 5 5

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

0 1 2 3 4 5 5

None 1 time 2 times 3 times 4 times5 or

more times

Andy’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 5

Total IPSS Score = 32

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Andy’s QoL Score = 6 (Terrible)

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 Andy’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

• Andy’s IPSS = 32 (severe symptoms)

• Andy’s Bother Score = 6 (terrible)

IPSS = International Prostate Symptom Score

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What Kind of Physical Examinations Would You Perform on Andy?

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Necessary examinations:

1. Abdominal exam2. Genital exam3. DRE4. Blood pressure5. Pulse6. Temperature

DRE = Digital Rectal Examination

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Results of the Physical ExamHeight 6 ft 0”

Weight 72 kg (158 lb)

General appearance He appears pale, underweight and fatigued

Abdominal exam His bladder is palpable No renal angle tenderness on both

sides

Genital exam No abnormal findings

DRE:- Anus and rectal ampulla- Prostate

- normal - markedly enlarged, firm and smooth

Blood pressure 128/82 mmHg

Pulse Normal

Temperature 36.5 °C DRE = Digital Rectal Examination

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Andy has had severe burning when he voids but he has experienced no fever or chills

If he had fever or chills he should be admitted to the nearest emergency ward for monitoring and treatment in case of potential septicemia

Note

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What Are the Possible Diagnoses for Andy?

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Possible Diagnoses for Andy

1. UTI complicating BPH

2. Gram negative urosepsis

3. Concomitant prostate cancer

4. Prostatitis

5. Acute urinary retention (with or without infection)

UTI = Urinary Tract InfectionBPH = Benign Prostatic Hyperplasia

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What Other Investigations Might you Consider at this Stage?

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Lab tests: Urinalysis: • Colour: Unremarkable • Turbidity: 8.0 NTU• pH: 7.5• Specific gravity: 1.020 • Protein, Glucose, Ketones: Negative• Leukocytes: 3+• Hemoglobin: 2+• WBC: Packed • RBC: 1-5 • Bacteria: Many

CBC: normal except WBC 8.5 x 109/L

Midstream urinalysis for culture and sensitivity: Result reported in 72 hours showed 108 E. Coli

Blood Cultures: Negative

PSA Levels: never do a PSA in such a setting.

Serum creatinine:110 μmol/L

Patient needs urgent ultrasoundPSA = Prostate-Specific AntigenWBC, RBC, CBC: (White, Red, Complete) Blood Count

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Note Never do PSA in acute settings

PSA = Prostate-Specific Antigen

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What is Your Diagnosis and Management for Andy?

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Diagnosis:Acute urinary retention with UTI – acute prostatitis is also a possibility as part of UTI

UTI = Urinary Tract Infection

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Diagnosis, Continued Clinically Andy has acute urinary retention with UTI. He must have

residual urine checked by ultrasound or catheterization

Assessment of Andy’s renal function is determined by his age, weight and gender

His renal function is used to determine the acceptable dose for Ciprofloxacin

Andy’s Creatinine Clearance is 75 mL/min which is indicative of very mild renal failure

UTI = Urinary Tract Infection

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Treatment:

When ultrasound confirms a residual urine of 500 mL, a foley catheter is inserted and ciprofloxacin hydrochloride prescribed: 500 mg BID for 14 days

Treatment

BID = Bis In Die (Twice Daily)

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Discussion

Based on Andy’s history of severe BPH and his acute symptoms, acute urinary retention with urinary tract infection is suspected

He also has very mild renal failure

He needs an indwelling foley catheter and broad spectrum antibiotics while awaiting blood and urine results

A teleconference with the urologist is recommended

Andy needs to be watched very closely; he is in danger of extreme complications because he has untreated retention associated with renal failure

Andy should at least phone you the next day and confirm that he is feeling better. Even if he was feeling better, he might deteriorate again!

BPH = Benign Prostatic Hyperplasia

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What Would be your Next Steps and Follow-up Strategy?

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Strategy: Referral to Urologist

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Discussion & Follow-up

Because Andy’s treatment options have been optimized and the BPH progression is still having a profoundly negative effect on his quality of life, Andy is referred to his urologist for urgent consultation

Because he had such long standing severe obstructive and irritative voiding symptoms while on α1-blocker therapy, it is likely that he has chronic retention secondary to BPH and would likely fail a trial of voiding without a catheter. A catheter should remain in place until seen by a urologist.

BPH = Benign Prostatic Hyperplasia

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What Options are Pursued by the Specialist?

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Options Pursued by Specialist

Treatment of UTI / prostatitis and AUR as ordered

Initiate treatment again with α1-blockers for short term and 5α-reductase inhibitor for long term

Trial voiding without catheter. If this fails consider cystoscopy and TURP.

UTI = Urinary Tract InfectionAUR = Acute Urinary RetentionTURP = Transurethral Resection of the Prostate

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At What Point will this Patient Return to his FP and What Should the Specialist

Recommend to the FP in Terms of Long Term Follow up?

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Family Physician Follow-up

FP can follow up after successful management of AUR (whether trial of voiding was successful or TURP was required) and can follow symptoms, DRE and PSA as per usual.

AUR = Acute Urinary RetentionTURP = Transurethral Resection of the ProstateDRE = Digital Rectal ExaminationPSA = Prostate-Specific Antigen

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End of Case 4