Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in General Practice. Your next patient is 65-year-old Harold Wilson, who did not state a reason for attendance. Please take a history and perform a relevant examination.
Patient History:
You were somewhat embarrassed about attending today, and the receptionist wanted to ask you what you were booking for which was awfully inappropriate!
You've been waking up at night to go to the loo for the past month. You even have to wee during the day more frequently (usually, you'd only go 2 or 3 times and never at night, now, it's close to 5 or 6 times in the day and once/twice at night). You often get a sudden urge to go to the toilet or feel like you might wee yourself (it's terribly embarrassing!), but you haven't had any accidents. Or at least not yet.
You wouldn’t say it hurts to pass urine, and you’ve never seen any blood or cloudiness in your wee. You don’t have any tummy pain and no fever.
You do notice you're straining to start urinating, but you've had that and the poor flow for a good couple of months now. It certainly is just the next step in the ageing process. You have noticed some dribbling at the end as well, and occasionally a feeling like you haven't done a great job emptying your bladder. Overall you need major plumbing service!
You haven't had any weight loss. You have had some back pain, but that's been going on for years with your arthritis. You don't believe it has worsened at all recently.
Ideas, Concerns, Expectations:
You think this is just a natural part of the ageing process. You knew it was coming, but you just can't manage when you always have to know where the nearest toilet is. You're just unable to go out and play golf like you normally do, and it's incredibly embarrassing when the hour strikes and you're mid-conversation with a friend. You have to suddenly conjure up a reason to dash and find the nearest place to urinate. (You start to get emotional and cry). You’ve even once had to do it out in the park! You want the doctor to find a solution for this because you simply cannot carry on with your life this way.
Past Medical History:
Arthritis
High blood pressure.
Drug History:
Oral Paracetamol and ibuprofen PRN.
Topical Ibuprofen gel PRN.
Indapamide.
NKDA.
Family History:
No history of kidney problems in your family.
Social History:
You live in a bungalow alone and only leave the house for shopping and golf.
You don't have any family who visits (your only daughter lives in New Zealand with her husband – she sends you the most beautiful postcards, but you really wish she'd come and visit you more often).
You've never smoked since you used to work in the army, and you drink the occasional beer or lager but nothing extreme.
If asked about caffeine, you love your coffee; you've always been drinking several cups since your army days.
Examination Findings:
No abdominal or suprapubic tenderness, masses or organomegaly.
If mentioned DRE = a non-tender, smooth, elastic, and firm enlarged prostate with the median sulcus palpable.
Differentials:
Benign Prostatic Hyperplasia (lower urinary tract symptoms (LUTS) in the presence of examination findings in an elderly male)
Prostatic cancer (important to exclude, less likely given examination findings and negative red flags)
Prostatitis (typical history involves pelvic pain, fever and dysuria with tender enlarged prostate)
UTI (no fever or dysuria, however)
Bladder cancer (typically haematuria with normal prostate)
Detrusor weakness/instability
Neurological conditions e.g. MS, spinal cord injury
Investigations:
Bedside:
Urine dipstick (infection, blood)
Patient voiding diary (quantify severity)
International Prostate Symptom Score (IPSS) to assess the severity
Bloods:
PSA (non-specific, though very elevated levels e.g. x10 are highly indicative of cancer)
U&E (associated renal impairment)
Imaging/ Special Tests:
Bladder USS and post-void residual volume
Flow rate measurement & urodynamic studies
Cystoscopy ± biopsy
Management: