JK is a 63-year-old male who presents with complaints of difficulty starting his urine stream and that he has to get up to urinate at night at least three times. He states there are times when he does not think he will be able to go.
Past Medical History
- Controlled hypertension
- Hypercholesteremia
- Type 2 diabetes controlled by diet
Medications
- Zestril, 5 mg once daily
- Simvastatin, 40 mg
- Niacin, 1,000 mg
- Baby aspirin, daily
Social History
- A six-pack of beer on weekends
- Nonsmoker
- Active in Lions club
Physical Examination
- Well-developed male
- Chest: clear to auscultation
- Heart: regular rhythm; no gallops, thrills, or murmurs
- Digital rectal exam: enlarged prostate Labs and Imaging
- Liver enzymes: normal
- Prostate specific antigen (PSA): 2.5 ng/mL
- Hemoglobin A1C: 6.9
- Office-based ultrasound: prostate enlargement approximately 41 cm3 • Postvoid residual urine volume: 300 mL
Discussion Questions
- The clinician prescribes dutasteride. What patient teaching should be included?
- In addition to taking the prescribed medication, the clinician suggests JK keep a voiding diary. What information should JK track in this diary, and what value does this information provide?
- JK fails to respond to the initial therapy. What second drug should the clinician add? What is the method of action of this drug and what advantage does this drug provide? What patient teaching should be included?
Full Answer Section
- Importance of Regular Check-Ups: Emphasize the need for regular follow-up appointments to monitor progress and PSA levels.
- Sexual Activity: Dutasteride can decrease sperm count and potentially harm a developing fetus. Advise JK to use a condom if sexually active with a woman of childbearing age.
- Do Not Share Medication: Inform JK that dutasteride is for him only and should not be shared with others.
Additional Considerations:
- Discuss potential interactions with other medications JK is taking (though unlikely with his current list).
- Instruct JK to report any severe or persistent side effects to his doctor.
- Briefly mention that dutasteride does not shrink the prostate but may help prevent further enlargement.
Voiding Diary (Question 2)
A voiding diary is a helpful tool to track urinary habits and can provide valuable information for both JK and his clinician. Here's what JK should track:
- Date and Time: Record the date and time of each urination throughout the day and night.
- Volume: Estimate the amount of urine voided each time (can be compared to a full water bottle for reference).
- Urgency: Note any urgency to urinate.
- Leakage: Record any episodes of urinary leakage.
- Fluids Consumed: Track the amount and type of fluids consumed throughout the day.
Value of Voiding Diary:
- Monitor Urinary Habits: The diary helps identify patterns in urination frequency, volume, and urgency.
- Assess Effectiveness of Treatment: It allows JK and his clinician to track response to dutasteride and identify if symptoms improve.
- Identify Potential Issues: The diary can help detect signs of urinary tract infections or other conditions.
- Guide Treatment Decisions: The information gathered can guide the clinician in adjusting treatment if needed.
Second-Line Therapy Option (Question 3)
If JK fails to respond adequately to dutasteride after a reasonable trial period (typically 3 months), the clinician might consider adding an alpha-blocker medication like
tamsulosin (Flomax).
Tamsulosin - Mechanism of Action and Advantages:
- Mechanism: Tamsulosin relaxes the muscles in the prostate and bladder neck, allowing for easier urination.
- Advantages: Tamsulosin works relatively quickly (within a few weeks) to improve urinary symptoms like difficulty starting urination and nighttime urination (nocturia). It can be a good option for men who need faster symptom relief.
Patient Teaching for Tamsulosin:
- Similar to dutasteride, explain the medication name, purpose, dosage, and potential side effects (dizziness, lightheadedness).
- Advise JK to avoid taking tamsulosin on an empty stomach as it can worsen dizziness.
- Inform JK that tamsulosin does not shrink the prostate but helps relax muscles for easier urination.
It's important to note that this information is intended for educational purposes only and does not constitute medical advice. Always consult with a qualified healthcare professional for diagnosis and treatment.