Unmasking cancer fear of patient with dysuria
CJ is a 67-year-old who presents with difficulty passing urine. He is having to get up twice a night and admits to some increase in daytime frequency. He says he really wouldn't have bothered you but his wife made him come.
Dr Richard Stokell advises.
Why has the patient come to see you?
Although the presented symptoms are important to elicit, I think it is important to look for the hidden agenda. Fears of prostate cancer may be related to friends or family who have suffered it. Depression in this age group often leads to so-called cancerphobia, where fairly normal symptoms are misinterpreted as cancer. Cultural factors affect symptom tolerance and his perception of the types and effects of treatment will be informed by lay advice.
Underlying fears of catheterisation and incontinence can either trigger or delay attendance depending upon the patient's beliefs. Questions such as 'what is particularly worrying you about these symptoms', 'do any of your friends suffer with their prostates....what has happened to them?' can reveal a lot about the patient's beliefs.
Does it matter what triggered the consultation?
That depends on your point of view. Symptoms of benign prostatic hypertrophy can be assessed in a reasonably objective way from history, urology symptom scores1 or flow rate.
What this approach fails to address is how much the patient's lifestyle is affected; how worried the patient is about cancer; and the patient's perception of the threat this disease poses to him. Understanding these factors is the key to providing appropriate information to the patient and arriving at an agreed management plan, without which concordance will be poor.
What tests should I do for this patient?
Abdominal examination is to exclude distended bladder and p.r examination can assess prostatic size and screen
for a hard, irregular gland. I would check U&E, glucose, MSU and perhaps PSA.
Isn't it best just to do a PSA test
to exclude cancer?
Unfortunately, although the test is easy to do, it often raises more questions than it answers. A normal result doesn't exclude cancer as 20 per cent of cancers will not cause a raised level.
Of those with an elevated level, most may not have prostatic cancer2 and depending on the level, and other factors such as age, health and examination findings, these patients may be offered watchful waiting
(or watchful worrying as I would prefer to call it) to see if levels rise
Pre-test counselling has to endeavour to inform the patient sufficiently to make a choice. Cancer Research UK produces an excellent leaflet to assist with this3. After counselling some patients really do elect not to have the test.
In most cases the investigations are normal and now is the time to reflect on the patient's original reason for attendance. Because we understand why he came, his fears and expectations, we can influence how he feels as well as treating his physical symptoms.
My patient elected to wait and see how his symptoms developed. He did have a PSA test, which was normal. He knows prostate cancer has not been excluded and he understands he has treatment options if his symptoms start to interfere with his life.
However, this disease does bring into focus the need to question interventions, which may not always be in a patient's best interests.
· Find out why the patient has come and what he expects
· Symptom tolerance in prostate disease is extremely variable and treatment should be individually tailored
· Pre-test counselling is important before PSA testing