A PSA Story, Part 2

This post is a follow-up to a previous post about Evan, my patient with a very high PSA. I should have mentioned that it was with his permission that I wrote about him, and that (of course) Evan is Not His Real Name.

It has been a month since I saw him in the clinic. He started taking Septra (trimethoprim-sulfamethoxazole) the next day and had no side effects from it. Several days later I received the results of the urine culture and sensitivity. The bacteria causing his infection were Kluyvera ascorbata, sensitive to ciprofloxacin.

I had never heard of this bacteria, and it seemed odd to me that it would be sensitive to ciprofloxacin but resistant to a six-week course of levofloxacin. I called my urology consultant. He had also never heard of the bacteria and was equally puzzled by the sensitivity report.

“Talk to an infectious disease person,” he said. “But go ahead and switch him to ciprofloxacin.”

Infectious disease (ID) is one of the few specialties that we do not have a consultant for at the Alaska Native Medical Center in Anchorage. To get an ID consult, I have to call the University of Washington in Seattle. They maintain a 24-hour phone consultation service—for every known specialty—known as Medcon.

I was quickly connected to an ID fellow and presented Evan’s case to him. He said that Kluyvera is a recently-delineated subgroup of Escherichia, the common gut bacteria that cause most urinary tract infections (the “E.” of E. coli). He was as puzzled as the urologist and I had been that it was sensitive to ciprofloxacin but apparently highly resistant to levofloxacin.

“Ciprofloxacin does have more specificity for the prostate and concentrates in the tissue better than levofloxacin does,” he said. “Definitely put the patient on six weeks of it, and then do follow up cultures.” He also agreed that with such a large post-void residual (300 mL), the patient needed to be self-cathing to help resolve the infection.

I sent an order to the pharmacy to send out ciprofloxacin to Evan’s village and notified the health aides that it would be coming and that Evan needed to start taking it right away. He could stop the Septra, as the bacteria were resistant to it.

The issue of teaching Evan to self-cath was somewhat trickier. I knew it was unlikely he would be able to fly in to Bethel just for this. If he were from one of the nearby villages on the Kuskokwim River, I would jump in my boat and go visit him at the village clinic to teach him how to do it. But his village is not on the Kuskokwim. I considered flying to his village on my day off, but did not really want to bear the expense of that myself (several hundred dollars). Then I remembered another resource: the public health nurses.

PHNs are employees of the State of Alaska. There is a long tradition here of village visits by PHNs and a more clinical focus to their work than in other places. The earliest access that Alaska Natives had to western medicine was provided by public health nurses who traveled by ship to the coastal and riverside communities. When I first came to Alaska, the PHNs made regular trips to all the villages in the Delta, providing well-child care, immunizations, Pap smears, and exams for sexually transmitted infections. Recent budget cutbacks have curtailed much of their travel, but PHNs still make some village visits.

I called their office and learned that Evan’s village had visit coming up. I spoke with Pam, the PHN who was going out and told her about Evan’s case. She said she would be glad to check up on him and teach him to self-cath, but she did not do prostate exams.

The day after her visit she called me to report that Evan was taking the ciprofloxacin without any problems, and that he was feeling much better. He could now urinate without any discomfort; but he still had the pressure sensation in his pelvis, which he continued to describe as “poking” pain. It was somewhat improved, though.

When I first saw him, he had reported a sense of incomplete emptying after urination; that, too, was now gone. Pam taught him to self-cath, which he was able to do without difficulty, though he really didn’t want to. And he had NO post-void residual. She marked the catheter for depth of insertion and measured it at over twice the length of his flaccid penis. I was delighted with this news; I immediately called him and said that he only needed to self-cath if the sense of incomplete emptying returned. He was quite happy about that.

In a few days it will be four weeks since Evan started taking the ciprofloxacin. I will call the health aides in his village and ask them to draw blood for a PSA level and get urine for urinalysis and culture. I am deeply hopeful that he has cleared the Kluyvera and that his PSA is back down to something less than 10. There is still the issue of whether I really felt a nodule; that follow up will require at least a trip to Bethel, and at least two digital rectal exams—mine and Dr. H’s. I want confirmation from a more experienced prostate examiner that a nodule either is, or is not, present. With these added data points I’ll consult the urologist again and we will arrange whatever next step Evan needs.