He was the last patient of the morning, and as usual, I was running about an hour behind by the time I got to him. He had a twenty minute appointment for abdominal pain. He was the third abdominal pain patient that morning; the first two had been women of reproductive age who also had twenty minute appointments.
The first thing he told me when I walked into the room was that he had to make his 3:00 check in to catch the last plane home. He had borrowed the $200 plane fare from his village council to come in for the appointment, and he couldn’t afford to stay over. He barely had money for lunch.
A bandy little man in his mid-forties, Evan (e-VAN) might weigh 135 pounds with all his clothes on and his pockets full of pennies. His round face and full cheeks proclaimed his Yupik Eskimo heritage. His English was good, so we didn’t need an interpreter.
I reviewed his chart before going into the exam room. I know several of his family members, but had never seen Evan before. He has had complaints of lower abdominal pain and dysuria (painful urination) for several months. He came to the hospital about two months earlier and was seen by one of the physicians in my clinic. Her work-up included a clean-catch urinalysis (CCUA), which showed more than five but less than ten white cells, and a few red cells; a complete blood count (CBC) with slightly high white cell count at 15,000; and a prostate specific antigen (PSA)--drawn before the prostate exam--of 11.6.
What? 11.6?? Holy cow. The top end of normal is 4, and the highest PSA I’d ever seen (not doing a lot of men’s health) was just over 7. But 11.6? Wow. She documented a normal and unremarkable prostate exam and diagnosed prostatitis. He was given a six-week course of levofloxacin and told to follow up in two months. Unfortunately, no urine culture was done.
The day before I saw him, he had gone to the village clinic and reported that he still had the abdominal pain, it still hurt to pee, and he was tired of how long this was taking to get better. He took all those pills the hospital sent out, so why wasn’t he any better? The health aide reported him to me during radio medical traffic; I did not have his chart in front of me, but said what I always say in such cases: any time the patient does not get better, he or she needs to come back to Bethel for a re-check. Especially for a complex complaint such as abdominal pain.
“The problem,” the health aide told me, “is money. He has no income, he lives by subsistence. He is uninsured.” Meaning no Medicaid to pay for his travel. As an Alaska Native, his health care and all his medications are free to him; but the transportation to get to that care is up to him. I asked her to see if his family or the village council could loan him the money to fly in, but did not know the outcome until the next morning when I saw his name on my patient schedule. I was relieved to know that he had made it.
Before I went in to see him, I had my nurse draw his blood for a PSA, ask him to void spontaneously for a CCUA, and then straight-cath him to get a post-void residual. She did; he had 300 milliliters of retained urine, which is high for a relatively young man.
He looked quite well. He had normal vital signs and was sitting comfortably in the chair. I had watched him walk in from the waiting area, and he moved easily. His manner was shy and soft-spoken; he answered questions clearly and was an excellent historian. He confirmed that he had taken every single one of those big antibiotic pills for a full six weeks.
“Even I took them,” he said, “I never got better. It stings when I pee, and it is poking pain down here.” He gestured to the supra-pubic area.
His abdominal exam was benign, no mass, no tenderness. His genital exam was normal. His rectal exam revealed a normal rectal sphincter and vault, with no evidence of an abscess. His prostate, however, was huge.
Now, the caveat here is that I have not done all that many prostate exams. I know boggy from firm, and normal from enlarged, and I have felt an asymmetric prostate. But I have never felt a prostate nodule, and I could not begin to estimate gram-weight based on my digital rectal exam.
Evan’s prostate was the biggest I had ever felt. With him bending over the exam table, my finger went straight in and then straight up. The consistency was firm and the shape seemed symmetric. He had the usual discomfort with the exam that most men do, but no remarkable level of pain. But then, on the left lower side, I noted a difference in texture. More hardness. Was it a nodule? I wasn’t sure. It caused him no additional discomfort when I pressed it.
With the exam over, Evan went to have lunch while we waited for the lab to report the CCUA and the PSA. Once I had those results, I would call the urologist in Anchorage for a consult.
The CCUA came back quickly, and showed thirty to fifty white cells, ten to twenty red cells, and positive nitrites. He definitely had a urinary tract infection. Since he reported no improvement with six weeks of levofloxacin, it was probably the same infection, resistant to that antibiotic, and now worse. Since a culture was not done, we can’t know for sure.
I waited all afternoon for the PSA result. My nurse called the lab several times and was told it wasn’t ready yet. While I waited, I talked to my favorite consulting physician, Dr. H. He is a family practitioner (FP), and one of the smartest docs I have ever worked with. I also just like him a lot, and enjoy learning from him.
When I told him about the physical exam and my concern that I had felt a nodule in Evan’s prostate, he held out his arm with the wrist extended. Pressing the bony prominence just distal to the radial pulse, he said “prostate nodule.” Pressing the large muscle at the base of the thumb, he said “normal prostate.” Pressing the space on the back of his hand between thumb and forefinger, he said “boggy prostate.” Okay, that was definitely a nodule that I felt.
Three o’clock came and went and Evan left to fly home to his village. Finally, about 4:30 I called the lab to find out what the delay was on the PSA. The lab tech apologized for the delay and said that he had never had so much trouble running this test before. He had to do multiple dilutions in order to get the machine to give a result. He had just finished the final run, and was reporting Evan’s PSA at 38.9. My heart sank.
I dialed the Alaska Native Medical Center in Anchorage and asked for the urologist on call, glad once again for the excellent specialty consultation and referral service we have available around the clock. He was on the phone with me in less than two minutes. I presented Evan’s case to him, and after hearing all the details, he gave me reassurance.
“A PSA that goes that high, that quickly, is highly unlikely to be cancer. If it is, then it is exceedingly aggressive, and the patient has an extremely poor prognosis. Much more likely is that this is prostatitis caused by a bacteria resistant to levofloxacin. Too bad a culture wasn’t done last time.”
He wanted more definitive imaging before speaking to the question of the nodule I felt. He asked if our ultrasonographer could image the prostate trans-abdominally; he knew we do not have a trans-rectal probe. I checked, the answer was no. He wondered if Evan might have a prostate abscess; he has seen very few of those in Alaska, but it is a possibility. He also wondered how well Evan would do with self-catheterization four times a day. “As much as patients don’t like it, it is the best thing for them when there is that much residual. It will allow his bladder to cycle, and keep him from re-infecting.”
“Start him on Septra, and then adjust according to sensitivity when the culture result comes back. Call me in a few days when you have that information,” he said.
Though it was after closing time for the village clinic, I called and was happy to find one of the health aides still there. I told her to call Evan and ask him to come by first thing in the morning to pick up the medication. I trust that he will, and that he will take every last pill we give him.
What I keep thinking about is that through this entire two months, Evan's complaint has always been that he has pain, never that he feels sick. He has never had fever, been nauseated, had a change in appetite or change in stool. His prostate is certainly large enough--swollen?--to cause the "poking" pain he describes.
But despite the reassurance, I am still worried about him. I know I felt a nodule. Regardless of infectious issues, he needs to go to Anchorage for definitive imaging of his prostate, and appropriate follow up with the urologist. When I spoke to him about possibly going in, he said that he could not go alone. “I’m not a city boy,” he said. “I’ll get lost.” The look in his eyes spoke volumes. He doesn’t have $500 for his own plane ticket, much less $1,000 to bring along an escort.
Somehow we will see to it that he gets there, and gets the care he needs. Stay tuned for the rest of the story…
Labels: Bush Medicine