CASE PRESENTATION

Urine Retention due to Suspect Benign Prostatic Hyperplasia

By : Prassaad Arujunan S.Ked Consultant : dr. Marta Hendry Sp.U

Patient Identification
Name Age Sex Address : Mr. FR : 74 years old : Male : Tanjung Raja, Kayu Agung, Ogan Komering Ilir Nationality : Indonesian Religion : Moslem Occupation : Farmer Admitted : 22nd April 2013

Anamnesis Autoanamnesis was taken on 1st May 2013

Chief complaint: Unable to void one week before admitted to hospital.

History of present illness

difficulty to void hesitancy beginning of urinary flow decreased force and caliber of stream sensation of incomplete bladder emptying, increasing of urinary frequency, voiding at night up to 6x at night (nocturia)

- difficulty to void - had to push to begin urination - decreased force and caliber of stream - stopped and started again when urinated - post void dribbling - Voiding at night up to 8x at night (nocturia) - difficult to postpone urination, - had sensation of incomplete bladder emptying. - Bloody urination (-), sandy urination (-), stone in urin (-) defecate (+) normal, fever (-), and loss of body weight (-)

- Unable to void - Bulging in suprapubic

Admitted to Charitas Hospital , a urethra catheter No.16 was fixed

RSMH (22/4/13)

6 Months

1 month

1 week

History of past illness:

No history of trauma at the genitalia, stomach/ hip and back bone area. No history of using urethra catheter. No history of urinary infections, no history of piuria No history of prostate, bladder, penis, urethra operation No history of urinary stone, bloody urine (-), back pain (-) No history of diabetes and stroke

Physical Examination
a) General Examination (On 1stMay 2013) Appearance : good Consciousness : compos mentis Blood pressure : 130/80 mmHg Pulse rate : 84 x/min Respiratory rate : 22 x/min Temperature : 36,8 0C

 Eyes : conjunctiva palpebra anemic (-/-), sclera icteric (-/-), pupils isokor, light reflex (+/+) Neck : no abnormalities Thorax : no abnormalities Abdomen : refer to local examination Genital : refer to local examination Upper extrimities : no abnormalities Lower extrimities: no abnormalities

b) Local Examination CVA region Inspection : bulging Palpation : pain Percussion : ballottement Suprapubic region Inspection : bulging (-) Palpation : pain (-) External genitalia region Inspection :uretrhra catheter No. 16F fixed, urine clear, bloody discharge (-), circumcised. Inguinal Region Inspection : no bulging right (-) (-) (-) left (-) (-) (-)

Rectal toucher ( Digital Rectal Examination ) TSA good, bulbous cavernous reflex (+), ampulla not collapse, smooth mucosa, mass (-), enlargement of prostate, upper boarder of prostate unpalpable, ruberry consistency, flat surface, no tenderness, nodule (-), feaces (+), blood (-).

Supportive Examination
Laboratorium findings (22/4/13) Routine blood: Hemoglobin : 12,7 gr/dL Hematocryte : 39 vol% Leucocyte : 7100/mm3 Thrombocyte : 337.000/mm3 LED : 10 mm/hour Diff. Count : 0/3/3/67/25/6

Clinical Chemistry: BSS : 102 mg/dL Ureum : 29 mg/dL Creatinine : 1,0 mg/dL Na+ : 144 mmol/l K+ : 4,9 mmol/l Urine analysis: Epitel cell : (-) Leucocyte : 2-5 / LPB Erytrocyte : 1 / LPB Silinder : (-)

USG

No abnormalities in right and left renal, no enlargement of kidney, sinus-renal parenchyma clear in appearance, pelvis calices not widening, no stone.

 Prostate : : Widening of prostate, 43 mm x 45 mm , weigh

36,9 gram, parenchym homogeneous.

Vesica urinary : shape and size is normal, the wall is irregular,

Differential Diagnosis
Urine retention due to suspect Benign Prostatic Hyperplasia Urine retention due to suspect Prostate Cancer

Working Diagnosis
Urine retention due to suspect Benign Prostatic Hyperplasia

Treatment
Transurethral Resection of Prostate (TURP)

Prognosis
Quo ad vitam : bonam Quo ad functionam : dubia ad bonam

Case Analysis
Based on history, the patient develop Lower Urinary Tract Symptoms (LUTS)

LUTS can be caused by several urological disorders such as benign prostatic hyperplasia prostate cancer prostatitis neurogenic bladder bladder neck stenosis urethral stricture urethral tumor Penis tumor urethral stone Phimosis Paraphimosis

Diagnosis can be removed through the history and physical examination of the following:

Patient aged 74 years and circumcised phimosis and paraphimosis can be removed. Fever (-), RT exam is not painful prostatitis (-) History of previous prostate surgery and trauma (-) bladder neck stenosis(-) DM (-), stroke (-), spinal trauma (-), defecate normal and from RT TSA good neurogenic bladder (-)

History of trauma (-), history of prostate operation, history of UTI (-), history of pyuria () and at genitalia region on local examination the patient using urethra catheter urethral strictures, urethral tumor, urethral stone, penis tumor (-) History of sandy urination (-), hematuria (-), urinary stone (-), back pain (-) urethral stones History straddle injury (-), a history of trauma to the abdomen / waist (-) urethral trauma

The differential diagnosis that cannot be excluded in this patient from history and physical examination is benign prostate hyperplasia and prostate cancer

From RT, prostate cancer can already be removed. From USG, there is enlargement of the prostate, weight 36,9 gram. But around the prostate does not look like the picture of the ultrasound image hipoechoic seen in prostate cancer.

 But the gold standard to differentiate benign prostatic hyperplasia and prostate cancer is histopathology from prostate tissue. We can conclude the working diagnosis for this patient is suspect benign prostatic hyperplasia. The treatment for this patient is Transurethral Resection of the Prostate (TURP). Prognosis for this patient, quo ad vitam is bonam dan quo ad functionam is dubia ad bonam.

THANK YOU FOR THE KIND ATTENTION