Case report

URINE RETENTION ET CAUSA BENIGN HYPERPLASIA PROSTAT By :

Arief Rahman (0718011046) Eka Aprilia Arum K (0818011017) Kania Anindita B (0818011071)

Perceptor : dr. Mars Dwi Tjahyo, Sp.U

Initial Name Sex Age Nationality Occupation Address

: Mr. S : Male : 50 years old : Javanese : Farmer : Lampung Timur

ANAMNESIS Taken From : Auto & alloanamnesis January 15th 2013 03.00 p.m. Chief complain : difficult to urination since 6 month before entering hospital Additional complains : Should straining during urination, small amounts, weak, and lethargic..

History of the Illness : Patient came to the Abdul Moeloek Hospital with difficult urination since six months before entering the hospital. Patients feel there are still remaining after urinating or not satisfied after urination, frequent urination stops, and weak urine flow. Patients often wake up at night because it feels the urge to urinate. Patients often urinate every half hour. Complaints difficult urination is accompanied should straining during urination, and in small quantities. Urinate reddish or with blood denied by the patient. Complaints accompanied with weakness and lethargy. Because of his complaints did not improve the patient came to the RSAM. The patient had no complaints body heat, and a good appetite.

Continue..........

The History of Illness: The patient had no history of hypertension The patient denies ever having a history of diabetes Family's diseases History: No relatives of patients family suffering from this disease before.

PHYSICAL DIAGNOSTIC
Present status : normal Generalist status : normal Lokal status : Region of the external genitalia:
Inspection: external urethral orifice no abnormalities, catheter inserted Palpation: two testes palpable, right and left, chewy consistency

Regio of Anal Inspection: Normal Forms, bump (-), hemorroid (-) Digital Rectal Examination: Tone of sphincter ani is strong, Rectal mucosa slick, mass (-), pain (-) Prostate palpable 6 cm, chewy consistency (such as touching the nose) and flat surface and smooth, pain (+), the upper limit of intangible Handschoend: There stool (slight, brownish yellow color), mucus and blood (-)

General Check up General condition Consciousness Height Weight Blood Pressure Pulse Temperature Breath (frequence&type) Nutrition condition Skin

: Mild illness : Composmentis : 164 cm. : 60 kg : 120/80 mmHg : 80 x/minute : 36,8 C : Regular 22 x/minute : Enough : Normal skin turgor

LABORATORY (RSAM JANUARY 12th 2013) Hb Leukosit Hitung jenis :

Basofil ` Eosinofil Netrofil batang Netrofil segmen Limfosit Monosit

: 12,3 gr/dl ( 13,5-18,0 gr/dl) : 11.200 /mm3 (4.500-10.700/ul)

:0% :1% :0% : 78 % : 11 % : 10 % (0-1 %) (0-3 %) (2-6 %) (50-70 %) (20-40 %) (2-8 %)

Bleeding time

: 2 minute

(1-7 minute)

DIAGNOSE
Working diagnosis

Urine Retension et causa suspect Benign Prostat Hiperplasia

Differential diagnosis Retensio urine et causa Benign Prostat Hiperplasia Retensio urine et causa Urinary Track Stone Retensio urine et causa Urethral Stricture Retensio urine et causa Carsinoma Prostat
Basic Diagnostic - Anamnesis - Physical diagnostic: rectal digital examination

MANAGEMENT
Overcoming difficult urination: Installation FoleyCatheter Maintaining Fluid Balance: IVFD RL Overcoming pain: analgesics (ketorolac) Prevention of infection: Broad Spectrum Antibiotics (Ceftriaxone) Planning BNO IVP, Ultrasound Pelvis Operative Plan: Trans urethral esection of the Prostate (TURP)

SUGGESTION EXAMINATION BNO, IVP USG Pelvis Laboratorium : Urinalysis, electrolyte level, complete blood

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

DISCUSSION
In this case, the patient had been diagnosed with retension urine et causa suspect benign hyperplasia prostat, based on history of illness, and the clinical appearance.

The anamnesis :

difficult to urination since 6 month before entering hospital there is residual urine after urination frequent stops during urination every a half hour get urination weak urine jet often waking at night because it feels like urination must be straining during urination as well as the amount of urine slightly.

Regio of Anal Inspection: Normal Forms, bump (-), hemorroid (-) Digital Rectal Examination: Tone of sphincter ani is strong, Rectal mucosa slick, mass (-), pain (-) Prostate palpable 6 cm, chewy consistency (such as touching the nose) and flat surface and smooth, pain (+), the upper limit of intangible Handschoend: There stool (slight, brownish yellow color), mucus and blood (-)

Benign Prostat Hyperplasia

INTRODUCTION:
Benign prostatic hyperplasia (BPH) is proliferation of the cellular elements of the prostate Second place disease after urinary tract stone disease 50% of Indonesian men over the age 60 y.o and 80% over age 80 y.o suffering from BPH Normaly prostat will proliferation in the third decade of life and clinically in the fifth decade of life

ANATOMY OF PROSTAT
The prostate is a genital organ found only in males because it is the only producer of semen produced by men. Have weight in adult 20 gr Prostate is a walnut-sized gland Produces Prostate Specific Antigen (PSA) Primary function is to secrete a slightly alkaline fluid that forms part of the seminal fluid, a fluid that carries sperm.

WHAT CAUSED BPH?

BPH is part of the natural aging process (increase in androgen receptor) Dihydrotestosterone (DHT) may play a role Unbalancing between estrogen and testosteron Reaction between stroma cell and prostat epitelial cell Decrease of death cell (apoptosys) Stem Cell Theory

SIGN AND SYMPTOM

Urinary frequency Urinary urgency Hesitancy Incomplete bladder emptying Straining Decreased force of stream Dribbling

DIAGNOSIS
Anamnesis - Ask the sign and symptom - Using International Prostat Symptom Score Physical diagnostic - Digital Rectal Examination Further examination - Urinalysis - Uroflowmettry - PSA (prostat specific antigen) - Imaging - Transrectal ultrasound of prostate

Anamnesis
The anamnesis consist of: Complaints are perceived and how old complaint that had disrupted History of other diseases and diseases of the urogenitalia tract (ever experienced injury, infection, or surgically) Medical history in general and state of sexual function Drugs that are currently consumed which may cause complaints micturition.

INTERNATIONAL PROSTAT SYMPTOM SCORE

Interpretation of IPSS: Score 0-7: mild symptoms Score 8-19: symptomatic moderate Score 20-35: severe symptomatic.

PHYSICAL DIAGNOSTIC
First examination for BPH is Digital Rectal Examination, include of:
larged prostate prostate consistency Nodules Sfingter ani tone

Palpation of abdomen for

enlarged bladder enlarged kidneys constipation

Further examination
Urinalysis
Reveal the leukosituria and hematuria Finding type of bacteria in urinary tract and sensitifity of bactery to antibiotic has been tasted

Uroflowmettry

is a diagnostic test used to measure the flow of urine during urination the patient will be asked to urinate into a funnel connected to the electronic uroflowmeter, which records data about the urine flow on a flow chart Normal range for uroflowmettry:
Ages 4 - 7

Ages 8 - 13

The average flow rate for both males and females is 10 mL/sec. The average flow rate for males is 12 mL/sec. The average flow rate for females is 15 mL/sec. The average flow rate for males is 21 mL/sec. The average flow rate for females is 18 mL/sec. The average flow rate for males is 12 mL/sec. The average flow rate for females is 18 mL/sec. The average flow rate for males is 9 mL/sec. The average flow rate for females is 18 mL/sec.

Ages 14 - 45

Ages 46 - 65
Ages 66 - 80

 PSA (PROSTAT SPECIFIC ANTIGEN)

PSA is synthesized by prostate epithelial cells and is organ specific but not cancer specific if PSA levels high means:
a. faster growth of prostate volume b. complaints due to BPH / emission rate of urine more worse c. the occurrence of acute urinary retention

Range PSA levels were considered with normal by age: 40-49 years: 0 to 2.5 ng / ml 50-59 years :0-3, 5 ng / ml 60-69 years :0-4, 5 ng / ml 70-79 years: 0 to 6.5 ng / ml

Imaging - Abdomen Plain Foto - Using to find:

- Stone in urinary trsct - Prostat stone or calculusIntravenous Pielography

- Intravenous Pielography IVP examination in BPH done by most urologists for revealed the presence of:
abnormalities in upper urinary tract diverticular seluler the bladder stone jar estimated residual urine volume estimates prostate size

 Trans Rectal Ultrasonography This examination can visually knowing: - Size and volume of prostat - Maligna hyperplasia prostat - Guidence for prostat aspiration biopsy - Number of residual urine - Finding another disease in vesica urinary

MANAGMENT

Watchfull and waiting

Using for patient with IPSS range <7 The treatment havent drugs, just education such as:
Dont drink coffee or alcohol after eat Reduce consumption of foods and drinks that irritate vesica urinary Limiting use influenza drugs, containing fenilpropanolamin Reduce eat hot and salt food Dont hold urine for too long

MEDICATION
Antagonis -Adrenergic Inhibitor

Working for inhibit the prostat smooth muscle contraction Effect: Type
Increase uronary flow Relieve frequnty symptom of urinary Increase quality of life

Non-specific fenoksibenzamin Specific

Short acting prazosin Long acting terazosin, doksazosin, tamsulosin

Side effect

Orthostatic hypotension Fatigue Headache Ejaculation retrograd

Inhibitor 5 -reductase

Working to blocks the conversion of testosterone to dihydrotestosterone Effect:

Relieve BPH symptoms Increase urinary flow rate Decrease the size of the prostate Decrease acute urin retension

Type of drug: Finasteride Finasteride can decresing of PSA until 50% from range of cancer early detection

SURGERY
PROSTATECTOMY A prostatectomy is using for benign disease (BPH) involves removal of only the inner portion of the prostate (simple prostatectomy) Indicated for prostat with size > 80-100 cm3 Complication:
Impotence Incontinence Retrograde ejaculation Strikture urethra

TRANSURETHRAL PROSTATECTOMY (TURP) "gold standard" of BPH Removal of the core of the prostate with a resectoscope (an instrument passed through the urethra into the bladder) Can repair 90% of BPH symptomp Complication:
Bleeding Incontinensia Contractur of bledder neck Erection disfunction

Trans urethral incision of the prostat (TUIP)

TUIP can only be done on men with smaller prostates The surgeon only makes one or two small cuts in the prostate with an electrical knife or laser The surgery mor faster than TURP Less complication

REfference
Anonim. 2010. Benign Prostatic Hyperplasia, www.2rui.comdiakses pada tanggal 3 Desember 2011 Anonim. 2010. Benign Prostatic Hyperplasia, www.cmc.cuk.ac.krdiakses pada tanggal 3 Desember 2011 Anonim. 2010. Pedoman Penatalaksanaan BPH di Indonesia. www.prostate-research.org.uk Arthur C. Guyton, dkk. 2006. Buku Ajar Fisiologi Kedokteran. Edisi 9. Jakarta: EGC Fleshman, James W. 1999. Schwartzs Principles of Surgery ed.7th. New York: Mc Graw-Hill, Nasution. 2007. Pendekatan Farmakologis pada Benign Prostatic Hyperplasia (BPH)http://www.tempo.co.id/medika/online/tmp.online.old/pus-3.htm.diakses pada tanggal 3 Desember 2011 Mc.Connell, Guidlines for Diagnosis and Managment of BPH. http://www.urohealth.org/bph/specialist.future/chp43.asp