Case Report

Susp. Benign Prostate Hyperplasia and Vesicolithiasis

By: Putri Dwi Kartini 04114708080 Supervisor: Dr. Marta Hendry Sp.U

SURGERY DEPARTMENT MEDICAL FACULTY OF SRIWIJAYA UNIVERSITY 2013

IDENTIFICATION
Name Age Sex Address Nationality Religion Occupation

Medical Record
Admitted

: Mr. RS : 73 years old : Male : Harisan Jaya, Ogan Komering Ulu Timur : Indonesian : Moslem : Retirement (builder) : 754231 : September 18th 2013

ANAMNESIS
Autoanamnesis taken on September 21th 2013

Chief Complaint Unable to void 1 month before admitted to hospital.

History of present illness

1 year
difficulty to void, had to push to begin urination decreased force and caliber of stream stopped and started again when urinated Voiding at night up to 5 times at night (nocturia), difficult to postpone urination had sensation of incomplete bladder emptying Bloody urination (-) Stone in urine (-) Defecate + normal Fever (-) Loss body weight (-)

6 months
pain when urinating uncomfortable when urinating stopped and started again when urination with changed the position of the body pain the lower abdomen that referred to the tip of the penis and the scrotum. Bloody urination (-) Stone in urine (-)

2 months
pain when urinating and become more severe after urination bloody urination stone in urination (+) Fever (-) Decrease of body weight (-)

1 month
unable to void and bulging in suprapubic admitted to Charitas Hospital and urethra catheter was fixed.

went to polyclinics Mohhamad Hoesin General Hospital Palembang to get more therapy. Admitted at September 18th 2013

History of past illness

No history of urinary tract infections. No history of using urethra catheter in long term use No history of prostate, bladder, penis, urethra operation No history of diabeties and CVD No history of postpone urination habit No history of trauma at the genitalia, stomach/ hip and back bone area. No history bone pain, paresthesias, weakness or spasticity of lower extremities and regional lymhadenopathy

History of Family disease

History with same complaint as the patient in family denied

PHYSICAL EXAMINATION
General Examination (September 21th 2013) Appearance Consciousness Blood pressure Pulse rate Respiratory rate Temperature Eyes : good : compos mentis : 130/90 mmHg : 88 x/min : 20 x/min : 36,70C : conjunctiva palpebra anemic (-/-), sclera icteric (-/-), pupils isokor, light reflex (+/+)

Neck Thorax Lung Cor Abdomen Genital Upper extremities Lower extremities

: no abnormalities
: no abnormalities : no abnormalities : refer to local examination : refer to local examination : no abnormalities : no abnormalities

LOCAL EXAMINATION
Abdomen

Inspection Palpation Percution Auscultation

: flat : no tenderness : tympani : bowel sound (+) normal

 CVA region Inspection : bulging Palpation : pain ballottement Percussion : pain Suprapubic region Inspection : bulging (-) Palpation : tenderness (+)

dextra
(-) (-) (-) (-)

sinistra
(-) (-) (-) (-)

External genitalia region Inspection : urethra bloody discharge (-), circumcised, urethra catheter no. 16F fixed Rectal toucher TSA good, enlargement of prostate, upper boarder of prostate unpalpable, ruberry consistency, flat surface, no tenderness, feces (+), blood (-).

SUPPORTIVE EXAMINATION
Laboratorium findings (07/09/13)

Routine blood
Hemoglobin Hematocryte Leucocyte Thrombocyte : 9,7 gr/dL : 29 vol% : 9.0/mm3 : 284 /mm3 (N : 14-18g.dL) (N : 40-48vol%) (N : 5000-10000/mm3) (N : 200.000500.000/mm3)

LED Diff. Count

: 120 mm/hour : 0/14/0/45/33/8

Clinical Chemistry:
BSS Ureum Creatinine Uric Acid Na+ K+ : 99 mg/dL : 39 mg/dL : 1,04 mg/dL : 8,1 mg/dL : 140mmol/l : 4,3mmol/l (N : 15-39mg/dL) (N : 0,9-1,3mg/dL) (N : < 8,4) (N : 135-155) (N : 3,6-5,5)

Urine analysis
Epitel cell Leucocyte Erytrocyte Silinder Kristal : Positive (+) : 20-25/ LPB : 80-100/ LPB : negatif : negatif (N : 0-5 / LPB) (N : 0-1 / LBP) (-) (-)

BNO
Result

Multiple semi radioopaque stones in pelvic cavity (size 1,5-2 cm)

USG

No abnormalities in right and left kidney, no enlargement of kidney,

pelvis calices not widening, no stone.

USG

Widening of prostate, 50 x 54mm,

USG

multiple acoustic shadow on vesica urinary, multiple stones (+)

DIFFERENTIAL DIAGNOSIS
Urine Retention ec. Suspect Benign Prostate

Hyperplasia + Vesicolithiasis Urine Retention ec. Suspect Prostate Cancer + Vesicolithiasis

WORKING DIAGNOSIS

Urine Retention ec. Suspect Benign Prostate Hyperplasia And Vesicolithiasis

TREATMENT

Transurethral Resection of Prostate (TURP) Vesicolithotomy

PROGNOSIS

Quo ad vitam
Quo ad functionam

: bonam : dubia ad bonam