A case of J.M., 80/M
J.A.M
80/M, Married
Filipino
Roman Catholic
DOB: June 24, 1942
Buenavista, Bohol
Chief Complaint:
Hematuria
History of Present Illness:
● 4 days PTC
○ Had onset of difficulty in voiding associated with
urinary hesitancy and pain
○ Tried to remedy by increasing oral fluid intake but with no
relief
○ In the interim, patient was not able to urinate for 2 days
○ Tolerated the condition, no consult done, no meds taken
History of Present Illness:
● 1 day PTC
○ Patient decided to take 1 Sambong tablet
○ Patient was able to urinate hours after, characterized as
dribbling and bloody amounting to approx. ½ cup, with 3
episodes
○ This was associated hypogastric pain with PS 3-4/10
○ Tolerated the condition. No consult done
History of Present Illness:
● Morning PTC
○ Still had one episode of hematuria, thus decided to seek
consult at VSMMC-ER
○ No fever, cough, nausea and vomiting, edema, changes
in bowel movements noted
Past Medical History:
● Non hypertensive, non-diabetic, non-asthmatic
● No history of childhood illnesses:measles, mumps, german
measles, and chickenpox.
● No past admissions
● No past surgeries
● No known food or drug allergies
Family History:
● No known heredofamilial diseases in the maternal or paternal
side
● One sibling has breast cancer
Personal and Social history
●
●
●
●
●
●
Occasional alcoholic beverage drinker
Non-smoker
Denies illicit drug use
Eats 3x a day consisting of rice, fish, and vegetables
Drinks 8-10 glasses of water a day
Lives with one child and spouse and two grandchildren
Physical Examination
● General survey: patient is awake, alert, not in respiratory
distress
● Vital signs:
Temp: 37.5 C
BP: 130/80 mmHg
RR: 20 cpm
HR: 80 bpm
O2: 99-100%
Physical Examination
Skin: senile turgor and mobility, warm to touch
HEENT: anicteric sclerae, pink palpebral conjunctiva, moist lips and
oral mucosa, no ear discharges, no alar flaring
C/L: ECE, clear breath sounds, no retractions
CVS: adynamic precordium, DHS, no murmurs
Abdomen: (+) distended abdomen, (+) tenderness hypogastric
area, NABS, soft, no organomegaly
Physical Examination
GUT: Grossly male genitalia, (-) KPS, (-) masses/lesions
Ext: (+)5 cm lacerated wound on left lower leg, Strong peripheral
pulses, CRT<2secs, (-) edema
Neuro: Cranial nerves intact
Sensory: 100% Motor: 5/5 on all extremities
DRE: (+) ~2-3 cm movable mass with rubbery consistency at 11
o’clock
Differentials
Prostate Cancer
Nephrolithiasis
Urinary Tract Infection
●
Rule in:
○ (+) advanced age
○ (+) difficulty voiding
○ (+) hematuria
○ (+) dysuria
○ (+) mass on DRE
●
Rule in:
○ (+) abdominal pain
○ (+) hematuria
○ (+) dysuria
○ (+) difficulty
voiding
●
Rule in:
○ (+) difficulty voiding
○ (+) hematuria
○ (+) dysuria
○ (+) abdominal pain
●
Rule out:
○ (-) nocturia
○ (-) frequent urination
○ (-) firm/hard mass
○ (-) no history of STI’s
○ (-) no family history of
prostate cancer
●
Rule out:
○ (-) nausea
○ (-) vomiting
○ (-) CVA tenderness
○ (+) mass on DRE
●
Rule out:
○ (-) nocturia
○ (-) frequent urination
○ (+) mass on DRE
Diagnosis
Urinary Tract Obstruction Secondary to Benign Prostatic
Hyperplasia
Lacerated Wound, Left lower leg
Basis:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Hematuria
Anuria
Abdominal pain
Difficulty voiding
Poor stream
(+) mass in DRE
Abdominal tenderness
Bladder distention
Advanced age (80yo)
Labs:
CBC
Urinalysis
Prostate Specific
Antigen (PSA)
Creatinine
BUN
BUA
SGPT
SGOT
HbA1C
Serum electrolytes
Gene Xpert
Lipid profile
Imaging
Chest X-ray PAL
Ultrasound KUB
CBC
WBC
HGB
HCT
PLT
N
7.92
115 L
31.70 L
193
82 H
L
11.50 L
M
5.90
E
0.50 L
B
0.10
Creatinine
11.14 H
BUN
74.80 H
BUA
10.60 H
Na
116.90 L
SGPT/ALT
23.00
K
3.63
SGOT/AST
40.00 H
Cl
83.00 L
HbA1C
5.50
iCa
1.00 L
T-PSA
20.57 H
Electrolytes
Plans:
Therapeutic
1.
2.
3.
4.
Tamsulosin 400 mcg/tab OD
Finasteride 5mg/tab OD
Cefixime 200mg/tab BID x 14 days
Infected wound:
Tetanus toxoid 0.5cc/vial injected via
deep IM on left deltoid
Tetanus Immunoglobulin 250 IU/ml
injected via deep IM on right deltoid
Plans:
Attach FBC
Advise for referral for evaluation to Urology
department
Case Discussion
● Benign prostatic hyperplasia (BPH) refers to the
nonmalignant growth or hyperplasia of prostate tissue
and is a common cause of lower urinary tract symptoms
in men
● Disease prevalence has been shown to increase with
advancing age
● Histological prevalence of BPH at autopsy is as high as
50% to 60% for males in their 60's, increasing to 80% to
90% of those over 70 years of age
Stromal and epithelial cell proliferation in the prostate transition
zone (surrounding the urethra) leads to compression of the
urethra and development of bladder outflow obstruction (BOO)
which can result in clinical manifestations of lower urinary tract
symptoms (LUTS), urinary retention or infections due to
incomplete bladder emptying
Observation
● Watchful waiting is a process to manage patients by giving
lifestyle advice
● Examples include weight loss, reducing caffeine intake or
reducing fluid intake in the evening, and avoiding
constipation to try and reduce risk factors and improve LUTS
Medical Therapy
● Alpha-blockers
➔ Alpha 1-adrenoreceptor blockage results in stromal
smooth muscle relaxation thus improving flow
➔ Examples include selective Alpha-blockers such as
Tamsulosin (400mcg once daily) and Alfuzosin (10mg
once daily)
● 5 alpha-reductase inhibitors:
➔ Such as finasteride (5mg once daily) and dutasteride
block conversion of testosterone to DHT
➔ Causing shrinkage of the prostate and takes several
weeks to show noticeable improvement
●
Antimuscarinics:
Increased urgency (overactive bladder) and frequency
blocking muscarinic receptors on detrusor muscle
reduces smooth muscle tone and can improve symptoms in those
with overactivity.
Examples include solifenacin, tolterodine, and oxybutynin
●
In practice, the combination of an alpha-blocker and alphareductase inhibitor is often used to achieve improvements in
voiding symptoms.
●
Surgery
Refractory urinary retention
Recurrent urinary infections
Haematuria refractory to medical treatment (other causes
excluded)
Renal insufficiency
Bladder stones
Increased post-void residual
High-pressure chronic retention (absolute indication
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