2. INTRODUCTION (CHIEF COMPLAINT)
A 74 years old male from Gorkha presented to district hospital outpatient
department with complaints of:
Increased frequency of micturition for 1 year
Poor stream for 1 year
Urgency for last 2 months
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3. HISTORY OF PRESENTING ILLNESS
The patient was apparently well 1 year back when he noticed increased
frequency of urine. The increment was insidious in onset, and gradually
progressive viz. up to 12 to 14 times a day without increasing water intake.
There is history of poor stream which exaggerated on straining. It was
sometimes followed by passage of few drops of urine in his undergarments.
There was also history of inability to hold urine once the urge initiates. On
few occasions he had soiled his clothes due to inability to hold the urine
before rushing for micturition. Sometimes, he had trouble starting the
urination as well.
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4. There was no history of blood in urine, trauma, instrumentation or
surgery of urinary tract.
No history of fever, reduced appetite or involuntary loss of weight.
No history of known chronic illness. No surgical procedures
performed. Not under any medication at present. No significant
family history.
Patient is a smoker with a history of 25 pack years and consumes 1-
2 glass of locally made alcohol daily for last 45 years.
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5. Mild = 0 –7
Moderate = 8 – 19
Severe = 20 – 35
This patient’s score based on
history = 18
6. EXAMINATION:
GC: Fair, Thinly built, Well oriented to time, place and person.
PILCCOD: Absent
No drowsiness, dry/covered tongue & Cheyne-Stokes respiration
Vitals:
BP: 150/110 mm Hg (right) and 160/100 (left)
RR: 22 bpm
Pulse: 95 bpm, regular, normal volume, character, arterial wall condition with no
radioradial or radiofemoral delay
sP02: 95% in room air
7. ABDOMINAL EXAMINATION:
Inspection: Normal shape of abdomen, all quadrants moving equally with
respiration. No dilated veins, scar marks, pigmentation, visible peristalsis. No
any abnormal mass
Palpation: No local rise in temperature. Tenderness absent on superficial and
deep palpation
Percussion: Each quadrant had tympanic note
Auscultation: Normal bowel sounds were present
Urinary System:
No swelling in loin and renal angle. Kidneys and bladder were not palpable.
Murphy’s Kidney Punch (Renal angle tenderness) was absent bilaterally.
8. PER-RECTAL EXAMINATION
Prostate Examination:
A swelling was palpated with smooth surface, firm rubber like
consistency, non tender with deepened median sulcus and lateral
grooves.
Mobility of rectal mucosa was not restricted.
Examination of perianal sensation and anal tone to detect S2 to S4
cauda equina lesion: Sensation and anal tone was normal.
Other findings of digital rectal examination were within normal limits.
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9. Respiratory Examination:
Inspection: No visible deformity, scar marks, dilated veins,
No use of accessory muscles of respiration
Palpation: No tenderness, abnormal mass. Position of trachea
Percussion: Resonant note
Auscultation: B/L equal air entry with no added sounds
Cardiovascular examination:
S1, S2, M0
No raised JVP, apical impulse normal, no crepitation or swelling of
extremities
10. NEUROLOGICAL EXAMINATION
Nervous System examination (to exclude a neurological lesion due to
diabetes mellitus, multiple sclerosis, cervical spondylosis, tabes
dorsalis):
GCS: 15/15
Cranial nerves were grossly intact
Sensory and motor examination was normal
Reflexes were normal
No signs of meningeal irritation
No signs suggesting cerebellar lesions
11. INVESTIGATIONS
Haematology:
(TLC =9.7*103/mm3, N=66%, L=30%, M=2%, L=2%)
Haemoglobin = 14.2 g/dL
Bio-chemistry:
Random glucose= 77mg/100 mL
Creatinine = 0.9/100 mL (0.7-1.4 mg/100mL)
Na+= 132 (Normal 135-148 mmol/L
K+= 4.2 (Normal 3.8-5.5 mmol/L)
Urine R/E was within normal limits
Ultrasound revealed Grade II enlargement of prostate 11
12. ADDITIONAL INVESTIGATIONS
THAT COULD BE DONE
Serum Prostate Specific Antigen:
Detection of prostate carcinoma (Normal: 4 ng/mL; Ca prostate: >10
ng/mL; >35 ng/mL: Very likely Ca)
Cystourethroscopy:
To exclude urethral stricture, bladder carcinoma and occasional non-
opaque vesical calculus
Urodynamics:
2 or 3 voids should be recorded (excess of 150-200 mL)
Flow rate <10 mL/s is significant (Normal: >15 mL/s; Intermediate: 10-15
mL)
Voiding pressure: >80 cm of H2O is significant (Normal: <60 cm of H2O;
Intermediate: 60-80 cm of H2O)
13. MANAGEMENT
Patient was counseled about the condition and probable need for surgery
for the same.
Drugs prescribed:
Tablet Nifedipine 10 mg PO stat
Capsule Tamsulosin 0.4 mg OD for 1 month
Tablet Finasteride 5 mg OD for 1 month
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14. OPERATIVE TREATMENT THAT
COULD BE PERFORMED
Transurethral resection of prostate
Freyer’s suprapubic transvesical prostatectomy
Millin’s retrograde prostatectomy
Young’s perineal prostatectomy
Transurethral balloon dilatation of prostate
Minimally invasive techniques:
Holmium laser - a pulsed solid state laser has been used to remove the
prostrate adenoma
Green light laser – use to vaporize the prostrate tissue, not as useful as
holmium laser
Intraurethral stent if patient unfit for surgery
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15. Indications of the Surgery Complications of the Surgery
Medical therapy has failed Water intoxication with CHF
Acute retention Hyponatremia
Chronic retention (Residual urine ≥ 200 mL, a
raised blood urea, hydroureter or
hydronephrosis and uraemic manifestations)
Incontinence
Complications of bladder outflow obstruction
(Stone, infection, renal failure, hydronephrosis
and diverticulum formation)
Uretheral stricture
Haemorrhage: Occasionally, venous bleeding
from a ruptured vein.
Retrograde ejaculation & impotence
Infection, Hemorrhage, Recurrence and Injury
to bladder or prostatic capsule
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16. NOTEWORTHY POINTS IN
MANAGEMENTWe had to send the patient to a private hospital as our USG machine was under
maintenance. He was very annoyed that government hospital didn’t had the
ultrasound facility
The patient was willing to take any medications for the urinary symptoms but was
very reluctant for any surgeries.
He said and I quote:
औषधी बरु जती खानुपरे पनन खान्छु । अप्रेसन त जे गरे पनन गर्दिन।
(Translation: I could take any amount of medications for my urinary problems but I will
not go for surgery at any cost)
He was also told previously that he had high blood pressure but had refused to be
under regular medications. He stated – “एकपटक प्रेसरको ओखनत खाएपछी सधै
खानुपछि। त्यो प्रेसर बढी भएर मलाई के र्ि समस्या र्दएको छैन।”
(Translation: Once I start medicines for high blood pressure, I have to be on it for rest of
my lifetime and the blood pressure is not causing any problems at present)
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17. HEALTH PROMOTION
ADVICE/LIFESTYLE MODIFICATIONS
Quit smoking and limit alcohol intake
Minimization of Salt intake (WHO: <5 g/1 teaspoon of salt a day,
no added salt, avoid more salty and spicy food)
Daily BP monitoring at local pharmacy and follow up
Decreasing fluid intake in the evening
Limiting diuretic products including alcohol and caffeine
Double voiding to empty the bladder more completely
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18. CLINICAL RESEARCH QUESTION
Efficacy of Tamsulosin Monotherapy compared with Combination
Treatment with Finasteride in a cohort of elderly patients (>65
years) with mild to moderate BPH based on IPSS
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19. REFLECTION
Though people’s opinion may seem outright wrong and invalid at
the first sight, the need to show respect, utter patience and
tolerance.
The role of counseling is to provide all facts and figures implying
truth not always to persuade or to guarantee dynamic change in
patient’s opinion.
No “all or none phenomenon” in medicine. Even though the patient
is not compliant, to the very least we could still provide some
treatment, health promotion measures or non invasive monitoring of
their health condition.