This document presents a case report of a 43-year-old male who presented with lower urinary tract symptoms including frequent and difficult urination for 5 months. On examination, his prostate was found to be enlarged, hard, and with two nodules. Tests found an elevated PSA level and bone metastases on bone scan. Based on the clinical findings and test results, the provisional diagnosis was carcinoma of the prostate, which was confirmed as metastatic carcinoma of the prostate based on further imaging and lab results. Proposed treatment included hormone therapy, chemotherapy, and newer systemic approaches.

1. A 43yrs old male with Lower
urinary tract symptoms
Presented By
Dr.A.S.M Tanvir Hasan
MS Resident (Phase B)
Department of Urology
Sir Salimullah Medical College Mitford
Hospital, Dhaka

2. Particulars of the patient
Name – Md Salahuddin ahmed
Age - 43 years old.
Sex- Male
Occupation - Tailor.
Religion - Islam
Marital Status – Married
Address – Chakbazar, Dhaka.
Date Of Admission – 14-05-2022
Date Of Exam-14-05-2022

3. Chief Complaints
- Difficulties in micturition for 5 months.
- Anorexia and Loss of weight for 6 months.
- Low back pain for last 2months

4. History of Present Illness
According to statement of the patient, the
presenting complaints started 5 months back with
difficulties in micturition in the form of frequency in
both day and night, initially 8-10 times/day but 15-
20 times/day for the last 2 months, associated with
nocturia, urgency and occasional urge incontinence.

5. History of Present Illness(Contnd…)
He also noticed poor flow of urine not improved by
straining rather stop and start, hesitancy with
prolonged terminal dribbling and sense of
incomplete evacuation of bladder. He also noticed
generalized weakness, anorexia and loss of weight
about 10kg for the last 3 months.

6. History of Present Illness(Contnd…)
• He gave no H/O - Haematuria, Calcuria or Pyuria,
Burning micturition, Fever with chill and rigor.
•No pain in loin, suprapubic or urethral region.
• There is no evening rise of temp, night sweat,
cough, hemoptysis or chest pain

7. History of Present Illness(Contnd…)
But he complains of pain
Site - in lower back and hip region,
Character - dull aching in nature,
Radiation - with no radiation,
Onset - it started gradually,
Duration - present almost all the time,
A/R factors - no A/R factors, and Previous episode
- he had never had a pain like this before.

8. History of past illness
He has no H/O of CVD or trauma. There was no
previous history of jaundice but history of single
blood transfusion. He was given 1 unit of PCV for
anaemia after admission in this hospital.

9. Other history
•Medication : Patient is normotensive,
nondiabetic, nonasthmatic and occasionally
taking drugs for low back pain from local
pharmacy.
•Diet and Allergy : He is habituated to Bangali
diet and has no known allergy to any diet or
drugs.
•Family history : Has come from lower
socioeconomic group, lives in rural area and
none of his family member has suffered from
such kind of illness. He have 1son and one
daughter.

10. •Personal history : He is non alcoholic,non
smoker.
•Immunization history :His immunization
history is not known.

11. General examination
• Appearance - Anxious and Imaciated looking.
• Mental condition - Intelligent.
• Cooperation -Cooperative.
• Decubitus - On choice.
• Body built – Below Average.
• Nutritional status – Below average.
BMI – 19.69 (height- 162 cm,weight – 52 kg)
• Anaemia - Mild.
• Jaundice - Absent.
• Dehydration-Absent.

12. General examination
•Pulse - 80 bpm.
• BP - 120/70 mmhg.
• Temperature – 99 °F
•Respiratory rate - 18 breaths/min.
• Ankle oedema - Absent.
•Lymph node - All accessible LNs are not palpable.
•Skeletal Deformity:Absent
•Thyroid Gland: Normal.
•JVP: Not raised.

13. On genitourinary system examination
•Renal angles – Both renal angles are non-tender.
•Kidney - Kidneys are not palpable
•UB is not palpable.
•Hernial orifices - Are intact.
•EUM, Penis, Palpable part of urethra,Scrotum,
Testes, Epididymis, Palpable part of vas, And
perineum---- Are normal.

14. Per Rectal examination
• No perianal fistula,sinus or Hemorrhoids found
• Prostate is –
Moderately enlarged.
Non tender.
Hard in consistency.
Surface is indurated with two nodule one on
• each lobe.
Rectal mucosa is fixed to it, and
Upper limit could be reached with difficulty.
• Anal tone :Intact.
• Perianal sensation & Bulbocavernous reflex are normal

15. Musculoskeletal and neurological System
Examination
•Bony tenderness over lumbar and sacral region.
•No motor or sensory deficit of both lower limbs
with - Intact knee and ankle jerk.

16. Alimentary System Examination
Abdomen:
Scaphoid in shape, flank is normal, umbilicus is
centrally placed & inverted.
There is no engorged vein, visible peristalsis, visible
cough impulse.
No ascites

17. •Others systemic examination:
- Are normal.

18. Salient features:
•Mr.Salauddin, 43years old tailor from Dhaka,
presented with the complaints of difficulties in
micturition for 5 months in the form of frequency in
both day and night, initially 8-10 times/day but 15-
20 times/day for the last 2 months, associated with
nocturia, urgency and occasional urge incontinence.

19. •He also noticed poor flow of urine not improved by
straining rather stop and start,hesitancy with
prolonged terminal dribbling and sense of
incomplete evacuation of bladder. He also noticed
generalized weakness, anorexia and loss of weight
about 10kg for the last 3 months.

20. • He gave no H/O - Haematuria, Calcuria or Pyuria. -
Burning micturition, Fever with chill and rigor. No
pain in loin, suprapubic or urethral region. There is
no evening rise of temp, night sweat, cough,
hemoptysis or chest pain.

21. •But he complains of pain in lower back and
hip region,which was dull aching in
nature,with no radiation, it started gradually,
but present almost all the time. There was no
aggravating or relieving factors, and he never
had a pain like this before.

22. •He has no H/O - Any other perurethral or per rectal
instrumentation or surgery. No H/O of CVD or spine
trauma.

23. Provisional Diagnosis
Carcinoma Prostate

24. Differential diagnosis:
1.Benign Enlargement of Prostate
2.Granulomatous Prostities

25. Why Ca-Prostate?
-History is relatively of short duration.
- Prostate is hard, indurated with two nodules.
-H/O anorexia, weight loss and bone pain.
- And patient is anaemic.

26. Investigations
Routine investigations:
• Urine for RME with C/S-
no pus cell but few RBC present(8-10/HPF)
• C/S – NO growth
• CBC – 8.9gm/dl
• S. creatinine :0.8mg/dl
• ECG
• X-ray Chest P/A view
• RBS

27. • S.calcium-8.20mg/dl
• S.PSA-41.6 ng/ml
• S.Bilirubin-0.16mg/dl

28. USG of KUB and Prostate with MCC and PVR.
- Volume of Prostate was 54gm
- Echogenecity of postate: Predominantly hypoechoic
lesion in comparison with the normal surrounding
peripheral glandular tissue.

29. Capsule of prostate:
- There is capsular bulging and irregularity associated with an
adjacent focal hypoechoic area often indicates malignant
capsular invasion.
MCC-320ml
PVR-65ml

30. CT scan of abdomen and pelvis-

31. •Bone scan-
A case of multiple osteoblastic skeletal metastasis.

37. Definitive Diagnosis
• Metastatic Carcinoma Prostate

38. Proposed Treatment
•Hormone Therapy:Androgen Deprivation Therapy(ADT)
•Systemic Chemotherapy
•Newer Systemic Approach: Tumour Vaccine(Sipuleucel-
T) and Gene therapy.

41. THANK YOU