Case Presentation (Surgery) : Anish Dhakal (Aryan)

CASE PRESENTATION
(SURGERY)
Presented by: Anish Dhakal (Aryan)
October 15th, 2019
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
2
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.
3
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.
4
Mild = 0 –7
Moderate = 8 – 19
Severe = 20 – 35
This patient’s score based on
history = 18
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
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.
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.
8
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
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
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
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)
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
13
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
14
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 Incontinence

raised blood urea, hydroureter or
hydronephrosis and uraemic manifestations)
Complications of bladder outflow obstruction Uretheral stricture

(Stone, infection, renal failure, hydronephrosis
and diverticulum formation)
Haemorrhage: Occasionally, venous bleeding Retrograde ejaculation & impotence

from a ruptured vein.
Infection, Hemorrhage, Recurrence and Injury

to bladder or prostatic capsule
15
NOTEWORTHY POINTS IN
MANAGEMENT
We 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 खानप
ु रे पनन खान्छु। अप्रेसन त जे गरे पनन गर्दि न।
(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 केर्ि समस्या र्दएको छै न।”
(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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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
17
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
18
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.
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CASE PRESENTATION

Acute retention Hyponatremia

Chronic retention (Residual urine ≥ 200 mL, a Incontinence

Complications of bladder outflow obstruction Uretheral stricture

Haemorrhage: Occasionally, venous bleeding Retrograde ejaculation & impotence

Infection, Hemorrhage, Recurrence and Injury

Quit smoking and limit alcohol intake

Though people’s opinion may seem outright wrong and invalid at

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