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Urinary Obstruction Case Studies
The 57-year-old patient noted urinary hesitancy and a decrease in the force of his urinary stream for several months. Both had progressively become worse. His physical examination was essentially negative except for an enlarged prostate, which was bulky and soft.
Studies
Results
Routine laboratory studies
Within normal limits (WNL)
Intravenous pyelogram (IVP)
Mild indentation of the interior aspect of the bladder, indicating an enlarged prostate
Uroflowmetry with total voided flow of 225 mL
8 mL/sec (normal: >12 mL/sec)
Cystometry
Resting bladder pressure: 35 cm H2O (normal: <40 cm H2O)
Peak bladder pressure: 50 cm H2O (normal: 40-90 cm H2O)
Electromyography of the pelvic sphincter muscle
Normal resting bladder with a positive tonus limb
Cystoscopy
Benign prostatic hypertrophy (BPH)
Prostatic acid phosphatase (PAP)
0.5 units/L (normal: 0.11-0.60 units/L)
Prostate specific antigen (PSA)
1.0 ng/mL (normal: <4 ng/mL)
Prostate ultrasound
Diffusely enlarged prostate; no localized tumor
Diagnostic Analysis
Because of the patient’s symptoms, bladder outlet obstruction was highly suspected. Physical examination indicated an enlarged prostate. IVP studies corroborated that finding. The reduced urine flow rate indicated an obstruction distal to the urinary bladder. Because the patient was found to have a normal total voided volume, one could not say that the reduced flow rate was the result of an inadequately distended bladder. Rather, the bladder was appropriately distended, yet the flow rate was decreased. This indicated outlet obstruction. The cystogram indicated that the bladder was capable of mounting an effective pressure and was not an atonic bladder compatible with neurologic disease. The tonus limb again indicated the bladder was able to contract. The peak bladder pressure of 50 cm H2O was normal, again indicating appropriate muscular function of the bladder. Based on these studies, the patient was diagnosed with a urinary outlet obstruction. The PAP and PSA indicated benign prostatic hypertrophy (BPH). The ultrasound supported that diagnosis. Cystoscopy documented that finding, and the patient was appropriately treated by transurethral resection of the prostate (TURP). This patient did well postoperatively and had no major problems.
Critical Thinking Questions
- Does BPH predispose this patient to cancer?
- Why are patients with BPH at increased risk for urinary tract infections?
- What would you expect the patient’s PSA level to be after surgery?
- What is the recommended screening guidelines and treatment for BPH?
- What are some alternative treatments / natural homeopathic options for treatment?
Expert Solution Preview
Introduction:
Urinary obstruction is a condition characterized by a blockage or narrowing in the urinary system, leading to impaired urine flow. The case study presented involves a 57-year-old patient who presented with urinary hesitancy and a decrease in the force of his urinary stream. The patient’s physical examination revealed an enlarged, bulky, and soft prostate. Various diagnostic tests were conducted to confirm the diagnosis of urinary outlet obstruction secondary to benign prostatic hypertrophy (BPH). The patient was subsequently treated with transurethral resection of the prostate (TURP) and achieved a favorable postoperative outcome. In this response, we will address the critical thinking questions related to the case study.
1. Does BPH predispose this patient to cancer?
Benign prostatic hypertrophy (BPH) itself does not directly predispose the patient to prostate cancer. However, the presence of BPH may complicate the diagnosis and management of prostate cancer. Both BPH and prostate cancer can coexist, and the symptoms of BPH may mask the presence of prostate cancer. It is essential to monitor patients with BPH for the development of prostate cancer through regular prostate-specific antigen (PSA) screenings and digital rectal examinations.
2. Why are patients with BPH at increased risk for urinary tract infections?
Patients with BPH are at an increased risk for urinary tract infections (UTIs) due to the obstructive nature of the condition. The enlarged prostate can cause urine stasis and create an environment favorable for bacterial growth. Urine retention behind the obstruction provides a breeding ground for bacteria, leading to ascending infections in the urinary tract. Additionally, the incomplete emptying of the bladder associated with BPH can further contribute to UTIs.
3. What would you expect the patient’s PSA level to be after surgery?
Following transurethral resection of the prostate (TURP), a surgical procedure performed to alleviate urinary obstruction in BPH, the patient’s PSA level is expected to decrease. Benign prostatic hypertrophy causes an elevation in PSA levels; therefore, surgical intervention to remove the obstructive prostate tissue would result in a reduction in PSA levels. Regular monitoring of PSA levels post-surgery is necessary to detect any significant changes that may indicate the presence of prostate cancer.
4. What are the recommended screening guidelines and treatment for BPH?
The recommended screening guidelines for BPH involve regular check-ups and discussions about urinary symptoms, followed by a thorough physical examination and medical history review. Prostate-specific antigen (PSA) blood tests and digital rectal examinations are commonly used to assess prostate health. Treatment options for BPH include watchful waiting, lifestyle modifications, medication therapy (alpha-blockers, 5-alpha reductase inhibitors), minimally invasive procedures (transurethral microwave thermotherapy, laser therapy), and surgical interventions (transurethral resection of the prostate, open prostatectomy) depending on the severity of symptoms and patient preferences.
5. What are some alternative treatments / natural homeopathic options for treatment?
Alternative treatments and natural homeopathic options for BPH include herbal remedies such as saw palmetto, pygeum africanum, stinging nettle, and beta-sitosterol. Some studies suggest that these substances may have modest benefits in reducing urinary symptoms associated with BPH. However, it is important to note that the evidence regarding their efficacy is inconclusive, and patients should consult with their healthcare provider before starting any alternative treatment. These remedies should not replace or delay appropriate medical evaluation or prescribed treatments for BPH.
