CASE PRESENTATION , DISCUSSION AND SHARING OF INFORMATION ON DIFFICULT URINATION

Roberto N. Gonzales Jr. MD.

Department of Surgery

Ospital ng Maynila Medical Center

P.A.

77/M

From Sta. Mesa Manila

CHIEF COMPLAINT:

Difficulty to Urinate

HISTORY OF PRESENT ILLNESS

3 mos PTA         (+) voiding difficulty

                                                (Frequency, Urgency,             Hesitancy,Nocturia,                                                                            intermitency, sensation of incomplete emptying,

                                                weak urinary stream)

                            (+) hypogastric pain

                            (+) consult Pvt MD

                                         Rx- Rowatinex, Hytrin, Inoflox

                                        Sx- FC was inserted

                                        Sent Home

2 mos PTA       difficult voiding symptoms persisted

                          (+) blood in urine

                          (+) consult Gen. Hosp. in Dagupan city

                                    PSA- 3.2 ng/ml (N)

                          sent home with foley catheter

2 wks PTA       difficult voiding symptoms persisted

                           (+) consult at OMMC  surgery opd

            ADMISSION                                   

<!--[if !supportLists]-->n<!--[endif]-->Past Medical History:

            No history of previous hospitalization no operation

            (+) HPN HBP 160/100, UBP 120/80

            (-) DM, (-) Asthma

<!--[if !supportLists]-->n<!--[endif]-->Family History

            Unremarkable

<!--[if !supportLists]-->n<!--[endif]-->Personal and Social History

            Unremarkable

PHYSICAL EXAMINATION

Conscious, coherent, ambulatory

BP 130/90  PR 110    RR 22  T 37.6’C

HEENT: pink palpebral conjunctiva, anicteric sclerae, no TPC, no CLAD

CHEST/LUNGS: SCE, no retractions, clear BS

HEART: adynamic precordium, NRRR, no murmur

ABDOMEN:

  (+) flat abdomen normoactive bowel sounds,  (-) tenderness , (-) organomegaly

EXTREMITIES:

                        full equal pulses

RECTAL EXAM:

            good sphincteric tone, non-collapsed rectal vault, (+) feces on tactating finger,

             prostate- size (+1), firm, smooth, symmetrical(median furrow, lateral sulci not distorted), (-) tenderness

             (-)nodules/induration

SALIENT FEATURES

77/M

<!-Difficult voiding symptoms

            (Frequency, Urgency,Hesitancy

Nocturia, A sensation of incomplete emptying, A weak urinary stream,Postvoid dribbling)

Hypogastric pain

Blood in urine

DRE:   prostate- size (+1), firm, smooth, symmetrical(median furrow, lateral sulci not distorted), (-) tenderness

             (-)nodules/induration

PARACLINICAL DIAGNOSTIC PROCEDURE

DO I NEED A PARACLINICAL DIAGNOSTIC PROCEDURE?

                        yes

To assess the degree of bladder neck obstruction

To provide an estimate of prostate size and find other pathologic processes that will help in the formulation of management plan

Paraclinical Diagnostic procedure of Choice:

Trnsabdominal Ultrasound

Both kidney are normal in size

The urinary bladder shows multiple (2) high level echoes within with shadowing

The largest stone measures 23.6 mm

IMP: Multiple cystolithiasis, multiple tiny prostatic calculi

PRE-TREATMENT DIAGNOSIS

PRIMARY DIAGNOSIS:

            Bladder outlet obstruction 2’ to BPH with Cystolithiasis (95%)

SECONDARY DIAGNOSIS:

             Bladder outlet obstruction 2’ to prostatic cancer with cystolithiasis (5%)

GOALS OF TREATMENT

Relieve the urinary obstruction

Removal of stone

<!Prevent complication

                         Open Suprapubic Prostatectomy with cystolithotomy

OPERATIVE TECHNIQUE

Patient in modified trendelenburg position

Lower midline skin incision

Exposure of partially distended bladder, stay sutures placed in the bladder wall

Transverse incision 2 cm above the bladder neck to expose prostatic fossa

Evacuation of bladder contents

Circumferential bladder neck excision

Blunt enucleation of prostate

Hemostasis

Bladder closure

Placement of drain or suprapubic catheter

Skin closure

INTRA-OP DIAGNOSIS

Bladder outlet obstruction 2’ to BPH with Cystolithiasis

OPERATION DONE

            Open suprapubic Prostatectomy with cystolithotomy

POSTOPERATIVE DIAGNOSIS

             Bladder outlet obstruction 2’ to BPH with Cystolithiasis  s/p open suprapubic prostatectomy with cystolithotomy

SURGICAL TREATMENT
POST-OPERATIVE CARE

SUPPLY THE BASIC NEEDS OF THE PATIENT

COMFORT

ANALGESICS

MEDICATIONS – ANTIBIOTICS

FLUIDS AND ELECTROLYTES

SUPPORT ORGAN FUNCTION

WOUND CARE

MONITORING FOR COMPLICATIONS

ADVICE ON

HOME CARE

FOLLOW-UP PLAN

SURGICAL TREATMENT
POST-OPERATIVE CARE

RESOLUTION OF THE HEALTH PROBLEM

LIVE PATIENT

NO COMPLICATION

NO DISABILITY

NO MEDICO-LEGAL SUIT

DISCUSSION

  CYSTOLITHIASIS

Hippocratic Stones

More than 23 centuries ago, Hippocrates warned

             “To cut through the bladder is lethal”

Part of the Hippocratic oath includes

            ”I will not cut for stone, even for the patients in whom the disease is manifest; I will leave this operation to be performed by practitioners.”

His admonition to young physicians was to leave this highly risky and complicated procedure to the lithotomists of what could only be described as an art.

Famous historical figures who developed vesical calculi include

King Leopold I of Belgium

Napoleon Bonaparte

Emperor Napoleon III

Peter the Great

Louis XIV, George IV, Oliver Cromwell,

Benjamin Franklin

the philosopher Bacon

the scientist Newton

the physicians Harvey and Boerhaave

and the anatomist Scarpa

Definition of Terms

cyst/o-lith/o-tomy, incision to remove a tone or calculus from the urinary bladder Syn.                                         cystolithectomy

lith/o-clast, an instrument that breaks stones or calculi 

                        Syn. lithotrite

lith/o-cyst/o-tomy, incision into the bladder to

                                    remove a stone or calculus

lith/o-lapaxy, washing of stones from the bladder following crushing

lith/o-tomy, incision into a duct or organ to remove a

                                    stone or calculus

lith/o-tripsy, the process of fragmenting stones e.g.

                                    using shockwaves from a lithotriptor

lith/o-trite, an instrument for crushing stones

Vesical calculi

These stones are usually associated with urinary stasis, but they can form in healthy individuals without evidence of anatomic defects, strictures, infections, or foreign bodies.

The presence of upper urinary tract calculi is not necessarily a predisposition to the formation of bladder stones.

primarily affect men who are usually older than 50 years and have associated bladder outlet obstruction.

Etiology

Bladder outlet obstruction - most common cause --urinary stasis

 benign prostatic hypertrophy

urethral stricture

neurogenic bladder

bladder neck contracture

incontinence repair that is too tight

Cystoceles

bladder diverticula

urinary infections

Bladder inflammation secondary to external beam radiation or schistosomiasis

foreign bodies in the bladder that act as a nidus for stone formation.

Iatrogenic - suture material, shattered Foley catheter balloons, egg shell calcifications that form on a catheter balloon, staples, ureteral stents, migrating contraceptive devices, and prostatic urethral stents.

Noniatrogenic - objects placed into the bladder by the patients for recreational and various other reasons.

Pathophysiology

formed within the bladder

some within the kidneys                 

                         uric acid- bladder

                         calcium oxalate- kidney

uric acid most common type in adults (>50%).

ammonium acid urate, calcium oxalate, or an impure mixture of ammonium acid urate and calcium oxalate with calcium phosphate. -In pediatric population,

Vesical calculi

may be single or multiple, especially in the presence of bladder diverticula.

can be small or large enough to occupy the entire bladder.

 soft to extremely hard

smooth-faceted surfaces to jagged spiculated surfaces

most are mobile within the bladder, although fixed stones occasionally can be present when formed on a suture, on the intravesical portion of a papillary tumor or polyp, or on retained stents.

Clinical

completely asymptomatic

suprapubic pain, dysuria, intermittency, terminal gross hematuria, frequency, hesitancy, and nocturia.

sudden termination of voiding with some degree of associated pain, which may be referred to the tip of the penis, scrotum, perineum, back, or hip. The discomfort may be dull or sharp and often is aggravated by sudden movements and exercise.

Assuming a supine, prone, or head-down position may alleviate the pain that was initiated by the stone impacting the bladder neck. Parents of children with vesical calculi may notice priapism and occasional enuresis.

physical examination - suprapubic fullness , palpable distended bladder.

Signs of vesical calculi include microscopic or gross hematuria, pyuria, bacteriuria, crystalluria, and urine cultures demonstrating urea-splitting organisms.

abdominopelvic plain radiograph, However, adult calculi, which are composed predominantly of uric acid, may be radiolucent and, unless coated with calcium, are more difficult to visualize on plain radiographs.

Cystoscopy, noncontrast CT scan, and sonography are common methods used to confirm the presence of bladder calculi.

Indication for surgery

failure of medical management

recurrent infections

acute urinary retention

suprapubic pain, and significant gross hematuria

 investigate and correct the etiology of the underlying cause of stone formation (eg, bladder outlet obstruction, infections, foreign body, diet).

Benign prostatic hyperplasia

THREE COMPONENTS:
PROSTATE, URETHRA, BLADDER

A static component is the enlarged prostate itself, which obstructs urine flow.

A dynamic component is increased smooth muscle tone in the prostatic urethra which account for 40% of the obstruction

third component is the overactivity of the bladder

References:

Tanagho EA, McAninch JW. Smith’s General Urology, 13th ed. Appleton and Lange; 1992;378-392.

Walsh PC, Retik AB, Vaughan ED Jr, Wein, AJ. Campbell’s Urology, 7th ed. WB Saunder’s Company; 1998;1429-1472.

The following drugs exert its action the static component of BPH which is the enlarged prostate itself.

Alfusozin

Terazosin

Tamsulozin

Finasteride

2. Most common Bladder stones in adult

Calcium oxalte

uric acid

ammonium acid urate

cystine

Multiple Response Questions

3. The following are IRRITATIVE  lower urinary tract symptoms (LUTS)

Dysuria

Urgency

Hesitancy

Intermitency

4. The following is/are common cause(s) of bladder stones

Bladder neck obstruction

urinary infections

Bladder inflammation

foreign bodies