Case Presentation

Presented by:Dr. Muhammad Humayun KabirMBBS, FCPS (Surgery), MRCS

(Edin)BSMMU, Dhaka, Bangladesh

Particulars of patient

Name: Babu KhanAge: 55 yearsSex: MaleOccupation: welding workerAddress: DhakaDate of admission: 06.11.14Date of admission: 06.11.14Date of discharge:Date of discharge:

Presentation

Urinary frequency, urgency and nocturia for 03 months

Refractory urinary retention 01 months back

HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESSAccording to the statement of the patient, he was reasonably According to the statement of the patient, he was reasonably alright about 03 months back. Then he developed lower urinary alright about 03 months back. Then he developed lower urinary symptoms in the form of urinary frequency, urgency and symptoms in the form of urinary frequency, urgency and nocturia. He had burning sensation during micturition.nocturia. He had burning sensation during micturition.He also complained of difficulty in initiating voiding and He also complained of difficulty in initiating voiding and occasional poor urine flow. About one month back he suddenly occasional poor urine flow. About one month back he suddenly developed urinary retention when he was taken to a nearby developed urinary retention when he was taken to a nearby hospital and got relieved by continuous indwelling hospital and got relieved by continuous indwelling catherization. He was advised to take some medicines including catherization. He was advised to take some medicines including antibiotics and was discharged. About one week after that, his antibiotics and was discharged. About one week after that, his catheter was removed but he could not void and again catheter was removed but he could not void and again catheterized on that day. Then he attended urology OPD of catheterized on that day. Then he attended urology OPD of BSMMU for better management.BSMMU for better management.

He does not give any history of:He does not give any history of:

• Bleeding during micturition Bleeding during micturition

• Passage of any stone during micturitionPassage of any stone during micturition

• Loss of appetite or any loss of weight during this Loss of appetite or any loss of weight during this period.period.

• Cough, haemoptysis, chest pain, bone pain or Cough, haemoptysis, chest pain, bone pain or dyspnoea.dyspnoea.

• fever with chills and rigorfever with chills and rigor

• Traumatic injury to the spineTraumatic injury to the spine

History of past illnessYear2005:Year2005:

Patient gives a history of acute urinary retention in Patient gives a history of acute urinary retention in the year 2005 when he was taken to a hospital the year 2005 when he was taken to a hospital where catheterization was tried but failed, then a where catheterization was tried but failed, then a suprapubic catheter was inserted. Few days later, suprapubic catheter was inserted. Few days later, he was treated endoscopically under anesthesia (? he was treated endoscopically under anesthesia (? OIU). Patient could not produce any document but OIU). Patient could not produce any document but with this treatment, his urinary symptoms were with this treatment, his urinary symptoms were subsided.subsided.

Year 2007 and 2013: Year 2007 and 2013:

He got admitted twice in the department of He got admitted twice in the department of Neuromedicine, DMCH with the complaints of Neuromedicine, DMCH with the complaints of profound weakness and difficulty in moving his profound weakness and difficulty in moving his limbs. There he was treated conservatively and was limbs. There he was treated conservatively and was discharged after about 2 weeks. Again the pt could discharged after about 2 weeks. Again the pt could not produce any document to us but can remember not produce any document to us but can remember that he was advised to take syrup KT and plenty of that he was advised to take syrup KT and plenty of dub water throughout his life. dub water throughout his life.

He is hypertensive for about 12 years, diabetic He is hypertensive for about 12 years, diabetic but non asthmatic.but non asthmatic.

Drug historyDrug history

He takes tab Amlodipine 5 mg at night for control of He takes tab Amlodipine 5 mg at night for control of hypertension, Inj Actrapid for glycemic control.hypertension, Inj Actrapid for glycemic control.

Family history:Family history:

Married, having 3 children, all are in good health.Married, having 3 children, all are in good health.

Personal history:Personal history: Non-smoker Non-smoker

History of allergy:History of allergy:

No known history of allergy to any drug or food.No known history of allergy to any drug or food.

Systemic enquiry reveals no other abnormality.Systemic enquiry reveals no other abnormality.

General Physical Examination

Appearance: normal lookingBehaviour: Co-operativeAnaemia: absent Jaundice: absentPulse:80 bpmBP:120/70 mm of HgRespiration: 18 breaths/minOedema: absentDehydration: absent JVP: not raisedLymph nodes: not enlargedHeart: S1S2 normal, no added sound

Abdominal and genitourinary examination

Inspection:Patient is catheterized using a 16 Fr bichannel Foley catheter

connected with a closed collecting bag containing about 200 ml straw coloured urine.

Abdomen is normal in shape with centrally placed inverted umbilicus

No visible lump, engorged vein or any scar mark

Palpation: No palpable lump, no tenderness. Liver, spleen and kidneys are not palpableRenal angle: non-tenderUrinary bladder: not palpableTestes and both epididimis: normal

Percussion: No ascites

Auscultation: Bowel sound present

DRE: Perianal sensation- intact, anal tone – normalProstate is moderately enlarged, smooth, firm,

elastic, overlying mucosa is free.

Lower limb neurological and other Lower limb neurological and other systemic examination revealed no systemic examination revealed no abnormality.abnormality.

Salient Feature

Patient Mr Babul Khan, 55 years male from Dhaka, Patient Mr Babul Khan, 55 years male from Dhaka, was admitted in this hospital with the complaints of was admitted in this hospital with the complaints of lower urinary symptoms in the form of urinary frequency, lower urinary symptoms in the form of urinary frequency, urgency and nocturia. He had burning sensation during urgency and nocturia. He had burning sensation during micturition.He also complained of difficulty in initiating micturition.He also complained of difficulty in initiating voiding and occasional poor urine flow. About one month voiding and occasional poor urine flow. About one month back he suddenly developed urinary retention when he back he suddenly developed urinary retention when he was taken to a nearby hospital and got relieved by was taken to a nearby hospital and got relieved by continuous indwelling catherization. He was advised to continuous indwelling catherization. He was advised to take some medicines including antibiotics and was take some medicines including antibiotics and was discharged. About one week after that, his catheter was discharged. About one week after that, his catheter was removed but he could not void and again catheterized on removed but he could not void and again catheterized on that day. Then he attended urology OPD of BSMMU for that day. Then he attended urology OPD of BSMMU for better management.better management.

Salient FeatureHe does not give any history of hematuria, graveluria, pyuria, evening He does not give any history of hematuria, graveluria, pyuria, evening

rise of temperature, cough, hemoptysis, chest pain rise of temperature, cough, hemoptysis, chest pain and jaundice.He gives a history of acute urinary retention in the year 2005 when

catheterization was failed and a SPC was done. Few days later, endoscopic operation was done under anesthesia after which his urinary complaints improved but exact nature of operation could not be understood from any documents.

He got admitted twice in the department of Neuromedicine, DMCH He got admitted twice in the department of Neuromedicine, DMCH (2007 and 2013)with the complaints of profound weakness and (2007 and 2013)with the complaints of profound weakness and difficulty in moving his limbs. There he was treated conservatively difficulty in moving his limbs. There he was treated conservatively and was discharged after about 2 weeks. Again the pt could not and was discharged after about 2 weeks. Again the pt could not produce any document to us but can remember that he was advised produce any document to us but can remember that he was advised to take syrup KT and plenty of dub water throughout his life. to take syrup KT and plenty of dub water throughout his life.

Patient is hypertensive for the last 12 years and is taking antihypertensive drug (Tab Amlodipine 5 mg) and also diabetic taking insulin for glycemic control but not asthmatic.

On general examination, his vital parameters are within normal limit. The patient is catheterized using a 16 Fr bichannel Foley catheter. His kidneys are not palpable, renal angle nontender.

Lower limb neurological and other systemic examination reveals no abnormality.

Clinical diagnosisBEP with refractory urinary retention with hypertension with DM with penile catheter in

situ

InvestigationDate: 22.10.14Serum creatinine-1.8 mg/dl.CBC-

Hb- 10 g/dlESR- 45 mm at 1st hourN-60%, L-35%, M-02%, E-03%

Urinalysis: Pus cell : 2 -4/ HPF,

RBC- plenty/HPF, Protein, reducing

substance – nil

Blood sugar: 26.10.14 (with insulin)FBS: 6.4 mmol/L2HABF : 10.0 mmol/L

HbA1C: 9.3%

USG of the whole abdomen (25.10.14)

22.10.14Serum PSA : 0.71 ng/ml

Serum electrolytes

Date

09.11.14 12.11.14 14.11.14 15.11.14 17.11.14 22.11.14

Na (mmol/L)141 136 138 144 144 147

K (mmol/L)2.3 2.3 2.2 2.65 2.58 3.16

Cl (mmol/L)100 102 106 108 102.8 108.5

E-CO2

(mmol/L)20 29 32.6

Consultation with Department of Medicine, BSMMU was done for correction of hypokalaemia and they advised to inject Inj KT 3 amp (60 mmol) in 1 L of NS everyday which was started from 13.11.14 and continuing till date as per their advise but serum potassium is not yet corrected.

Evaluation for cause of hypokalaemia21.11.14:

24 hours urine volume: 4000 mlUrinary sodium excretion: 336 mmol/day

(Normal: 40-220 mmol/d)Urinary potassium excretion: 60 mmol/day

(Normal 25- 125 mmol/d)

Evaluation for cause of hypokalaemia20.11.14:Aldosterone in serum: 360 pg/ml

Normal range: 20-180 pg/ml (early morning), 30- 400pg/ml (upright 2 hours)

Plasma renin level: sent, report pending.

CT scan of the whole abdomen