Poor Urine Stream

Andy Lim

Outlines
1. 2. 3. 4. 5. 6. Case Presentation (summary) Provisional and Differential diagnosis History Taking Physical Examination Investigation Management

Case Summary
Mr AR, a 65 year old Malay gentleman, was presented to the Clinic with the chief complaint of weak urinary stream, and often need to strain the abdomino-pelvic muscle to maintain the urine flow. The symptom started 2 years ago, and it is progressively worsen. Until recently, 2months prior to admission, he also complained of increased urinary frequency in both daytime, and night (nocturia), hesitancy, intermittency, splitting of urine. However, there is no dysuria, hematuria, terminal dribbling, urgency, incontinence, and feeling of incomplete emptying of bladder. Also, there is no loss of appetite, loss of weight, fever or chills, no penile discharge. He is a chronic smoker, at least 6 sticks per day since age of 24. He does not consume alcohol, and does not take drugs. He has medical history of gout and type 2 diabetes mellitus. No previous hospitalization or surgery. No family history of prostate cancer, BPH or bladder cancer. Worked in an office as senior accountant, and does not expose to any harmful environmental carcinogenic material, like cadmium.

Provisional Diagnosis Benign Prostatic Hyperplasia (BPH) Differential Diagnosis

Urethral stricture Prostatitis Neurogenic bladder Bladder stones

To Rule Out : Prostate cancer Bladder Cancer

History Taking

HOPI
Site of pain, if any ? Radiation of pain, if any ? Onset of symptoms ? Progression of symptom ? Character of the pain ? Aggravating and Relieving factors ? Associating symptoms ?

Past Medical History

Diabetes Mellitus ? Peptic ulcer disease ? Previous MVA ? Or spine injury ? Any neurologic deficit ? Previously diagnosed STD ?

Past Surgical History

Any previous hospital stay ? Catheterization ? Pelvic surgery ? Sclerotherapy ?

Family History
BPH ? Prostate cancer ? Bladder cancer ? Diabetes mellitus ? Shy-Drager syndrome ?

Social and Personal History

Habitual : Smoking ? Consuming alcohol ? Taking drugs ? Dietary : Fatty food ? Balance diet ? Sugar / Sweet preferences ?

Occupational : Farmer (herbicide bentazone) Manufacture of batteries (cadmium) Manufacturing of metal or rubber (organic solvent - benzene, carbon tetrachloride) Sexual practise : Sexual promiscuity ?

Physical Examination

General Examination
Vital signs Pallor jaundice Hydration status Nutritional status Bleeding disorder

Abdominal Examination
Distended suprapubic region Suprapubic tenderness Dull over percussion

DRE
Enlargement ? diffuse ? or nodularity Consistency of lesion ? Surface ? edges ? Site of lesion ? Tenderness ?

Investigations

Full Blood Count

White blood cell count- To look for the presence of infection Prostatitis

Renal Profile
Urinalysis PSA Test

Assess the proper functioning of kidneys

Physical- Clear/ cloudy, colour Chemical- Leucocytes, nitrites, protein, blood, specific gravity, pH Microscopic Examination- Casts, hematuria, pyuria Renal calculi, bladder cancer, urinary tract infection

Prostate cancer( ), benign prostate

hyperthrophy, prostatitis

Ultrasound of the Urinary System Intravenous Urogram

Kidney, ureters, urethral, bladder and prostate Renal calculi, tumor, benign prostate hyperthrophy

Shows any blockage in the urinary tract Tumor, renal calculi

Urethrocystoscopy

Examination of bladder and urethral, biopsy Urethral stricture, bladder cancer, calculi

Uroflowmetry

Measures voided volume, voiding time, average flow rate, and maximum flow rate Urethral stricture, benign prostate hyperthrophy

Diagram of Intravenous Pyelogram

Management

Basic Management of LUTS in Men

LUTS: Urinary frequency Nocturia Urgency, with or without incontinence Hesitancy in initiating the stream Weak stream Dysuria Sense of incomplete bladder emptying Post void or terminal dribbling

Specialized Management of Persistent, Bothersome LUTS after Basic Management

International Prostate Symptom Score (IPSS Score)

Additional Slides

Pathogenesis of BPH
Androgens
1
Dihydrotestosterone (DHT) acts on stromal cells and epithelial cells

Androgen Receptors

1
2

More heterogenous distribution (epithelial and stromal cells) Hyperplastic prostatic tissue

DHT binds to nuclear androgen receptors Stimulates the synthesis of DNA, RNA, growth factor, cytoplasmic protein

Hyperplasia of epithelial and stromal cells

Thank You ^_^