Dysuria

Name : Chathiya Banu

M/Num : MBBS 1608-7368
History
Chief Complaint
A 65-year-old Indian male, with
multiple comorbidities presented
due to dysuria 3 days prior to
presentation to the private GP
clinic.
HOPI
The dysuria was for 3 days which gradually turned to
be painful and bothersome
The dysuria was non-specific and noted to be constant
while he micturates
No precipitating, relieving or aggravating factors
There is no specific timing related to the dysuria
There is however, mild degree of straining and feeling of
incomplete voiding, increased frequency, and nocturia
during micturation for 6 months.

However, there is no hesitancy, weak stream of urine,

irregularity in streaming of urine or post-micturation
dribbling, urgency or incontinence

The urine colour is dark, with normal amount, however is

foul-smelly for few months. Urine was also frothy.
However, there is no hematuria
No suprapubic / loin pain or abdominal and inguinal
discomfort
Patient had similar symptoms on 2015 but additionally
with hematuria and was given Tamsulosin but patient
discontinued.
Eventually on 2016, he was admitted in ICU for fluid
overload secondary to CKD and kidney
Patient also complaints of sore throat of sudden onset for
2 days.
There is nocturnal cough noted by this patient for over a
year. Very little sputum, colorless. No blood in sputum.
There is mild orthopnea that aggravates if patient lies flat
and talks on phone to long. However, there is no postural
nocturnaldyspnea (PND).
No fever, chills, rigor, runny nose, muscle pain, lethargy,
malaise, rashes, loss of weight & appetite, nightsweats
noted.
Patient, who is a known case of diabetic foot ulcer also
complains of pain at the ankle and plantar aspect of
foot of right leg for 3 days. Pain score at ankle is 5/10
while pain score at foot is 4/10. Character is pricky,
aggravated by walking, relieved by rest.

No precipitating factors. Walking distance is limited for

this 3 days. Patient used to do stationary cycling with
slow effort 3 times/ week but currently could not do due
to the pain. Otherwise, his daily activities are
uninterrupted.
No discharge such as pus or blood coming up from the
wound or at the leg.
There is no wound, or pain at the left leg.
Patient denies knee/ toes pain and stiffness
 Review of Systems
Systems Symptoms
Renal Dry skin, pruritus,
• No reduced urine output, nausea, vomiting, loss of appetite, loin
pain
CVS Has mild reduced effort tolerance ( can only climb 3 -5 stairs , able
to walk for less than 100 m distance) & nocturnal cough
• No chest pain, palpitation, lethargy, dizziness
Respi • No SOB, wheezing, LOA, LOW, fever, nightsweats
MSK Ankle and foot pain
• No joint pain, stiffness, knee / toe pain, redness or swelling
• Dry skin, dark discoloration
Systems Symptoms
Hematology • No lethargy, dizziness, paleness
Endocrine • No heat intolerance, loss of weight/ appetite
GIT • No abdominal pain, diarrhea, vomiting, bloody stool,
alternating bowel habits
Opthalmology • Poorer vision with haziness on left eye, excessive lacrimation
• No diplopia, floaters,
ENT •Mild tinnitus
•No vertigo, no loss of hearing

CNS • No slurred speech, weakness, excessive drooling, loss of

consciousness
Past Medical & Surgical History
Known case of DM for over 18-19 years
 On insulin & oral anti-hyperglycaemic
 Compliant
 Diet under control
 Frequent complain of hypoglycaemia
DM complications
- Rt foot : Diabetic ulcer for 14 years, open wound, closed
4 times in 14 years.Admitted due to gangrene for right
toe on 2009. Refused amputation of right toe, defaulted
follow up at GH after discharge and followed up
Ayurvedic treatment in 2009. Currently following up at
private GP for wound dressing 1 time/ week. Otherwise,
daily wound dressing is done by wife or daughter.
 Lt foot : Had history of diabetic foot ulcer at plantar
aspect of medial foot 2017 . Admission in 2017 for foot
abscess. Positive for enterocci faecalis, followed up
under private IM specialist. Currently, wound
completely healed.
 CKD : stage 4 on 2016. On fluid restriction :800-1000
ml/ day and low protein diet. Follow up under private
hospital nephrologist. Not prepared/ planned for
dialysis.
Hypertension
Diagnosed 15 years ago
Had history of admission due to HPT urgency in 2011.
On anti-hypertensives. Currently compliant to
medications and diet.
Triple Vessel Disease
 Follow up under IJN
 Suggested CABG but patient refused. Instead did
angioplasty for LAD on 2019under a different
cardiologist in a private hospital.
 Currently, still following up under IJN. Compliant to
medicine.
 Recent ankle brachial index (ABI) : 0.55 (Lt leg), 0.83 (Rt
leg) and planned for doppler ultrasound in 2 weeks.
Diabetic retinopathy & cataract
 Left eye : Previously done vitro-retinal surgery in 2012.
Currently diagnosed as macular edema by
opthalmologist 2 months ago. Under pharmacological
management. No surgical intervention suggested.
 Right eye : Laser photocoagulation therapy done for
cataract in 2011.
 Vision is gradually worsening, partially dependent for
few daily activities like reading small letters and finding
missing items. Otherwise, can still ambulate well.
PMH
No recent history of hospital admission/ procedures
(urinary cathetrisation) done in the past 30 days
Drug History
Aspirin 100 mg + glycine 45 mg 1 tab dly
Bisoprolol 5 mg 1 tab bid
Felodipine 10 mg 1 tablet om
Frusemide 40 mg 1 tab om
Atorvastatin 20 mg 1 tab dly
Insulatard 16 units daily
Actrapid 16 units tid
Sitagliptin 100 mg 0,25 tab dly
Pantoprazole 40mg 1 tab dly
Folic acid 5 mg 1 tab dly
Ascorbic acid 100mg 1 tab dly
Vit B complex 1 tab dly
Cilostazol 100mg 0.5 tab bid
Mecobalamin 0.5 mg 1 tab tid
Eye drops : Maxitrol, nevanac and systane both eyes 6 hoursly for 1 month
Allergy History
No drug allergy
No food allergy
Family History
Both parents passed away in their 70s. Reasons
unknown
Second brother of the sibling passed away due to heart
disease at 40 years
Youngest brother had CKD and heart disease and
passed away : 52 years old
Eldest brother : Alive but has recently underwent
CABG
No family history of malignancies (prostate/
renal/bladder ca)
Social History
Patient is a retired teacher
Currently staying at home with wife and 2 daughters
Ex chronic smoker : stopped 24 years ago
Occasional alcohol drinker :Stopped 10 years ago
Not sexually active
No recent history of travel/ using public toilets/ did
not have contact with anyone ill recently (TB, flu-like
illnesses)
 DDx
Often Missed
1. Prostatis
Probable 2. Foreign body
1. UTI 3. Acute fever

2. BPH
Masquerade
3. Pyelonephritis
4. Depression
5. Diabetes
Red Flags 6. Drugs
4. Neoplasia : bladder,
prostate, uethra Pt Trying to tell
5. Infection : Herpes  Anxiety
6. Bladder calculi
Physical Examination
General Examination
Patient is medium built, appears alert, conscious
Not in pain
No respiratory distress or ill-looking features
No supporting equipments like walking stick
 Urinary & GIT
Inspection
Abdomen looks distended. No scars, dilated vein
Umbilical is inverted, centrally located
Inguinal orifices intact

Palpation
No tenderness/ guarding upon palpation
No mass palpable
No hepatomegaly
No spleenomegaly
Kidney not ballotable
Bladder not palpable
Percussion
Resonant at all quadrants
Bladder not detectable

Auscultation
Bowel sound present and normal : 25 per min
No renal/ aortic bruit

Renal punch
-ve
DRE & Prostate examination
Normal tone, no bleeding in stool
Presence of globular sized prostate gland, around 3
finger breadths medial sulcus obliterated
Mildly enlarged
No tenderness upon palpation
Firm consistency with smooth surface
Systems Findings
CVS Apex beat not displaced, Dual Rhythm No Murmur (DRNM) no
additional heart sounds, no bibasal crepitation
Respi Inspection : No deformities/ respiratory distress ( ableto speak in
full sentence)
Palpation :
- Trachea central
- Chest Expansion : Normal
- Percussion : Resonant
-Asucultation : No bibasal crepitation

Lower limb Inspection :

examination -Partial missing of 1st digit of rt foot
-Shiny surface ,loss of hair distribution on pretibial area of both
lowe limbs
- Dark discoloration at pretibial, ankle and gaiter region of both
lower limbs
- No visible veins
- A DFU wound observed at rt foot at platar aspect of 1st digit.
- Clean wound, gauze not soaked, no discharge (pus/ blood), no
foul smell
System Findings

Lower Limb Palpation

-Temperature : normal in both legs
- Dorsalis pedis pulse : Unableto appreciate in right limb

Range of motion
- Intact

Lymph node Cervical region

: not enlarged

Throat Not erythematous, no exudates, tonsils not enlarged

Examination

Camera Left eye : Macular edema of the left eye

Fundoscopy Right eye : Dark spots indicative of photocoagulative theraphy
Vital signs
Temperature: 37.2 °C
BP : 140 / 58 mmHg
Pulse : 72 bpm
Oxygen : 95 %
Respiratory rate : 14 bpm
Pain score: 2/ 10
Investigations
Investigations Findings
FBC •WBC : 11.2 X 10 ^ 3 u/L (H)
•RBC : 4.10 x 106 6 u/L (L)
•Hb : 10.6 g/dL (L)

•Other parameters : normal

Urinalysis •Specific gravity : 1.020

•Reaction (pH) : 6.0
•Glucose : negative
•Protein : +++
•Leucocyte, nitrite : -
•ketone,urobilinogen, bilirubin, blood : -ve
Ix Findings
Renal profile • Sodium : 138 mmol/L
•Potassium : 4.2 mmol/L
•Chloride : 104 mmol/L
•Urea : 11.8 mmol/L
•Creatinine : 224 umol/L
•eGFR : 19 ml/min/1.73m2

Serum PSA 1.5 ug/L

Kidney, bladder, •Simple cyst at rt kidney (Bosniak I)
ureter (KUB) • Prostate mildly enlarged
ultrasound scan • No parenchymal lesions, no masses, no hydronephrosis
Diagnosis
Benign Prostatic Hyperplasia (BPH) complicated by
CKD
Problem List
1. Prostate mildly enlarged
2. Comorbids :
 DM and its complications ( Retinopathy,
nephropathy
 diabetic foot ulcer (open wound),
 ABI suggestive most probably peripheral vascular
disease
 HPT
 Triple vessel disease
1. Sore throat (no infections)
2. Ankle pain ( no signs of infection)
Management
1. Educate and reassure pt
 Explain about BPH findings in the pt
 Explain on risk factors and probability of developing
infection

2. Pharmacological
 Alpha blockers : Prazosin 2 mg 1 tab bid for 4-6 weeks
 Follow up & monitor for side effects
 Phytotherapy: Hexanic extract of Serenoa (HESr)
3. Sore throat
 Lozenges ( anti-biotics not required for now)
 Review if it gets worse or develop fever in 3 days
(teleconsultation)

4. Ankle pain
 No limitation in ROM, thus suggest offloading shoes
for diabetes wound to reduce pain
 Review again upon follow up , xray if indicated
3. Follow up :
After 6 weeks
International Prostate Symptoms Score (IPSS) and
Quality of Life (QoL) Index : if > 3 : optimise
medication ( + 5-a Reductase inhibitors (5-ARIs))
Voiding diary:
 note the volume of void, fluid intake and time of each
event over the course of 3 days
 non-invasive and useful in differentiating patients with
OAB, inappropriate fluid intake, and nocturnal polyuria
 Normal : urine passed in 24 h : 1.5 L -2.0 L (2/3 : waking
hrs, 1/3 : night
4. Comorbidities
 Educate and reassure
 Watch out for signs of infection
 Hygiene (UTI), Lifestyle modification(diet)
 Optimise other medications
 Monitor parameters
 Wound dressing & debridement

5. Medical Leave : not needed