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A 72-year-old man (Mr Johnson) presents to the surgical assessment unit. He has been complaining of a 3-year history of marked lower urinary tract symptoms (LUTS) and a recent history of bed-wetting. He has noticed his urinary flow has diminished significantly over time, and now he just ‘dribbles’. He tells you he spends ‘hours’ in the toilet as it takes him a long time to void. He wakes up five times a night to pass urine. Mr Johnson saw his GP today regarding these symptoms. The GP noticed a large abdominal mass. He felt uncertain about this abdominal mass and hence he referred the patient for your assessment and management. Mr Johnson has an non-significant past medical history.
Examining his abdomen you note him to have a full bladder to the level of the umbilicus. This mass is dull to percussion and painless on palpation. He has not really noticed his bladder become full overtime. Digital rectal examination (DRE) revealed a large benign-feeling prostate, no masses and normal anal tone and sensation. His biochemistry reveals markedly deranged renal function, which is a new finding.
1 What is Mr Johnson’s likely diagnosis and how would you manage him initially?
The likely diagnosis is high pressure chronic retention (HPCR). He is likely to have a large residual volume. He has renal dysfunction resulting from ‘back pressure’ on the kidneys. Your initial management should consist of:
He does not necessarily require IV fluids straight away, as initially the diuresis is a physiological one. He would require IV fluids if the diuresis is prolonged or he becomes symptomatic with postural hypotension.
2 What investigation would you request and why?
A renal tract ultrasound scan is needed to check for bilateral hydro-ureteronephrosis. This usually resolves with catheter drainage and as renal function improves.
3 On catheterization he has a residual volume of 3 L. Over that day he has significant diuresis. Can you explain the physiological process of this?
Initially there is a physiological diuresis with the excretion of retained fluid. This can be followed by a pathological diuresis because of the following:
4 What are the other indications for TURP?
Other than HPCR, the following are indications for TURP:
5 If Mr Johnson was multiply comorbid, precluding him from operative intervention, what would his management options be?
Clean intermittent self catheterization (CISC) or a long-term catheter (LTC) are the only other management options.