Urology
CASE 63: DiFFiCulty paSSing urine
history
An 81-year-old man presents to the emergency department complaining of difficulty in passing urine. On questioning, he reports a worsening urinary stream over the past 6 months, together with increased nocturia. There is a recent history of bedwetting. He has no pain. He opens his bowels 3–4 times a week and his last bowel motion was 2 days ago. He is on insulin for type 1 diabetes. He also takes aspirin 75 mg od and simvastatin 20 mg od. He lives alone and mobilizes well with a walking stick. He is a non-smoker and has the occasional whisky at night to help him sleep.
examination
On examination of the abdomen, there is a palpable suprapubic mass, which is non-tender and dull to percussion. The rest of the abdomen and genitalia are unremarkable. Digital rectal examination reveals an enlarged smooth-feeling prostate gland.
INVESTIGATIONS
|
|
Normal |
Sodium |
134 mmol/l |
135–145 mmol/l |
potassium |
5.1 mmol/l |
3.5–5.0 mmol/l |
urea |
20.2 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
334 mmol/l |
44–80 mmol/l |
Questions
•What is the diagnosis?
•Why does he recently complain of bedwetting?
•How should this patient be managed?
•What features on digital rectal examination would make you suspicious of prostate cancer?
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100 Cases in Surgery
ANSWER 63
This patient has chronic urinary retention secondary to a benign prostatic enlargement. Acute and chronic retention are usually differentiated by the presence or absence of pain. Acute retention is painful, unlike chronic retention, when the bladder accommodates the increase in volume over time. A recent history of bedwetting is associated with a picture of chronic retention with overflow incontinence, which usually occurs at night.
A urethral catheter should be inserted and the colour of the urine and residual volume noted and recorded in the notes. In cases of chronic retention, the residual is often high (>2 L). The urine output should be monitored, as the patient may develop a diuresis. If the urine output is greater than 250 mL/h, intravenous fluid replacement in the form of 0.9 per cent normal saline is necessary to avoid hypovolaemia. The urine should be dipstick tested and sent for microscopy and culture. If positive for infection, antibiotics should be started. His renal function needs to be monitored to assess a response to treatment, and if not improving early consultation with the renal physicians is recommended. Constipation or urinary tract infection can compound the problem and they need to be treated accordingly. Often the patient has a history of lower urinary tract symptoms, which in this case are both voiding and storage in nature.
A digital rectal examination should be performed for patients in retention, noting the following points:
•External appearance of the anal orifice
•Rectal masses
•Consistency of the prostate
•Presence of a median sulcus
•Presence of nodules within the prostate
•Fixity of the prostate gland
•Estimated size of the prostate gland
•Anal tone
Features that suggest carcinoma of the prostate include hard gland, loss of normal contour (craggy prostate), loss of the midline sulcus, palpable nodule and a fixed gland. In cases of benign prostatic hyperplasia, the prostate feels enlarged and smooth as in this case.
KEY POINTS
•acute retention is differentiated from chronic retention by the presence of pain.
•precipitating factors, e.g. constipation, urinary tract infection, excessive alcohol, need to be screened for in the history.
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Urology
CASE 64: teStiCular lump
history
A 31-year-old male stockbroker presents with a lump in his right testicle. He tells you it is uncomfortable while walking, and describes a dragging sensation. He also complains of generally feeling ‘run down’ but puts this down to stress at work, and has an irritable cough. He is a smoker of 20 cigarettes a day.
examination
On examination, a 3-cm palpable lump is felt on the inferior aspect of the right testicle. The rest of the testis and epididymis can be felt separately, and the mass does not transilluminate. It is not particularly tender to palpation. Abdominal examination is unremarkable.
INVESTIGATIONS
Urinalysis: clear
Questions
•What is the likely diagnosis?
•What investigations are necessary?
•How do you differentiate between the different scrotal swellings?
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100 Cases in Surgery
ANSWER 64
The likely diagnosis is a testicular tumour. Ninety per cent of testicular tumours are germ cell tumours and are subdivided into seminomas and non-seminomatous germ cell tumours (NSGCT).
!Risk factors
•age: common between 20 and 40 years
•Cryptorchidism
•race: more common in Caucasians
•previous testicular tumour
•Family history
•Klinefelter’s syndrome
The patient’s complaint of a cough should be taken seriously, as metastases to the lungs are possible with testicular tumours. A complete physical examination of the patient should be performed as there is potential for secondary deposits in the chest and brain. Lymphatic spread is to para-aortic lymph nodes in the abdomen rather than inguinal nodes in the groin, which only occur if the tumour erodes and involves the scrotal skin.
The diagnosis is confirmed with a scrotal ultrasound and serum tumour markers. Alphafetoprotein is elevated in NSGCT. The beta subunit of human chorionic gonadotropin (b-HCG) is elevated in NSGCT and in approximately 20 per cent of seminomas. Lactate dehydrogenase can be elevated in metastatic or bulky disease. All these markers are useful in monitoring disease progression and recurrence following various treatments. A computerized tomography scan of the chest and abdomen is required for staging purposes.
When examining a lump in the scrotum, it is important to determine whether you can get above the swelling. If you cannot get above the swelling, then it may be a hernia. You should then ask yourself the following questions:
•Can the testis and epididymis be felt?
•Does the swelling transilluminate?
•Is the swelling tender?
•Lump not confined to the scrotum (cannot get above the lump):
•Inguino-scrotal hernia: unable to get above swelling, cough impulse, does not transilluminate, can feel testis separately
•Infantile communicating hydrocoele: unable to get above swelling, no cough impulse, transilluminates, cannot feel testis separately
•Lump confined to the scrotum (can get above the lump):
•Vaginal hydrocoele: testis and epididymis not felt easily, swelling transilluminates
•Haematocoele, syphilitic gumma, tumour: testis not readily identifiable, lump does not transilluminate
•Epididymal cyst: lump arising from epididymis that is felt and easily definable, swelling transilluminates
•Infection, e.g. epididymo-orchitis, tuberculosis or tumour: testis identifiable does not transilluminate
Acute inflammatory conditions such as epididymo-orchitis and acute haematocoele are associated with severe tenderness and erythema of the overlying skin.
KEY POINT
• Systematic examination is crucial in differentiating the causes of a scrotal swelling.
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