Benign Prostatic Hyperplasia Can Be Protective

A Case Study

Jessica Wilkinson, MBChB; Jonathan Bird, BSc, PA; Edmund Leung, MBBS, MRCS, DMSc, FRCS

Disclosures

Urol Nurs. 2020;40(5):248-250. 

In This Article

Case Report

An 86-year-old gentleman with a background of Crohn's disease and Crohn's-related small bowel resections, enterocutaneous fistulae, and benign prostatic hyperplasia (BPH) attended a urology clinic at the local public hospital with recurrent urinary tract infections, pneumaturia, and debris in his urine. His other medical history includes ischaemic heart disease, cerebral vascular disease with minimal residual weakness on the right side, hypertension, BPH, and osteoarthritis. There is no history of diabetes mellitus.

Current medications include bendroflumethiazide, isosorbide mononitrate, lisinopril, aspirin, pravastatin and tamsulosin. The patient is a widower, retired laborer, and lives alone with caregivers attending to his bungalow twice a day. There is no relevant family history that could contribute to the presenting complaint.

Clinical Interaction

Physical examination revealed the patient was quite frail with very poor mobility. There was no gross anemia or the stigmata of any paraneoplastic signs. Blood profiles revealed a white cell count within normal limits. Urinalysis and culture demonstrated both excessive red and white cells and Escherichia coli. The patient underwent a cystoscopy, which showed no definite fistulae but increased amounts of debris and a moderate-sized bladder diverticula with a tight bulbar urethra. Computer tomography (CT) urogram confirmed air in the bladder and ureter (Figure 1).

Figure 1.

Air Inside the Bladder Scan on CT Urogram

Results of Clinical Interaction

Management plans were to commence daily trimethoprim, encourage water intake, and referral to a general surgeon. Once again, no obvious positive findings were detected on physical examination. Rectal examination revealed Grade 4 hemorrhoids but no stigmata of Crohn's disease. The patient was sent for a contrast CT, which failed to demonstrate a fistula. The patient declined colonoscopy. He was then discharged from secondary care to be managed by his general practitioner with long-term antibiotics and observation.

One year later, the patient again began to experience pneumaturia and a change in bowel habit. He was again referred to general surgeons. This time, the patient agreed to undergo a colonoscopy and repeated contrasted CT; a colovesical fistula was demonstrated (Figures 2 and 3).

Figure 2.

Both Arrows Point to the Colovesical Fistula and Tract Between the large Bowel and Bladder

Figure 3.

Second CT Scan Showing Enlarged Prostate

Clinical Implications

Given the demonstration of an ongoing colovesical fistula, being much more obvious on the second CT, the general surgeon discussed the medical and surgical treatment options with the patient: long-term antibiotics, increased oral fluids, and/or a long-term catheter with regular flushing by the community nurse, versus diverting stoma and/or resection and repair of the bladder wall.

However, following a thorough anaesthetic assessment, the patient was deemed an unsuitable surgical candidate. With shared decision-making, conservative management was elected. There was no requirement to upgrade his current social care package. The patient was followed up in clinic three months later, when his BPH had progressed, so much so that he was now passing urine per the rectum. Incidentally, the patient no longer complained of recurrent urinary tract infections and reported his quality of life was now much improved.

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