Cases

CASE 1

A 50 year old diabetic female presented with burning micturition associated with urinary frequency & suprapubic pain.

WHAT IS THE FIRST STEP IN THE EVALUATION OF THIS PATIENT ?

URINANALYSIS
Color : Yellow
Appearance : Cloudy
Sp. Gravity : 1.033
pH : 6.5
Protein : Negative
Glucose : Negative
Ketone : Negative
Bilirubin : Negative
WBCs : 40 – 50 / HPF
RBCs : 7-10 / HPF
Casts : None
Crystals : None
Squamous epithelia : 2 -3 / HPF


WHAT IS THE MOST LIKELY DIAGNOSIS & THE CAUSATIVE MICROORGANISMS ?

Dx. : Cystitis

Causative microorganism : Most likely E.coli

HOW WOULD YOU TREAT THIS PATIENT ?

Oral antibiotics for 3 – 5 days.

If this patient presented to you with recurrent infection associated with left loin pain, nausea & hematuria; how would you evaluate her ?

Urinanalysis

Urine cultue

U / S

KUB

URINANALYSIS

Color : Yellow
Appearance : Cloudy
Sp. Gravity : 1.033
pH : 8
Protein : Negative
Glucose : Negative
Ketone : Negative
Bilirubin : Negative
WBCs : 40 – 50 / HPF
RBCs : 12 - 15 / HPF
Squamous epithelia : 2 -3 / HPF

WHAT IS THE MOST APPROPRIATE RADIOLOGICAL MODALITY ?

CT scan

WHAT IS THE DIAGNOSIS & THE CAUSATIVE ORGANISM ?

Struvite stone ( MAP stone ).

Urea splitting microorganisms.

HOW WOULD YOU TREAT HER ?

PCNL

Controlling the infection (pre, peri, postoperatively)
Good hydration
Good glycemic control


If this patient neglects herself & develops fever & chills associated with costovertebral angle tenderness; what is the most likely diagnosis & how would you treat her ?

Dx. : Acute pyelonephritis

Management :
- Hospitalization
- Parenteral antibiotics ( 7 – 10 days )

CASE 2

A 27 year old pregnant lady discovered during prenatal U/S to have antenatal hydronephrosis. How would you interfere ?

Watchful surveillance

HOW WOULD YOU EVALUATE HER POSTNATALLY ?

U/S in the first week of life

WHAT ARE THE POSSIBLE UNDERLYING CAUSES ?

PUJ obstruction

VUR
Posterior urethral valve ( males only )


HOW CAN YOU DIFFERENTIATE BETWEEN THESE THREE CONDITIONS ?

PUJ obstruction

U/S : AP diameter of the renal pelvis, kidney size.

IVP

CT scan

Radionuclide renography : the best radiographic study.

U/S



IVP

CT scan

VUR
Voiding cystourethrogram

POSTERIOR URETHRAL VALVE

Voiding cystourethrogram.

Excretory urogram.

CASE 3

A 70 year old male presented with hesitancy, decreased force & caliber of stream, sensation of incomplete bladder emptying, excessive straining, urgency, frequency & nocturia.

What we call these symptoms collectively? And how we classify them?

Lower urinary tract symptoms :

1- Obstructive symptoms

2- Irritative symptoms

What are the differential diagnosis of these symptoms?

UTI
BPH
Urethral stricture
Bladder neck contracture
Vesical stone
Ca prostate
Neurogenic bladder disorders

How would you evaluate this patient ?

History
Previous urethral instrumentation, urethritis, or trauma
Hematuria & pain
Hx of neurologic diseases, stroke, DM, back injury

Physical examination

DRE : smooth, firm, elastic enlargement of the prostate.

Focused neurologic examination.

Lab findings
Urinanalysis : to exclude infection or hematuria
RFT
Serum PSA (optional)

Additional tests

Upper tract imaging (optional)
Cystometrograms & urodynamic profiles (optional)

How can you assess the severity of these symptoms?

AUA self-administered questionnaire

What are the therapeutic options for BPH?

A-Watchful waiting
For mild symptom scores (0-7)

B-Medical therapy

Alpha blockers
5 alpha reductase inhibitors
Combination therapy

C-Surgical treatment

Indications :
Refractory urinary retention
Recurrent UTI
Recurrent gross hematuria
Bladder stones
Renal insufficiency
Bladder diverticulum


What is the gold standard surgical technique?

TURP

What are the indications of open prostatectomy?

Indications
Too large prostate
Associated bladder pathology
Dorsal lithotomy position is not possible

If following prostatic resection, patient is discovered to have >5% cancerous prostatic tissue; how would you stage this condition?

T1b

What is your further management ?

DRE (nodular surface, induration)
PSA
TRUS
Prostatic biopsy


Additional tests
RFT
CBC
Alkaline phosphatase
Bone scan
Axial imaging (CT & MRI)

What is the most common histological subtype of prostatic carcinoma ?

Adenocarcinoma

How would you treat this patient ?

Radical prostatectomy

CASE 4

A 65 year old smoker male presented with painless, intermittent hematuria for the last 6 months associated with urinary frequency, poor appetite & weight loss. He is a worker in a rubber industry.

How would you evaluate this patient ?

Investigations
Urinanalysis
CBC
Renal function test
Urine cytology
Tumor markers

Imaging modalities

U/S : fixed mass
EXU : filling defect
CT & MRI : looking for LN
Cystoscopy : is the definitive method
Molecular markers : done on the tissue

U/S



IVP

CYSTOSCOPY

How would you stage this disease?

By :
CT scan
TUR

What is the stage of this lesion if it is reaching the deep muscular layer ?

T2b

What is the most common histological subtype of this tumor?

TCC

If you know that this is an Egyptian patient, What is the possible histological subtype? Why?

Squamous cell carcinoma (due to Schistosomiasis)

How would you treat him ?

Radical cystectomy