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Hesitancy-difficulty starting urination or keeping it flowing

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70-year-old - elderly, immunocompromised, common health issue(DM,Heart disease),normal aging process can lead to incrased bladder contractibility,decrease bladder compliance,resulting in urgency and frequency

male - male disease (prostate ca)

urinary frequency, urgency, and hesitancy - caused by uti,overactive bladder,medication side effects,bladder muscle problem

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UTI

Lower urinary tract syndrome

Obstruction of UT

Trauma involving UT

Kidney stone

Enlargement of prostate(d/t Prostate CA or medication)

Prostatitis

DM

Aging related - Muscle weakness(inner sphincter and external sphincter)

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Onset - gradual(BPH/overactive bladder/Neurological issue) or sudden(UTI/Prostatitis)

Characteristics- urine- large amount or small amount? have to get up at night?colour? odour? pain whne urinating?

Associated symp-fever?swelling in extremities? weight loss? loss of appetite?

Pain- difficulty starting to urinate d/t pain,ask on characteristic of pain(sharp/dull/intermittent)

Timing - constatnt or intermittent,changes in severity of symp.

Exacerbating/Relieving factor- any food/medication taken that may have made the condition worse or better

PMH - History of UTI,surgeries(urinary catherization)

Medication history- diuretics?

Allergy history

Family history - similar symp in family members?history of prostate problem,endocrine disorders,UTI

Social history- occupation(dehydration,unhygenic-UTI),dietary(oxalate rich food-kidney stone),Alcohol and smoking

Marital status/sexual activities

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1.PSA blood test

-to screen if there is prostate ca, it measure prostate specific antigen and usually do with digital rectum examination

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1.waking up multiple times each night to urinate

-nocturia, more common in older, also other problem like DM (non neurologic ) can cause this problem

2.approximately 2 months ago

-indicate chronic, develop slowly over time

-symptom worsen

3.reports that he often has difficulty falling back asleep after awakening, and the loss of sleep was affecting his quality

of life.

-cause fragment sleep, can lead to anxiety

-ada scor to know severity of condition, IPSS

4.family history of prostate cancer

-high risk to get prostate ca, can cause obstruction to urethra

5.had a prostate exam including PSA blood test performed 15 years ago, with normal results.

-not warranty there will be no prostate issue, recommend to take test again

6.The patient was diagnosed with hypertension at age 55 and takes

enalapril.

-long stand HTN

-control with medication

7.father was diagnosed with prostate cancer at 62,died at age 86 and his brother was diagnosed with prostate cancer at age 43, still alive

-2 times risk to get prostate ca

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UTI

Lower urinary tract syndrome

Obstruction of UT

Trauma involving UT

Kidney stone

Enlargement of prostate(d/t Prostate CA or medication)

Prostatitis

DM

Aging related - Muscle weakness(inner sphincter and external sphincter)

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1.vital sign (temp, bp, hr, rr)

-we check to know urgency and critical of the symptom

2.physical examination

any pallor, alert, or distress

abdominal examination : IPPA

-percuss for any dullness

-palpate kidney, lateral side, suprapubic region

-auscultate

3.neurologic examination- cari balik

4.DRE (digital rectal examination)

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1. DRE - examine lower rectum, anus, prostate gland

2. Perineal sensation - sensory perception at the perineal, between anus and penis

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1. Vital signs - temperature normal - no infection, HR normal -normal cardiac fx, RR and BP normal (under control)

2. no costovertebral angle tenderness - no kidney problem

3. bladder felt distended on palpation - bladder enlarged - holding more urine than normal - incomplete emptying (can be normal if the bladder is full) - ask patient empty the bladder first before the examination (depends on test - best to have full or empty bladder)

4. genital exam is normal - genital no scars, no lesions and mass

5. Digital rectal examination reveals a prostate is enlarged in size, smooth, and non- tender with no nodules --> possible prostate problem - prostate cancer may have irregularities on palpation, prostatitis also can cause non-cancerous nodules

6. anal sphincter tone and perineal sensation is normal - no neurological condition

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UTI

Lower urinary tract syndrome

Obstruction of UT

Trauma involving UT

Kidney stone - loin to groin pain, positive murphy sign

Enlargement of prostate(d/t Prostate CA or medication)

Prostatitis

DM

Aging related - Muscle weakness(inner sphincter and external sphincter)- normal

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1. Blood test (FBC)

2. Blood glucose

3. Urinalysis - composition of urine

4. Renal function test - assess in FBC

5. PSA test

6. Prostate biopsy (but invasive)

7. Imaging - ultrasound, MRI

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1. IPSS score - international prostate symptoms score, to assess severity of symptoms in bph

2. postvoid residual urine volume (PVR) - amount of urine left in the bladder after voiding

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1. blood test

All normal, no anaemia, no infection, no bleeding disorder, normal kidney function

2. His IPSS score was 21 and prostate specific antigen was 4.2 ng per mL

21: severe lower urinary tract symptoms

PSA: more than 50 normal is 4.0

PSA 4-10 suspicious of 25% chance of prostate ca

3. Ultrasound scan showed an enlarged prostate gland measuring 55 cc in volume postvoid residual urine volume (PVR) of 60 mL

confirm prostate enlargement (normal:20-25 cc)

PVR: less than 50ml is normal, indicate patient has urinary retention due to obstruction by enlarged prostate

4. Transrectal ultrasound-guided prostate biopsy showed benign prostatic tissue with stromal and glandular hyperplasia

non-cancerous tissue

5. diagnosed with benign prostate hyperplasia

prostate enlarged but not cancerous

occur in elderly men

6. started medication therapy with tamsulozin and finasteride

to treat bph

tamsulozin: relax muscle of prostate and bladder

finasteride: shrinking prostate, decrease dht

7. follow-up visit after a week he reports significant symptom improvement and quality-of-life improvement and he tolerated the medications well.

good prognosis

8. He was advised to continue therapy with annual DRE and PSA.

to monitor progression of the disease