Urology Assessment

Tn. A. H.
409-41-62, 68 year old
Reporting patient from urology outpatient clinic
Chief complaint:
Patient was unable to urinate since 1 month ago
History of present illness:
Patient was unable to urinate since 1 month ago. He had history of Lower Urinary Tract
Symptoms since 6 months ago. He had no history of dysuria, hematuria or passing stone.
There was no history of fever, cloudy urine, flank pain. He had not been taken any medication.
He had no history of spinal or straddle injury. No history of urethral instrumentation before.
One month ago, patient underwent urethral catheter placement and given Harnal 0,4 mg
daily. After 5 days of consumption, the urethral catheter was taken off, yet he failed to urinate.
History of past medical illness:
No history of diabetes mellitus
No history of hypertension
No history of Cerebrovascular Disease
Physical examination
General status: Fully alert, with stable hemodynamics
Urologic status:
Right flank: Mass (-), percussion pain (-), tenderness (-)
Left flank: Mass (-), percussion pain (-), tenderness (-)
Suprasymphisis: Bladder felt empty, no mass
External genitalia: on Folley Catheter 18 Fr, urine output 1500 2000 cc/day, clear and yellow
Digital Prostate Examination:
Sphincter Ani Tone: Good
Prostate: Smooth surface area, Consistency rubbery, Pain (-), Nodule (-), Estimated Prostate
Weight > 60 g
Bulbocavernosus reflex (+)
Laboratory examination (9/2/16)
Complete blood count: 14.4/42.6/8180/496000
Electrolyte: 138/3.51/95.6 (normal limit)
Random blood glucose: 96 mg/dL (normal limit)
Ur/Cr 14/0.7
PSA 5.03 mg/dl
Urinalysis clear, yellow, acidity 6.0, specific gravity 1.005, WBC 1-2/HPF, RBC 0-1/HPF,
bacteria (-), leukocyte esterase
Trans Abdominal Ultrasonography
Intra Vesical Prostate Protrusion 16 mm
No sign of bladder stone

Trans Rectal Ultrasonography

There was hyperechoic lesion
Volume: 66,1 cc
Anatomical Pathology (22/2/2016)
Conclusion: Hyperplasia Prostate
We diagnose the patient with
Urinary Retention due to Benign Prostate Hyperplasia
Th/ we plan to perform
Trans Urethral Resection Prostate