Dr. Kube: How a man's bladder problem became a prostate predicament
Jim came to the emergency department complaining of severe pain in his lower abdomen and he couldn't help but to pace around as the triage nurse got him checked in.
He was so uncomfortable that he deferred all questioning to his wife. He had been having difficulty urinating over the past several days and for the previous eight hours was unable to pass any urine at all. She said that he had tried everything, even running water in the bathroom.
The triage nurse put an IV in Jim and used an ultrasound to scan his lower abdomen to see how much urine he was retaining, which is called a bladder scan. It showed that Jim had about a liter of urine in his bladder, which explained his discomfort. She called me from triage and asked for an order to put a catheter into Jim’s bladder to drain the urine. A urinary catheter is a tube that drains urine from the bladder through the urethra, which is the tube that connects the bladder to outside.
Enlargement of the prostate is a very common cause for urinary retention in a male, which is what I suspected was going on with Jim. In a male the prostate gland surrounds the urethra in the pelvis and when enlarged, it can cause decreased urine flow. If the flow is diminished enough that urine is unable to pass, we place a catheter in the emergency department (ED) to fix the obstruction at least temporarily.
After the nurse was able to successfully place the catheter, Jim was brought back to his room in the ED. By the time I saw him, he was smiling and said he was feeling much better. I pressed on his abdomen, and he said the pain he had been experiencing was almost completely gone. I looked at the bag attached to this catheter and there was about a liter of clear, yellow urine in the bag. I asked Jim more about his urinary symptoms.
Jim said he had intermittent difficulties with initiating his urine stream and did get up frequently during the night to urinate. This was the first time he was unable to get any urine to come out. These symptoms all fit with benign prostate enlargement, which means that the prostate is enlarged but not due to a serious cause like cancer. I asked him if he had had his PSA (prostatic specific antigen) level checked and he vaguely remembered having it checked several years prior.
PSA is a protein that is produced both by normal and malignant cells in the prostate gland. There are several conditions that can increase the PSA level, including inflammation or infection of the prostate, benign enlargement of the prostate and prostate cancer. PSA testing can be used in conjunction with physical exam findings and an individual patient’s risk factors for prostate cancer. In general, the higher the PSA level, the more likely it is that a man has prostate cancer. Jim admitted he hadn’t seen his family physician regularly over the past few years due to some other health issues he had been dealing with and probably hadn’t checked his PSA in a while.
Jim underwent a CT scan of his abdomen and pelvis while he was in the ED, and it showed that Jim’s prostate was quite enlarged and there was some irregularity to his prostate gland that was suspicious appearing. Additionally, the radiologist saw a few abnormally enlarged lymph nodes, which raised the concern that Jim’s prostate enlargement was due to cancer as opposed to benign enlargement.
I reviewed the results of Jim’s work up in the ED with Jim and his wife. I was able to get him an appointment to see our urologist a few days later. Before he left the ED, his nurse taught him and his wife how to care for the catheter at home.
After he saw the urologist, Jim underwent additional testing to determine the cause of hisenlarged and abnormal appearing prostate. The urologist checked Jim’s PSA level, which was elevated. He underwent a biopsy of his prostate that unfortunately confirmed the diagnosis of prostate cancer. He also had a PET scan that indicated the cancer had spread outside his prostate gland to nearby lymph nodes in his pelvis.
The urologist referred Jim to see an oncologist. Oncology reviewed his treatment options,discussed the potential risk and benefits of the various treatments, and ultimately started him on hormonal chemotherapy. He was also scheduled to see a radiation oncologist to see if radiation would be a treatment option.
Jim ultimately being diagnosed with prostate cancer was not what I expected when I saw him in the ED. Most cases of urinary retention that I see in the ED are due to benign prostate enlargement. While the symptoms of benign prostatic enlargement and prostate cancer can be similar, prostate cancer is frequently asymptomatic, which can make it challenging to diagnose.
The oncologist was hopeful that Jim would respond well to his oral chemotherapy and told Jim and wife that he did not think this diagnosis would change his life expectancy. Jim did have some difficulties dealing with his cancer diagnosis and felt frustrated that he had not caught the diagnosis sooner. After several appointments with his oncologist, he ultimately was hopeful that his treatment regimen would suppress further growth of his cancer and he would have many years of good health ahead of him.
Dr. Erika Kube is an emergency physician who works for Mid-Ohio Emergency Services and OhioHealth.
drerikakubemd@gmail.com
This article originally appeared on The Columbus Dispatch: Man's bladder problem leads to unexpected prostate cancer diagnosis
