The patient is an 80-year-old male, height: 166 cm, weight: 57 kg, nationality: Han nationality, occupation: freelancer. He was admitted to the hospital because of "progressive dysuria for more than 10 years, aggravating for more than 1 month." About 10 years ago, the patient developed progressive dysuria without obvious incentives, such as waiting for urination, labored urination, thinning of the urination line, and incomplete urination. In 2015, he underwent transurethral resection of the prostate in our hospital and was discharged after his condition improved. About a month ago, the above symptoms aggravated, and the effect of oral "anti-inflammatory drugs" at home was not obvious. Now the patient came to our hospital for further diagnosis and treatment. After the outpatient examination, he was admitted to the Urology Department of our hospital with "prostatic hyperplasia and cystitis." Since the onset of the disease, the patient has had no chills, no fever, normal diet and sleep, normal bowel movements, normal urination as described above, and no significant change in weight.
The patient's previous physical condition was good. In 1970, the patient underwent subtotal gastrectomy for "peptic ulcer," and the postoperative recovery was satisfactory. In 2015, the patient underwent transurethral resection of the prostate due to benign prostatic hyperplasia, and the postoperative recovery was satisfactory. The patient denied the history of hypertension, diabetes, coronary heart disease, viral hepatitis, tuberculosis infectious disease and close contact, denied any history of major trauma or blood transfusion and denied any history of drug or food allergies. Vaccination history unknown. Parents are not consanguineous, deny family history of disease and similar medical history.
The patient is in fair general condition, temperature: 36 C, pulse: 67 beats/min, respiration: 18 breaths/min, blood pressure: 169/97 mmHg. Abdomen is flat, no varices or scarring of the abdominal wall, no gastrointestinal pattern or peristaltic waves, soft to palpation, no pressure or rebound pain in the abdomen, liver and spleen are not palpable under the ribs, no percussion pain in the liver or kidney area, negative mobile turbid sounds, normal bowel sounds, no significant abnormalities in the bladder area. Rectal palpation: enlarged prostate, about 5*5*6 cm, tough, no hard nodules, no pressure pain, superficial central sulcus.
Ancillary examination: PSA assay: TPSA: 1.91 ng/ml, FPSA: 0.56 ng/ml. urine routine: BACT-M: 879/ul, WBC: 98.0/ul, BC: 2 +, BLD: 1 +, PRO: 4 +, NIT: 1 +, no abnormalities in the rest of the indicators. Coagulation analysis + D-dimer assay: DD: 0.63 mg/L, the remaining indicators were not abnormal. Liver function + cardiac enzyme assay: TP: 60.1 g/L, ALB: 34.9 g/L, CKMB: 33.2 U/L, no abnormalities in the remaining indicators. Urine culture + colony count: no bacterial growth in urine culture of the middle urine. Urology ultrasound shows prostate size is about 5*5*6 cm, the volume of diverticular urine was about 184 ml and the volume of residual urine in the bladder was about 125 ml. CT scan of the kidney and ureter and bladder + enhanced CT of the lower abdomen showed that the bladder was full, multiple stones were seen in the bladder, the larger one was about 2.7*3.6 cm; the bladder wall was thickened and strengthened, and multiple cystic pouch shadows were seen in part of the bladder wall protruding outwards with clear borders, the larger one was about 10.5*6.5 cm in size. The larger one is about 10.5*6.5 cm in size and contains stones. The prostate was enlarged and multiple foci of calcification were seen (Figure 2A). Diagnostic imaging: (1) bladder stones, cystitis and multiple diverticula formation. (2) prostatic hyperplasia and calcification. Cardiac ultrasound and cardiac function measurements: degenerative aortic lesion with a small amount of regurgitation, calcification of the posterior mitral leaflet annulus with a small amount of regurgitation, a small amount of tricuspid regurgitation, and left ventricular hypo-diastolic function. Pulmonary mediastinal CT scan: (1) multiple foci of fibrosis and microscopic sclerotic foci in the lungs, (2) double pulmonary emphysema, (3) calcification of the aortic and coronary artery walls. Pulmonary function measurements: normal ventilation, mildly reduced small airway function, normal ventilation reserve function. Electrocardiogram suggests: sinus rhythm; high voltage on the left ventricular surface and ST-T changes. Ultrasound of the liver, gallbladder, spleen and kidney: no significant abnormalities on ultrasound of the liver, gallbladder, spleen and kidney.
Combining the patient's history, physical examination and ancillary examination, the initial diagnosis was: (i) prostatic hyperplasia; (ii) cystitis; (iii) bladder stones; (iv) bladder diverticulum; (v) bladder diverticulum stones; (vi) emphysema; (vii) post-gastrectomy for most of the stomach. The diagnosis of this patient is relatively easy, with typical clinical symptoms and imaging examinations. It should be noted that the clinical symptoms of bladder diverticula are generally not obvious. Larger bladder diverticula are prone to secondary infection, stone formation, and even tumor occurrence. The diagnosis is mainly based on imaging examinations. In addition, bladder stones in middle-aged and elderly people need to consider whether there is prostatic hyperplasia, because bladder stones are often secondary to urinary tract obstruction caused by prostatic hyperplasia. The patient's diagnosis and treatment process were shown in Figure 1.
As the patient has cystitis as well as bladder stones, he has been advised to drink more water to dilute the urine and reduce bladder irritation, and also to use the antibiotic cefotaxime sodium (2g, bid) reasonably to fight infection and treat cystitis.