This case involves a 52-year-old male with T12 AIS A SCI secondary to a car accident in 2012. His bladder management consisted of intermittent catheterization (IC) 4-5 times per day in addition to using a condom catheter for concomitant urinary incontinence, especially during his wheelchair basketball sports activity. The patient had a 6-year history of 3-4 Escherichia coli rUTIs per year accompanied by high fever with chills and associated temporary urethral secretion. With the onset of the UTI symptoms, his urinary incontinence ceased temporarily and the following day he would notice a thick, purulent urethral discharge. Repeated renal ultrasound evaluation did not reveal stones, renal dilatation or parenchymal abnormalities.
Due to the urethral discharge, a periurethral source of infection/abscess was suspected. A urethral swab/secretion culture revealed >10,000 E. coli cfu/hpf. Transrectal prostate ultrasound (TRUS) and lower abdominal magnetic resonance imaging (MRI) were conducted and both tests were without any significant findings.
Urodynamics in the absence of UTI demonstrated a stable bladder pressure system with neurogenic detrusor underactivity accompanied by stress urinary incontinence due to urethral sphincter deficiency. Bladder compliance was normal at 79.
Cystourethroscopy demonstrated a normal urethra and bladder; however, there was an incidental hypertrophic verum montanum (Fig. 1). Given the limited findings yet rUTIs, it was hypothesized that the hypertrophic verum montanum was acting as a source of temporary obstruction during a prostatitis inflammation process. After thorough discussion, the individual underwent endoscopic removal of verum montanum (Fig. 2).
Urodynamic studies were repeated post verum montanum resection demonstrating similar neurogenic detrusor underactivity and urethral sphincter deficiency with an abdominal leak point pressure (ALPP) at 100 cmH2O. Clinical recommendations for management consisted of continuing self-IC 4-5 times per day and avoidance of Valsalva/straining maneuvers for bladder emptying. Our goal to avoid rUTIs was to maintain a low-pressure reservoir that was emptied completely via IC and to avoid Valsalva/strain voiding to minimize pressure in the prostatic area.
Due to the failure of appropriate culture-sensitive antibiotics to eradicate the rUTIs and the new findings of prostatic calcifications (Fig. 3), a TURP was recommended. An uneventful TURP was performed 3 months after the last rUTI, and pathology revealed chronic inflammatory elements and small abscesses in the prostate gland (Fig. 4). The individual has been followed for the past 4 years and he has been free of UTI symptoms and urethral discharge after the TURP.
Urodynamic testing was repeated 1 year after the TURP and demonstrated stable bladder pressures with neurogenic detrusor underactivity and stress urinary incontinence with urethral sphincter deficiency but now with a lower ALPP of 70 cmH2O. The lower ALPP can be explained by the decreasing of "urethral resistance" after TURP. The individual continues to manage his bladder by IC and avoid straining. To manage his stress incontinence due to sphincter deficiency, he continues to use a condom catheter. The TURP did not have any adverse effects on his bowel or sexual function. The individual also uses intracavernosal alprostadil injections for his neurogenic erectile dysfunction with good results.