Urology Inpatient Consultation

14/05/2024

Reason For Consultation: Acute urinary retention (AUR) and gross hematuria.

History of Present Illness: 72 yo M (Robert Vance, MRN: 849-201-44) admitted 12/05/2024 for CAP and NSTEMI, started on IV heparin and ceftriaxone. Developed suprapubic pain and inability to void this AM at 06:00. Bladder scan showed > 800 mL. Nursing attempted 16 Fr Foley placement x2, resulting in gross hematuria with clots and failure to advance past the prostatic urethra. Patient reports 8/10 suprapubic pain, relieved slightly by passing small amounts of bloody urine around the catheter attempt. Denies prior trauma. Reports a 2-year history of worsening LUTS (weak stream, hesitancy, nocturia x3) poorly controlled on tamsulosin.

Relevant Urologic History

• BPH diagnosed 2020; managed medically with tamsulosin. No prior urologic surgeries, cystoscopies, or episodes of AUR. No history of nephrolithiasis or GU malignancy.
• Progressive obstructive LUTS over the past 6 months, now complicated by acute retention and traumatic catheterization in the setting of systemic anticoagulation.

Past Medical/Surgical History

HTN, HLD, T2DM, CAD (NSTEMI current admission), BPH. Surgical history: Laparoscopic cholecystectomy (2015), right inguinal hernia repair (2018).

Allergies

Penicillin (rash)

Current Medications

• heparin 1,000 units/hr IV continuous
• ceftriaxone (Rocephin®) 1 g IV Q24H
• azithromycin (Zithromax®) 500 mg PO Q24H
• acetylsalicylic acid (aspirin, Ecotrin®) 81 mg PO Q24H
• atorvastatin (Lipitor®) 80 mg PO QHS
• lisinopril (Prinivil®) 20 mg PO Q24H
• metformin (Glucophage®) 1,000 mg PO BID
• tamsulosin (Flomax®) 0.4 mg PO QHS

Review of Systems

Constitutional: Negative for fever, chills. CV: Chest pain resolved. Resp: Mild cough, no SOB. GU: Positive for suprapubic pain, inability to void, gross hematuria. Negative for flank pain, dysuria prior to catheter attempt.

Physical Exam

Most Recent Vitals

• T 36.8 °C, BP 148/86 mmHg, HR 88 bpm, RR 16/min, SpO2 96 % on RA.
• Alert, oriented x3, in moderate distress secondary to bladder distension. No pallor, icterus, or peripheral edema.
• Abdomen: Soft, non-distended, palpable and tender bladder to the level of the umbilicus. No CVA tenderness. Genitourinary: Normal circumcised phallus, dried blood at meatus, testicles descended bilaterally without masses or tenderness. DRE: Enlarged, smooth, symmetrical prostate (~60 g), no nodules, no boggy areas, normal rectal tone.
• CV: RRR, no murmurs. Resp: Bibasilar crackles, improved.

Imaging

• Bladder scan (14/05/2024 06:15): > 800 mL.
• Renal/Bladder US (14/05/2024 09:30): Bilateral mild hydronephrosis, no shadowing calculi. Distended urinary bladder containing mobile echogenic debris consistent with blood clots; enlarged prostate indenting the bladder base.

Labs

• 14/05/2024 08:00: WBC 11.2 x10^3/µL, Hgb 12.8 g/dL (down from 13.5 g/dL on admission), Plt 210 x10^3/µL, Na 138 mmol/L, K 4.2 mmol/L, Cr 1.4 mg/dL (baseline 1.0 mg/dL), PTT 68 sec, PSA 3.2 ng/mL (from 01/2024). UA: Grossly bloody, > 100 RBC/hpf, 10-20 WBC/hpf, negative nitrites, negative leukocyte esterase. Urine culture pending.

Assessment

In brief: - 72 yo M with BPH on IV heparin for NSTEMI who developed AUR complicated by traumatic Foley attempt, false passage, and gross hematuria with clot retention and mild post-renal AKI.

Objective Data

"Exam notable for" palpable, tender suprapubic mass, blood at urethral meatus, and ~60 g prostate on DRE, "labs were significant for" acute Cr elevation to 1.4 mg/dL and Hgb 12.8 g/dL, "imaging demonstrated" mild bilateral hydronephrosis and bladder clot burden, concerning for BPH-induced acute urinary retention and iatrogenic urethral trauma.

Recommendations/Plan

Acute Urinary Retention and Urethral Trauma

• AUR secondary to BPH, exacerbated by inpatient immobilization and acute illness, complicated by urethral false passage and hematuria from traumatic catheterization while on IV heparin.
• Differential diagnosis: BPH, urethral stricture, bladder neck contracture, urothelial carcinoma.
• Monitor BMP and CBC Q24H to track renal function and Hgb stability. Follow up pending urine culture.
• Placed 20 Fr 3-way Coudé catheter at bedside without difficulty; irrigated 150 mL of dark clots until efflux cleared to light pink. Started continuous bladder irrigation (CBI) with NS at moderate rate to keep efflux light pink/clear. Continue tamsulosin 0.4 mg PO QHS; initiate finasteride (Proscar®) 5 mg PO Q24H to reduce prostatic vascularity and volume (discussed side effects including decreased libido and ED).
• Outpatient TURP vs HoLEP if patient fails subsequent voiding trials once cardiac status stabilizes and anticoagulation can be safely bridged/held.
• Maintain strict I&Os, monitor for post-obstructive diuresis (notify Urology if UOP > 200 mL/hr for 2 consecutive hours).
• None required at this time.
• Keep Foley in place for minimum of 7 days to allow urethral healing. Discontinue CBI once hematuria resolves for 24 hours. Voiding trial (TOV) in outpatient Urology clinic 1 week post-discharge.

Mild Post-Renal Acute Kidney Injury

• Mild AKI (Cr 1.4 mg/dL) secondary to bladder outlet obstruction and bilateral hydronephrosis, expected to resolve with decompression.
• Differential diagnosis: Obstructive uropathy, pre-renal azotemia, contrast-induced nephropathy.
• Repeat BMP tomorrow AM.
• Avoid nephrotoxic agents; maintain euvolemia with maintenance IV fluids if post-obstructive diuresis occurs.
• Relief of obstruction achieved via 3-way Coudé catheter placement.
• Encourage oral hydration once cleared by Cardiology.
• None.
• Daily inpatient urology follow-up until CBI is weaned and Cr returns to baseline.

Additional Notes: (include only when applicable and available)

• Educated patient on the nature of BPH, the mechanism of urethral false passage, and the rationale for prolonged catheterization to prevent urethral stricture formation.
• Instructed nursing and patient to avoid catheter manipulation. Advised patient to report severe bladder spasms, bypassing of urine, or cessation of catheter drainage immediately.
• Patient expressed concern regarding discharging home with a catheter; reassured him that home care teaching and leg bag supplies will be arranged prior to discharge.

Dr. Marcus Vance, MD Department of Urology

This note was prepared with assistance from an AI transcription tool that complies with HIPAA requirements. The patient consented to use of this tool before it was used.