“My personal plumbing is a mess.” The case of Earl C. Earl C. presented to the emergency room unable to urinate. The diagnosis was acute urinary retention, a common but not readily explainable...

“My personal plumbing is a mess.” The case of Earl C.

Earl C. presented to the emergency room unable to urinate. The diagnosis was acute urinary retention, a common but not readily explainable complication of chronic urinary obstruction due to benign prostatic hyperplasia (BPH). Earl’s medical history revealed nocturia two to three times each night, a symptom suggesting chronic urinary retention from obstruction. He also reported difficulty starting his stream and had trouble maintaining it, which further suggested chronic prostatic obstruction. Digital rectal palpation confirmed that his prostate was enlarged. His prostate was also tender, which suggested the possibility of prostatitis. It was likely chronic bacterial prostatitis because he had no history of fever or pain to suggest acute prostatitis. His history of “bladder infection” after cystoscopy and bladder surgery 15 years earlier could have been cystitis or prostatitis or both. Such infections often occur after bladder instrumentation. One of the diagnoses on tissue removed by his TUR prostatectomy was “chronic prostatitis,” confirming the clinical history. Further validation of infection came with the finding of a few E. coli in urine submitted for culture.

The pathology specimen also confirmed the presence of clinically suspected BPH. Before beginning to resect tissue through the cystoscope, the bladder was inspected for the possible recurrence of low-grade papillary urothelial bladder cancer from 15 years earlier. No evidence of recurrence was noted, an important finding because urothelial cancers are prone to regrow even after complete removal. This precaution was especially warranted because the most important risk factor is smoking (Earl was a smoker), most urothelial neoplasms occur in middle age to older adults (Earl was 61), men are much more often affected than women, and the prognosis is worse for African Americans.