By Tedler D. Depaynos, MD
We were having cups of unending black coffee when a young colleague related his experience regarding a patient with signs of prostatic enlargement and initially diagnosed to have Prostatic Malignancy. Together in our round table was a curious lawyer friend with grayish hair obviously very interested on the medical tale because he apparently was also manifesting similar signs of prostatic enlargement.
My colleague’s patient was a 57 year old male bank employee. He has been urinating at least 3 – 4 times per night which made him uncomfortable and eventually became irritating to his bedmate. The patient never mentioned this to his bedmate but there were times when he had to exert effort in urinating. It was months after when he suddenly had blood in his urine that made him “nervous”. Despite the hesitation, his “nervousness” forced him to mention this to his bedmate who urged him to visit my colleague who is their family MD.
Initial impression was Urinary Tract Infection or UTI but because of his age, his nocturnal urination and absence of painful urination or dysuria and other concomitant considerations were entertained. Because of the sudden bloody urine an enlarged prostate was mainly considered by their family MD.
The main function of the male prostate is to secrete fluid where the sperm swims. Without the fluid the semen would appear gel-like and the sperms would just be plastered. Hence, it contributes to fertilization. With enlarged prostate, our lawyer coffee mate argued that it should be more advantageous because more fluid would be secreted which unfortunately does not happen.
It is located just at the bladder exit so that with enlargement, urine exit would be obstructed. Hence, signs of prostatic enlargement or prostatomegaly would be urination with effort, dribbling, frequency and nocturnal urination sometimes every 2 hrs and feeling of urinary retention. They may appear all at the same time or 1 or 2 at a time just like in the patient. Because of the difficulty of urination, lines of customers may form, awaiting for their turn and murmuring curses may sometimes be heard. Our lawyer coffee mate confessed that he sometimes had heard the murmured curses behind him while using a public urinary bowl.
A simple urinalysis confirmed the UTI of the patient and likewise a plain Ultrasound (UTZ) revealed a “moderately enlarged prostate gland”
There are various causes of an enlarged prostate. It could be due to plain infection causing “prostatitis” or enlargement usually due to ageing called Benign Prostatic Hypertrophy or BPH. It could be due to tumors which may be benign or malignant. It may also be due to Tuberculosis. Experienced Urologists who have done hundreds of Digital Rectal Examination could sometimes be more reliable than plain UTZ. They could surmise the cause of the enlargement and they can even calculate the weight of the prostate which is normally 20 gms. just by their examining finger. They obviously have untiring experienced fingers.
Because of the bloody urine of the patient a possible malignant etiology was highly entertained. This was buttressed by the patient’s blood test of an elevated Prostatic Specific Antigen or PSA which may imply the possibility of Prostatic Cancer when elevated. His family MD then referred him to a young Urologist who trained at Veterans Hospital where most of the patients are elderlies.
The possibility of a malignant lesion was then meticulously explained to the patient which made him unfortunately more “nervous” if not for the calming embrace of his wife. The consulted Urologist then after a Digital Rectal Examination recommended a prostatic biopsy mainly because of the elevated PSA. A biopsy will definitely rule out or confirm the impression so that if positive, an early surgery might be required. It was the wife that vocalized the patient’s confirmation.
The Prostatic Biopsy was done by the young Urologist under local anesthesia and as an out-patient procedure. Despite the obvious “nervousness” of the patient who felt a little dizzy after, he definitely underwent the procedure bravely and even requested his wife just to stay outside.
It was after a week of “sleepless nights” when the final result of the biopsy was released. Both the patient and his wife were with all smiles when they handed their copy to their family MD. Their smiles widened when the MD read again openly the result of the biopsy which was “negative for malignant cells”. The enlargement was due to BPH which may be curable with the medicines prescribed by the young Urologist They partly attributed the good results to the murmured prayers of their neighbor while they butchered a native chicken and had long sips of native wine. Obviously, their family MD just smiled.
As we parted our lawyer friend requested to be referred to the consulted Urologist which I gladly did. He also hinted that he might also consult the “murmuring” neighbor of the patient later.**