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Case Studies That Go Beyond The Textbook

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PROSTATE DISEASE

Case Study: Recurrent Hematuria and Clot Retention in a 63-Year-Old Male

Case Study: When a "Simple" UTI Hides a Deadly Secret

Introduction Urinary symptoms in aging men are often dismissed as benign prostatic hyperplasia (BPH), a common condition that can cause difficulty urinating and urinary retention. However, when gross hematuria and recurrent clot retention accompany these symptoms, a deeper investigation is warranted. This case study presents the diagnostic journey of a 63-year-old male who initially sought care for what appeared to be a routine episode of BPH-related urinary retention but ultimately revealed a far more ominous underlying pathology. With a markedly elevated prostate-specific antigen (PSA) level of 50.9 ng/mL, persistent hematuria despite resolved infection, and recurrent complications, this patient’s story underscores the importance of vigilance in distinguishing between benign conditions and life-threatening diseases such as prostate cancer. Through this case, we explore the diagnostic challenges, management strategies, and lessons learned for both clinicians and patients.

A 63-year-old man’s battle with blood in his urine uncovers a medical emergency hiding in plain sight. This case reveals how a common prostate issue can mask a life-threatening diagnosis—and why doctors must never ignore a sky-high PSA.

Patient Profile

  • Name: Mr. K.A. (fictionalized)
  • Age: 63 years
  • Occupation: Shipping professional
  • Medical History:
    • Benign prostatic hyperplasia (BPH)
    • Type 2 diabetes (HbA1c 6.9%)
    • Hypertension
    • Prior UTI with multi-drug resistant Morganella morganii
  • Social History: Married, devout Catholic, independent in daily activities, regular walker.

Presentation: A Cascade of Crises

On January 24, 2025, Mr. K.A. awoke unable to urinate, with blood filling the toilet bowl. His primary doctor diagnosed BPH-related urinary retention but failed to insert a catheter. A urologist succeeded—but the relief was short-lived. Within days, he suffered:

  • Recurrent clot retention requiring emergency catheter replacements
  • Persistent gross hematuria despite antibiotic treatment
  • Anemia (Hb 12.4 g/dL) from ongoing blood loss

The Smoking Gun: A PSA That Screamed Danger

While treating his UTI with meropenem cleared the infection (repeat culture negative), a critical clue emerged: PSA 50.9 ng/mL—40 times higher than normal. This wasn’t just BPH. The prostate was sending an SOS.

Key Findings: Connecting the Dots

  • Lab Results:
    • Hb 12.4 g/dL (anemia)
    • PSA 50.9 ng/mL (markedly elevated)
    • HbA1c 6.9% (suboptimal diabetes control)
  • Imaging: Abdominal scan showing BPH and post-void residual urine.
  • Physical Exam: Unremarkable except for anxiety and catheter in place.

The Differential Diagnosis: Beyond Infection

Why was the bleeding unstoppable? Possible culprits:

  1. Prostate Cancer: The PSA level pointed to malignancy—ulcerated tumors likely caused relentless bleeding.
  2. Bladder/Prostate Stones: Mechanical irritation from stones could explain clots.
  3. Chronic Inflammation: Prior MDR UTI may have damaged bladder lining.
  4. Catheter Trauma: Repeated insertions worsened urethral injuries.

The Intervention: Racing Against Time

The medical team sprang into action:

  • Urgent Cystoscopy: Revealed a mass on the prostate—cancer confirmed.
  • Suprapubic Catheter: Placed to minimize further urethral trauma.
  • PSA Monitoring + Imaging: MRI showed localized prostate cancer without metastasis.
  • Diabetes Optimization: Added empagliflozin to improve glycemic control.

Outcome: A Life Saved by Persistence

Mr. K.A. underwent robotic prostatectomy. Pathology confirmed high-grade adenocarcinoma. Post-surgery:

  • Hematuria resolved
  • PSA normalized (0.2 ng/mL)
  • Diabetes under better control (HbA1c 6.5%)

Why This Case Matters

This story teaches us:

  • Never Underestimate PSA: Even in BPH patients, a PSA >10 ng/mL demands biopsy.
  • Infection ≠ Full Picture: UTIs can coexist with cancer—always investigate bleeding.
  • Trauma Begets Trauma: Repeated catheterization worsens outcomes; opt for suprapubic routes early.

Take-Home Message for Patients

If you’re a man over 50 (or have urinary symptoms):

  • Get Screened: Annual PSA + digital rectal exam.
  • Report Blood in Urine: It’s not “just a UTI” until proven otherwise.
  • Control Diabetes/Hypertension: These conditions worsen urologic outcomes.
Conclusion This case highlights the critical need for a high index of suspicion when managing older males with urinary symptoms, particularly when accompanied by red flags such as gross hematuria, elevated PSA, or recurrent complications. While benign prostatic hyperplasia (BPH) is a frequent cause of lower urinary tract symptoms (LUTS), it should never overshadow the possibility of malignancy, especially in patients with alarmingly high PSA levels. In this case, the initial presentation of acute urinary retention and hematuria was attributed to BPH and a multi-drug resistant UTI caused by Morganella morganii . However, the persistence of hematuria and the discovery of a PSA level 40 times above normal prompted further investigation, ultimately leading to the diagnosis of high-grade prostate adenocarcinoma. The management of this patient required a multidisciplinary approach, involving urology, infectious disease, and endocrinology teams. Key interventions included cystoscopy to identify the source of bleeding, placement of a suprapubic catheter to minimize urethral trauma, and robotic prostatectomy to address the malignancy. Additionally, optimizing glycemic control and addressing cardiovascular risk factors were essential to improving overall outcomes. This case offers several important takeaways for clinical practice: PSA Should Never Be Ignored: Even in the presence of BPH, a PSA >10 ng/mL warrants urgent biopsy to rule out malignancy. Infection Control Is Only Part of the Picture: While treating UTIs is crucial, unresolved symptoms such as hematuria must prompt further investigation into structural or neoplastic causes. Minimize Trauma in Recurrent Cases: Repeated urethral catheterization can worsen bleeding and clot formation; early consideration of suprapubic catheterization may prevent complications. Patient Education Is Paramount: Men over 50, particularly those with risk factors like diabetes or hypertension, should be encouraged to undergo regular PSA screening and report symptoms such as hematuria promptly. From an academic perspective, this case also raises questions about the role of advanced imaging (e.g., multiparametric MRI) in early detection and whether biomarkers beyond PSA could improve diagnostic accuracy. Furthermore, it emphasizes the importance of personalized medicine—balancing aggressive intervention for malignancy with conservative management of comorbidities like diabetes and hypertension. Ultimately, Mr. K.A.’s journey from a seemingly routine urinary complaint to a diagnosis of prostate cancer serves as a powerful reminder of the complexities of urologic care. By maintaining a systematic and thorough approach to evaluation, clinicians can ensure that no stone is left unturned in the pursuit of accurate diagnoses and timely interventions. This case reinforces the adage that in medicine, the simplest explanation is not always the correct one—and sometimes, the most devastating diseases hide behind the most common symptoms.

Final Thought: Mr. K.A.’s story is a reminder—sometimes the loudest alarm bells come in the quietest symptoms. Listen to your body, and demand answers.

Disclaimer & Credit: All medical articles including ours, are informative and provide population trends not specific to individuals which can be very different. Always seek personalized medical advice from your doctor for individual healthcare decisions.

Posted March 15, 2025