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Int. J. Pharm. Med. & Bio. Sc. 2014 Ather Pasha and Suhail Bin Ahmed, 2014

ACUTE RETENTION OF URINEA RARE PRESENTATION OF TYPE 2 DIABETES

MELLITUS (DM): A CASE REPORTAther Pasha1* and Suhail Bin Ahmed1

Case Report

Diabetes Mellitus is causing a big socioeconomic burden in developing countries. Inadequateeducation and awareness about disease and its complication has further added to existingscenario particularly in India. Common clinical features of Diabetes Mellitus include polyuria,polydipsia and weight loss, nonhealing skin infection. Here we report an unusual case of DiabetesMellitus presenting as acute retention of urine due to prostatic abscess, which completelyrecovered with conservative treatment, highlighting complete evaluation, early diagnosis,treatment and prevention of complications.

Keywords: Diabetes Mellitus,Clinical Examination, Prostatic Abscess, Trans Rectal Usg,Antibiotics, Insulin

*Corresponding Author: Ather Pasha atharpasha@yahoo.com

INTRODUCTIONDiabetes Mellitus Type 2 is a commonmetabolic disorder characterized byhyperglycemia due to progressive beta cellfailure, insulin resistance and increasedhepatic glucose production leading to acuteand long term chronic complications.According to WHO Estimate for year 2000,there were 171 million adults with diabetes inthe world. In 2011 the International DiabetesFederation (IDF) set the figure at 366 million,this is predicted to rise to 552 million by 2030.The greatest increase is expected to be seenin India (~50 million) Hyderabad one of majorcities in southern India is considered as capital

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Int. J. Pharm. Med. & Bio. Sc. 2014

1 Department of Medicine, DCMS, Hyderabad.

of Diabetes Mellitus in India.

CASE REPORTA 61 year male patient without significant pastmedical or surgical history presented with acuteretention of urine with denovo hyperglycemia withinsitu foley’s catheter. He initially visited to a nearbylocal hospital for acute retention of urine where foleyscatheterization was done for normal urine flow. Hisroutine cell count, Blood chemistry and USGAbdomen were within normal limits. His blood sugarwas found to be 296 mg/dL. He was treatedsymptomatic ally suspecting urosepsis with iv fluids,antibiotics (third Generation cephalosporins) andinsulin for 3 to 4 days. Later foleys was removed and

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Int. J. Pharm. Med. & Bio. Sc. 2014 Ather Pasha and Suhail Bin Ahmed, 2014

was discharged on oral antibiotics and oralhypoglycemics.

Later same day by evening he again developedretention of urine and fever with chills and washenceforth referred to our hospital (Princess EsraHospital) for further management. Onexamination, pulse was 100/min, and BP was100/70 mmHg with postural hypotension. Therewas no Icterus, pallor, normal JVP with no pedaloedema. On examination of abdomen there waspain in suprapubic region and there wassuprapubic dullness on percussion.Cardiovascular system examination was normal.Examination of chest was unremarkable.

Investigation revealed haemoglobin 13 g/dL,total white cell count 15,300/cm with raisedneutrophil count. ESR 25 mm at 1 h, serumbilirubin 0.81 mg/dL, serum albumin 3.4 g/dL,SGPT 23 U/L, alkaline phosphatase 129 IU/L, PT12 s with INR 1.00. The random plasma glucoselevel was 356 mg/dL. His HbA1c was12.4%.Blood urea, sr. creatinine were normallimits. CUE showed 5-6 pus cells, initialultrasound scan of abdomen showed significantamount of urine in bladder and hence wascatheterized. Urine and blood samples for c/swere sent. He was febrile and his sugars wereon high levels hence started with iv fluids,antipyretics, antibiotics, insulin and othersupportive care. On careful history patient hascomplain of constipation prior to retention of urine.

A per rectal examination was done whichrevealed tender prostate with positive fluctuationsign. Ultrasonography of abdomen was normal,transrectal ultrasound was done which showedprostatic abscess involving left lobe measuring3.8 cm (Figure 1).. Surgical opinion was takenand was advised to continue conservative

treatment with follow up scan later. Antibiotic wasupgraded to piperacillin/Tazobactum. He washospitalized until his leukocytosis was normalizedand been free of fever for 2 days. He improvedsymptomatically, follow up transrectal USGshowed diminishing abscess size. Urine andblood cultures were sterile. Foleys catheter wasremoved and there was no discomfort for passingurine. He was discharged on oral antibiotics andinsulin to follow up in OPD later.

Figure 1: Transrectal Ultrasound ShowingProstatic Abscess

Figure 2: Prostate and Adjacent Structures

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Int. J. Pharm. Med. & Bio. Sc. 2014 Ather Pasha and Suhail Bin Ahmed, 2014

DISCUSSIONHere the patient was rehospitalized due toincomplete evaluation in terms of complete historyand physical examination, as it was difficult tocorrelate between denovo high blood sugars andacute retention of urine. Majority of patients Type2DM present with osmotic symptoms ornonhealing skin infections, we have seen rarepresentation of Type2 DM already reported likeAcute MI, Stroke, Ketoacidosis, Erectiledysfunction.

Higher frequency of infection in DM is causeddue to reduced response of T cells, damage toneutrophil function, depression of Humoralimmunity, but occurrence of prostatic abscessnowadays is very rare. The differential diagnosisbetween acute prostatitis and prostatic abscesshas always been difficult. The distinguishingpalpatory finding of a tender, fluctuant prostateon rectal examination has not been a constantoccurrence. Recent imaging methods such asTRUS (trans-rectal ultrasound) have beensuggested as a noninvasive technique veryhelpful for the diagnosis of pathological conditionsof the prostate. The sonographic pattern ofprostatic abscess is characteristic and can beeasily differentiated from other glandular lesions.While it is generally accepted that surgicaldrainage is most important in the treatment of aprostatic abscess, the exact method of drainageremains controversial. USG guidance is preferredto surgery because of its lower risk ofcomplications. Trans-rectal USG also makes itpossible to follow up abscesses that were nottreated with drainage or puncture but withantibiotic therapy alone.

Here in our case as the abscess size wassmall and there was easy availability of transrectal

USG, patient was treated conservatively withbroad spectrum antibiotics successfully withfollow-up scans. As the HbA1c was high at thetime of presentation, he was initiated on premixedinsulin for better glycemic control for Improvingimmune status and faster healing of abscess.

CONCLUSIONIn conclusion, we present denovo type 2 diabeticwho presented with urinary retention contrary toclassical symptoms of osmotic symptomssecondary to prostatic abscess, which requiredappropriate antibiotic therapy according to urineculture and sensitivity with clinical improvement.TRUS was important in achieving diagnosis andwas cost-effective, non invasive and helpful formonitoring the size of abscess. In conclusionsmall prostatic abscess can be managedconservatively with monitoring of abscess sizewith complete resolution which we have seen inour patient.

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