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Presentation Case of Hematuria and Enlarged Prostate

The Phone Call

On a Monday morning at 8.00 a.m. I got a call. As I picked up the phone, the caller sounded seismically shaken and very nervous, said he from the other end, “Doctor, I am passing blood in urine, I am feeling frequent urge for urination but passing small quantity of bloody urine. I am highly upset; I don’t know what to do, please help me.” That is what my patient could briefly say about his condition through his emergency call to me. He is 64 year old and has been coming to me for the last many years for all his periodical complaints. On further inquiry he yielded more details of his complaint. Till a day before, he did not have any problem whatsoever. That day also he got up as usual in the morning, went out for his morning walk, came back, had his bath followed by a cup of tea and had no problem until then. But all hell broke loose after half an hour when he started feeling repetitive urge for urination. The colorless urine gradually started turning yellow to brownish and to blood red. All this progressed in period of half an hour. Though he did not feel pain anywhere, but he felt very restless due to persistent urge and found himself in strange agony. The over powering weakness kept him lying down.

Immediate Action

For this particular condition I found Lycopodium coming to my mind instantly. I knew from his earlier anamnesis, he had Lyco. traits. I knew him to be a pretty fast eater, he takes tea, milk etc. very hot, he is prone to flatulent and digestive disorders, always amenable to Lyco. In that state of emergency I prescribed him three doses of Lycopodium 200C one hourly.. I got quite an encouraging feed back in the evening. Three doses of Lyco reduced his persistant urge for micturition considerably and acted well in relieving the agonising restlessness, but there was not much change in the colour of the urine and his temperature rose to 101°C. Those around him were pleasantly intrigued to find him feeling better despite onset of fever. I then prescribed three doses of Hamamelis virginica 1000G, to be taken one hourly later in the evening. Next day I was informed that the urine-colour had been turning lighter and lighter . By that evening the urine became almost colourless with no apparent traces of blood, meanwhile the temperature also returned to normal. During all that period I had to give only two more doses of Lyco and none of Hamamelis besides the initial three.


My patient on having first time experience of hematuria was struck with horror on finding blood coming out in place of urine. But on seeing himself extricated from that frightening condition, to near normalcy within 8 to 10 hours he showered all praise on homoeopathic treatment.

 

Master Guidelines

I am reminded here of the oft-repeated words of Dr. Surmeet Mavi: staunch follower of Dr. Prafull Vijayakar’s Predictive Hornoeopathy in Punjab “All that glitters is not gold and all that disappears is not cure.” Although my patient reported normal by that evening but I knew his case needed further investigation and follow up. According to urologists, the specialists in this field, the hematuria inflicting a male in sixties has to be viewed seriously. It inevitably calls for locating a cause owing to the ubiquitous risk of malignancy at this age. As per the authoritative clinical information available on the subject, when hematuria is the sole presenting symptom especially at this age, the most likely causes could be renal carcinoma, papilloma of the bladder, benign prostate hypertrophy or in some case schistosomiasis. Mindful of these aspects, I had advised my patient on the very first day to get the urine test done and to go in for ultrasonography (USG) of KUB region on the following day. His urine test for culture indicated presence of E.Coli and his USG report revealed moderate prostatomegaly (grade II) with 250 ml of residual urine after emptying full bladder volume of 500 ml. No stones were seen in the area scanned including the kidneys. All this information facilitated me to arrive at the cause of hematuria. It became obvious that the enlarged prostate gland’s size underwent sudden increase because of inflammation caused by the superimposed infection due to E. Coli. This in turn gave rise to hematuria. The prostatic obstruction became instrumental in retaining 250 ml of urine even on emptying bladder. Meanwhile I have been keeping my patient on placebo for three weeks. Thereafter he reported everything normal, having no more urinary complaint. Thus the curative impulse triggered by Lyco at the outset had transmitted the stimulus to the targeted areas, ameliorating hematuria and its concomitant conditions completely, besides establishing a feeling of well-being subsequently.

 

Clinical Procedures

However, in order to eliminate the risk of malignancy I advised my patient to get two types of tests done, blood test for PSA (Prostate Specific Antigen) and urine test for the detection of malignant cells. The urine test had to be done at least three times, on alternate days, as a single test showing negative is not considered reliable. Thankfully his urine test on all the three days showed absence of malignant cells and also indicated completely sterile urine confirming the disappearance of E.Coli, the pathogenic organism that had caused the urinary infection at the outset. His serum PSA showed 3.8 ng/ml, which was well within the normal range. PSA is a prostate specific antigen and is found in benign, maliganant and metastatic prostate cancer. Detection of elevated PSA levels play an important role in the early diagnosis of prostate cancer. One may wonder, why on earth a homoeopath should indulge in such an extravaganza, after all he has ‘to treat the patient, not the disease’ But I have my own valid reasons to adopt such a methodology. I live and practice in Mohali a town which has now transformed itself into an extention of Chandigarh. And the patients coming to me are mostly well-educated and well-informed about the modern healthcare facilities. Most of them would have already had their checkups done in such prestigious institutions as PGIMER(Post Graduate Institute of Medical Education &Research) Chandigarh, INSCOL (an Apollo subsidiary), FORTIS (Ranbaxy promoted hospital) at  Mohali. Such enlightened patients consider it their right to know from the doctor the status of their disease. In the course of treatment the relevant lab tests, USG, CT scans/MRI etc. give precise information about the factual condition of the patient and impart a definite measure of confidence in him besides actually helping a homeopath to monitor the progress of treatment.

 

Treatment of Choice

Coming back to my patient’s treatment, the acute stage of his complaint was already satisfactorily resolved, what now remained to be treated in him was the benign hyperplasia of the prostate (BHP). It is worthwhile to consider here the options available elsewhere for the treatment of BHP. Allopaths regard surgery as the treatment of choice, of course in certain conditions. Dr. B.S. Aulakh, a highly reputed urologist and head of Renal Transplant Unit of DMC College and Hospital Ludhiana says in an article published in The Tribune, “Transurethral Resection of Prostate (TURP) is the best option and the gold standard. It is the operation I perform most commonly. It also yields the tissue for histopathological analysis.” Of course, allopaths also take up medical management of some cases where either surgery is not recommended or when the patient has mild symptoms with reasonably good urinary streams. The treatment is ostensibly suppressive, blocking certain cellular grouping in the body to reduce the intensity of symptoms. For instance a group of allopathic drugs called alpha-blockers used for controlling hypertension are also utilized for relieving BHP symptoms. A few alpha-1-receptor blockers in common use are Prazosin, Terazosin, Indoramine etc. They do have clearly indicated side-effects as per their accompanying literature. I have found many of the patients of BHP coming to me, have been on Pfizer’s Minipress XL, an alpha-blocker (Prazosin). Dr. BK. Sharma former Director of PGIMER Chandigarh wrote in a published article about the drug finasteride (Cipla’s Fincer) which helps in relieving BHP symptoms. It belongs to 5-Alpha-Reductor Inhibitor category. It enzymatically blocks the effect of testosterone on the prostate to provide relief form obstructive symptoms. However it has been generally observed that a patient gets some relief from BHP symptoms only as long as he is on these drugs, once the drugs are withdrawn, he is back to square one.

 

The sole purpose of my peeping into the allopathic management of BHP is only to propagate and proliferate awareness amongst us, as to what type of treatment is being offered by others of our ilk and how can it be evaluated or compared with what homoeopathy offers in identical circumstances. In this age of competitiveness when healthcare, on having undergone a paradigm shift, has become a big business, we have got to see collaterally, as to where do we stand vis-à-vis other systems of medicine.

 

Further Investigation

At this stage I wanted to ascertain the extent to which the condition of my patient was precisely affected by BHP. I therefore asked for his latest USG report which he readily brought just the second day. The USG, besides indicating enlarged prostate, showed 120 ml of residual urine after emptying the bladder. On my coaxing him further to tell about any other complaint he disclosed hesitatingly about his feeble urinary stream. He had to get up at night about three, four times to pass urine. At times he had sudden urge, not easily controllable. He did not have anything like ineffectual urge for urination. But he did take time longer to empty the bladder obviously due to slow and feeble stream. Feeble stream, in fact is a comparative term, whereas it can be precisely measured these days. I arranged for his uroflowmetry at a reputed hospital equipped with a special machine utilized for this purpose. The patient with a full bladder is allowed to void urine on to the receiving container of the machine, which instantly records on a graph paper, the flow time, maximum flow rate, average flow rate and the voided volume. My patient’s uroflowmetric data showed maximum flow rate 9 mI/sec, voiding time 102 sec, voided volume 605 ml. This data is was utilized to monitor the progress of treatment as I did at a letter stage.

 

Digging Deeper

It is a known fact that the enlarged prostate obstructs the outflow of urine from bladder by compressing and distorting the prostatic urethra, resulting in abnormal quantity of residual urine even after emptying the bladder. This causes stasis and rise in pressure within the urinary tract predisposing to urinary infections, hematuria and stone formation. The raised pressure, by way of back pressure, may as well lead to hydroureter and hydronephrosis of kidneys ultimately resulting in kidney failure, if the condition is not timely checked. So this was the high time for my patient to be treated suitably to prevent all those complications. To make sure that there is nothing more left in him to be treated, I asked him on his subsequent visit, whether he had any more complaints. With little inhibition, he came out with yet another disclosure. Said he, “Doctor, I have a strange feeling of tenderness in my right groin, it is painful on pressure, it is the tenderness with a feeling of bearing down pain towards the region of scrotum. It aggravates on sitting for long and relieves on rest, on lying down. This presistant nagging feeling makes me anxious and worried as to what next is in store for me.” This had been continuing with him for two weeks. Another complaint he pointed was that he never felt hungry and had a poor appetite and a normal thirst and that he was prone to frequent complaints of flatulence and diarrhea. I interpreted his specific symptoms of pain in right groin pointing to a rubric “pain along the right spermatic cord extending down to epididymis.”

 

Friend's Advise

I have an urologist friend from a reputed Chandigarh hospital, I casually discussed this case with him as to what could be the cause behind that complaint of pain and tenderness along the spermatic cord. He immediately replied, “Bladder Stone”. I counteracted his conjecture apprising him of the patients’ ultrasonography report which did not show of any stone anywhere in the KUB area. He explained that often it so happens that a small piece of stone gets stuck somewhere in bladder which escapes detection through USG and that feeling of tenderness and pain along spermatic cord is a sure sign of bladder stone which eventually may pass out through urine. His diagnostic assessment sounded quite logical and acceptable.

This reminded me of my patient’s disposition of stones, as he had a history of impaired functioning of gall bladder causing frequent attacks of dyspepsia and flatulence. His X-ray taken at that time showed sludge in gall bladder, an indication of formation of gall stones. The complaint of course was then alleviated with infrequent doses of Lycopodium. All this conclusively showed his constitutional propensity to billiary and urinary calculi.

 

Totality of Symptoms

Coming to sum-up his symptoms including all the physicals and generals gathered above, what now remained was to peep into his mind. But then I knew him for many years that he was a soft spoken, mild-mannered and decent gentleman of compromising disposition. Temperamentally, he was balanced and was able to control his temper even in provocative situations. He was easily swayed by emotions, in that respect, he was sentimental and sympathetic in nature. With advancing years he was often found little absent-minded and unobserving and could be easily distracted when absorbed in himself Although he was a hot patient, hut due to loss of body heat with ageing, he felt equally chilly in winter, he was averse to tight clothing, especially around waist and always kept his belt loose. While he is fond of reading and writing but lately he found himself making mistakes in writing, such as omitting letters during writing letters etc.

 

On recapitulating all the facets of his personality and encompassing and resurrecting all the significant symptoms comprising totality, the following rubrics were selected to repertorise his case

 

  • Prostate gland, enlargement
  • Bladder, retention of urine, enlarged prostate
  • Bladder urination, feeble stream
  • Bladder calculi
  • Pain spermatic cords extending down to epididymis
  • Mildness (mild yielding disposition)
  • Absent minded (unobserving)
  • Mistakes, writing in, omitting letters
  • Sentimental
  • Heat (hot patient)                               
  • Clothing (loosening amel.)

 

 

Differentiation of Remedies

Two remedies were found prominently indicated Pulsatilla and Berberis vulgaris on repertorisation. Puls. was found in 10 out of 11 rubrics and Berb was mainly found in rubrics based on physical symptoms besides a few others. Obviously Puls came out to be the his remedy meeting most of his constitutional symptoms and Berb could be labeled, as some homoeopaths prefer to call, as organ remedy. I therefore decided to prescribe Puls. in potency 1000C only intermittently and Berb. in 30 C in daily doses. First he was given Pulsatilla 1000C one dose and placebo for two weeks. He came after two weeks and reported feeling better but the specific complaint of pain and tenderness along the spermatic cord had not yielded appreciably. I then prescribed him Puls 1000C one dose and Berb. 30C thrice daily for a month. On next visit after a month he reported marked relief from pain in right groin and informed about the improved urinary flow. I then kept him on Berb. 30C TDS for five months and gave Puls. 1000C three times during that period. I also gave Thuja 1000C in single dose separately once only... On his subsequent visit, considerable improvement was seen in his condition. His peculiar tenderness and pain in right spermatic cord had disappeared completely except for occasional feeling of tenderness only after abnormal exertion. His uroflowmetric test showed maximum. urinary flow rate increased to 12 mi/sec. from 9 ml/sec. His USG at that stage showed residual urine 80 ml after emptying the bladder. Thus both the test reports were very encouraging and gave a clear indication of substantial decrease in prostatic obstruction achieved during the six month of his medication. In the following three months he was given Puls. I000C only twice and Berb. 30C twice daily. This happened to be the last course of his treatment. His last visit culminated in thanks-giving. On his arrival itself he declared to have been satifactorily cured and said; “Doctor, I don’t think I need any more sweet pills now, my recent test reports are the testimony to my confidence.” He produced two reports, both showing further improvement in his parameters.

 

Benign hyperplasia of prostate (BHP) is an inevitable off-shoot of ageing. By the age of 80 years, 90% of men would show enlargement of the prostate but symptoms of enlargement are present in not more than one-third of them. At the age of my patient (64) it is unnatural to attempt to retract the enlarge prostate back to the days of youth by any kind of medication. One should only aim at restoring the normal function, free from all discomforts. As the above case illustrates, this can possibly be accomplished by homoeopathy. Somebody rightly said:

“Homoeopathy has long has been the Cinderella of medicine. The time has come for this neglected handmaid to shed the cloak of passivity and boldly proclaim its efficacy and advantages over other systems of medicine.”

 

 

 

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Comment by Kuldip Singh on June 25, 2012 at 10:20am

Thanks Dr.Jagdip, for your nice comments.

Comment by Jagdip Singh on June 24, 2012 at 11:50am

A very good case, nicely managed, well elaborated and tastefully explained.Such cases so well  treated and beautifully presented are really helpful.

Comment by Kuldip Singh on June 21, 2012 at 10:01am

Dr. Sajjadakram, Thank you very much for your appreciation and encouragement.

Comment by sajjadakram on June 20, 2012 at 9:58pm

Perfect case taking.Perfect management and perfect cure.Congratulation.

sajjad.

Comment by Kuldip Singh on June 19, 2012 at 2:28pm

Dear Debby

I thank you very much for your very significant words of appreciation. I feel greatly encouraged.

Comment by Debby Bruck on June 19, 2012 at 10:40am
Most marvelous and thorough investigation. Quick action. Thoughtful and caring. Most appreciative of this case.

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