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Abstract: The patient in this case is a middle-aged male who had dyspareunia after catheterization 5 years ago, but did not receive special treatment. 5 days ago, the dyspareunia worsened due to cold and was accompanied by a painful sensation. He came to our hospital and was diagnosed with prostatitis after relevant examinations and combined with the patient’s complaints. After 1 week of admission, his symptoms improved and he was discharged with consent and continued follow-up.
Basic information】Male, 46 years old
Disease Type】Prostatitis
Hospital】The First Hospital of China Medical University
Time of consultation】August 2016
Treatment plan】Oral medication (levofloxacin hydrochloride tablets, finasteride tablets, tamsulosin hydrochloride extended-release capsules, moneywort capsules)
【Treatment cycle】Inpatient treatment for 1 week, continuous follow-up
Effectiveness】The condition has improved and the discomfort has basically disappeared.
I. Initial consultation
The patient, 46 years old, reported that after catheterization for saphenous varicose vein surgery 5 years ago, he had dyspareunia, and his symptoms decreased after a few days, but he kept having dyspareunia. 5 days ago, after blowing the air conditioner at home, his symptoms worsened, and he felt laboriously waiting for urination, with cramping pain, especially when passing stool. For further treatment, he came to the hospital. The physical examination in the outpatient clinic suggests slight pressure pain in the lower abdomen, no rebound pain; anal finger diagnosis prostate II large, tough texture, slight pressure pain, central sulcus becomes shallow, no nodules, exit finger sleeve without blood, can be initially diagnosed as prostatitis. The patient felt painful and was then removed and admitted to the hospital for further treatment.
II. Treatment history
According to the patient’s symptoms, routine blood and urine tests, as well as urine-prostate fluid tests, were performed and secondary care was given. The results of the examination suggested a decrease in lecithin vesicles or a tendency to pile up. Combining the results of other examinations, the diagnosis of prostatitis, cystitis and urethritis could be confirmed, and drug anti-infection and symptomatic treatment needed to be given. The main medications include levofloxacin hydrochloride tablets for antibacterial control of inflammation; finasteride tablets for control of prostatic hyperplasia; tamsulosin hydrochloride extended-release capsules to relieve urinary difficulties; and moneylily capsules to relieve painful urination and difficulty in urination. In addition, hot water sitz bath is then performed to promote local blood return.
III. Treatment effect
On the second day of treatment, the patient’s urinary pain was significantly reduced compared with the admission; on the third day, there was still a feeling of perineal swelling, and urination was not smooth, but there was no obvious painful urination, indicating that the treatment plan was effective, and the treatment was continued; on the seventh day of hospitalization, the patient complained that the painful urination disappeared, and the feeling of perineal swelling also basically disappeared, and the physical examination indicated that the prostate pressure pain disappeared, and there was no rebound pain and pressure pain in the abdomen. The patient agreed to be discharged from the hospital after the integration of his personal wishes.
IV. Notes
The patient is very happy that his condition has improved after 1 week of in-hospital treatment, and I am also pleased that the patient has improved. Considering the patient’s strong desire to be discharged from the hospital, he was instructed to ensure regular work and rest after discharge, try to wake up early and go to bed early, avoid staying up late for a long time, and maintain a healthy diet without spicy and stimulating food to avoid aggravation of inflammation; he should also insist on local hot water sitz bath to promote blood circulation; and pay attention to personal hygiene, clean the perineum daily and change clean intimate clothing; finally, the patient was advised to add clothes according to The actual fact is that you can find a lot of people who are not able to get a lot of money for their own personal use.
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Although prostatitis is highly prevalent in men aged 31-40, similar to this article in men under 50 years old, the incidence is also higher. In addition to the annual routine physical examination, when there is difficulty urinating, painful urination, should be alert to the occurrence of prostatitis, should be consulted as soon as possible, after a clear diagnosis more take medication antibacterial anti-inflammatory, and with the improvement of lifestyle habits, or hot water sitz bath and other methods, most patients can be cured.