Kamlesh and I share a strong and long bond of friendship right from my first year of MBBS when we first met. He opted for post-graduation in a different faculty whilst I was more inclined towards surgery. We were still friends and it continued till I moved to UK and he moved to Nagpur, one of the cities in Maharashtra. Initially we kept in touch but then it became infrequent. In the end, it got limited to text messages and Facebook birthday messages only. With Covid-19 crisis and routine OPD being cancelled patients are approaching me for video consultation. During the lockdown I have been providing an online consultation service and care via teleconsultation. I had SMS 8 days ago stating that Dr Kamlesh S has booked an appointment with me for a video consultation. I became curious as to whether it was my friend Kamlesh or someone else hence decided to call my friend Kamlesh and it turned out to be him, my friend!

He was disturbed, troubled and confused as to what was wrong with him. Up until that point he had good health, but for past 2 days he had developed severe pain in the bladder area, pain on urination, and raised frequency of his urination, in the absence of fever. Being a friend as well as a doctor colleague I offered him to help on the phone, but he insisted on video consultation since he had already uploaded his investigations and details on to it. He told me that he came to know about my video consultation from my Facebook page. Accordingly, we met again in an hour or so on my video consultation. He never had any urinary problems in his life before. The reason I decided to share this case with you all is because of many unusual aspects to this case and with reference to his case I can advise others too about the importance of healthy habits in our lives.

Surprised by his sudden onset of severe symptoms he was confused as to what was happening with him. His urine he said was clear, no blood, no cloudy colour and no foul smell. On the face of it, it looked like a urine infection (UTI), which are rare in males compared to females and specially in his age group being in his 40s. Males above 50 years of age are more prone to UTIs due to their prostate problems. He told me that the pain was so severe that it kept him awake in the night. He had no previous urine infections, no previous trouble with urination, no history of sexually transmitted diseases and no kidney stones. It wasn’t making sense as to why he developed sudden symptoms. Being a doctor himself he had his urine checked and shared the findings with me. His urine was absolutely normal, which changed the whole scenario. To consider a possibility of urine infection, there has to be some indication on urine test or a positive test in some ways unless patient is on antibiotics. This was rather puzzling and also misleading.

He also suffered from anal fissure, which is a crack in the back passage causing problems. He had some problems around the area including pain. As per him the pain was new, and he had never experienced it before even with his anal fissure. In the background of his symptoms, clear urine, pain in the anal canal area there were many possible diagnoses, but the first and foremost was acute prostatitis (infection of gland sitting below our bladder). Other possibilities were urinary tract infection, kidney stone and cystitis (inflammation of bladder wall) which again was odd to have in absence of positive urine test. My working diagnosis of that evening in absence of any other investigation was acute prostatitis for which I started him on antibiotics to take orally (sent prescription through video consultation) as he did not have fever. However, I wasn’t fixated on that diagnosis and wanted to make sure that I have ruled out other possibilities. I also advised him to get sonography (ultrasound scan) done for his kidneys, ureters and bladder to make sure I wasn’t missing anything (referral letter sent through the consultation).

As a doctor one has to continuously explore the rationally and possibilities behind the diagnosis made. In my practice I always make a point to listen to the patient as to what they want to say. I also concentrate on subtle clues patients give through the conversation, which as a vigilant doctor I need to pick. Since there were no known causes for his symptoms, I started exploring least known scenarios. I identified from the conversation that he had been working really hard due to Covid-19, didn’t have time to eat and drink much in this hot weather. On further questioning I assessed that he was certainly dehydrated! Now the jigsaw puzzle started fitting in place. Yes, it was his dehydration, which was at the root of all his problems. I always advice patients to drink plenty of water and avoid dehydration as it may cause many other problems such as urine infection, stone formation along with other problems secondary to dehydration.

My work wasn’t finished there as since he was working with coronavirus patients, I also wanted to make sure that he hasn’t become positive to virus and developed a rare possibility of Corona virus induced Viral Cystitis. I advised him to get himself tested for the Covid-19. There was a recent study on the coronavirus patients in an extremely high profile

European Urology journal, “Urinary Frequency as a Possibly Overlooked Symptom in COVID-19 Patients: Does SARS-CoV-2 Cause Viral Cystitis?” where they proved that coronavirus patients can get above symptoms and the diagnosis of the viral cystitis.

He called me next day with the result of ultrasound scan (sonography) and also sent me a copy along with films. His Covid-19 test was negative hence corona viral cystitis was unlikely in his case. He had no stone and prostate was normal on the study. Most baffling finding on ultrasound was the bladder showing signs for severe acute cystitis. It was very unusual that within two days he had developed such a severe cystitis which caused so much swelling of his bladder wall that it could become visible on sonography. He had repeated his urine examination again on that day which showed some signs of infection. Despite being on oral antibiotics he had developed fever, which wasn’t there till the day he spoke to me. Things were not quite right with him, and his condition was deteriorating.

He was certainly heading towards more intense treatment. I advised him that I’ll need to change him on broad spectrum antibiotic by intravenous route (inside blood). I also advised him to send his urine and blood for bacterial culture to see whether he grows any bacteria. The culture and sensitivity check are very important to make sure whether there is any bacterial growth and if there is any then whether the bacteria are non-responding (resistant) to any of the antibiotics. He wasn’t keen on getting admitted to the hospital but through the hospital he was working, with my help and recommendations he managed to organise daily three doses of intravenous antibiotics to be given at home. I wanted him to drink plenty of fluids too in order to avoid dehydration and to dilute his urine. I have also explained him that at some stage he will need cystoscopy (endoscopic procedure to look inside his bladder). However, I would like to take this opportunity to alert everyone against the dehydration as it could be more disastrous than you think.

After two days of intravenous antibiotics, good anti-inflammatory medicines, plenty of fluids orally he started feeling 100% better. His pain subsided, urine frequency came back to normal and fever subsided. I had advised him few days of rest from work. His blood cultures were negative, but urine cultures grew bacteria called E. Coli (commonest bacteria to cause urine infection) but the antibiotics I had started him on were perfect for that bacteria and was working well. Looking at the response I changed his antibiotics to oral (to be taken by mouth instead of vein). In terms of cystoscopy he prefers me to carry out this procedure and he would travel to me after the lockdown. He has now started going back to the hospital as he was worried about care of coronavirus patients, whilst following my advice to keep himself well hydrated.

We all get busy with our work and with our daily routine. No doubt we may have stressful job, may not get time for ourselves but it is very important to look after ourselves. It is important to keep ourselves well hydrated to avoid problems arising from it. Kamlesh had to learn his lesson hard way but we need to start drinking plenty of water from today only! Everyone says that how can doctor become sick? For those people who have that question, “we are also a human being like you.

MY ADVICE:

• Always listen to your body, empty your bladder (pass urine) regularly every 3-4 hours.

• No matter what you are doing, make a point to keep yourself well hydrated by drinking plenty of fluids regularly.

• Avoid constipation, eat high fibre diet, fruits to prevent constipation as it can cause many other problems such as urine infection, blocked urine along with causing bowel problems.

• In case of diagnosing conditions certain rare possibilities should always be kept in mind.

• Many a times along with clinical judgement certain investigations are also helpful like in Dr Kamlesh’s case.

• In case of recurrent urine infections, it is important to have cystoscopy (camera test of bladder) done to make sure that there are no sinister causes like cancer.

• Last but not the least is to keep yourself safe from coronavirus as it can affect any part of your body for which treatment may be difficult.