Urination Problems After Procedure in a Man Treated for BPH

Darshan Rola; Brian Zacharias; Neal Patel; Dhiaeddine Djabri; Alexandra Gabro; Alex T. Villacastin, MD

Disclosures

April 01, 2022

The diagnosis of LUTS or BPH is made in the setting of characteristic urinary symptoms when the history, physical examination, and laboratory/urodynamic tests do not identify another cause of the LUTS (other than BPH).[2] Findings such as poorly controlled diabetes and glycosuria, use of medications (such as diuretics or anticholinergics), or excess intake of fluids before bed may point toward a cause of LUTS other than BPH. The presence of casts in the urine would indicate pathology of the upper urinary tract, such as the kidneys or ureters.

Because the condition is rarely life-threatening, assessment of the severity of the symptoms and their impact on the patient is useful in determining whether medical and/or surgical treatment should be initiated. Patients with LUTS secondary to BPH but without significant impairment or distress may be offered counseling on lifestyle interventions that have been shown to have a beneficial impact on symptoms, including limitations of alcohol and caffeine intake, nighttime fluid restrictions, and medication adjustments (such as taking diuretics in the morning).[3]

Medical interventions are generally the next step in management when conservative approaches are unable to provide adequate symptom relief or the burden of symptoms increases. Medical therapy is directed at the type of symptoms that are most predominant. Patients with storage-type symptoms (coexisting overactive bladder) may be treated with beta-3 adrenergic agonists or anticholinergics, whereas those with voiding-type symptoms may be treated with alpha-adrenergic receptor blockers; phosphodiesterase type 5 inhibitors; or 5-alpha reductase inhibitors, such as finasteride.

Surgical intervention in the management of BPH is typically indicated when LUTS are refractory to medical therapy. However, surgery may also be offered to patients who decide to forgo initial medical intervention (a relative indication). Absolute indications for surgery include refractory or recurrent urinary retention; recurrent urinary tract infections, bladder stones, gross hematuria; or bilateral hydronephrosis.[3] Many surgical options are available, including TURP, transurethral vaporization of the prostate, water vapor thermal therapy, photoselective vaporization of the prostate, and laser enucleation of the prostate. The selection of a surgical procedure is based on factors such as a patient's prostate size, symptom burden, and potential complications.

TURP is one of the criterion standards of prostatic ablative therapies used in the surgical management of BPH. It provides long-term relief of bladder outlet obstruction, and reported reoperation rates range between 5% and 15.5%.[4] The morbidity (< 1%) and the mortality (< 0.25%) are exceptionally low despite the typical age at which this procedure is offered (most patients are older than 70 years).[5]

However, complications of TURP still do occur. Technical complications of TURP include clot retention, retrograde ejaculation, bleeding and the need for transfusion, transurethral resection (TUR) syndrome (a dilutional hyponatremia that can result nausea, vomiting, hypertension, and bradycardia), urinary retention, and urinary tract infection. Retrograde ejaculation is one of the more common complications of the TURP procedure. In this process, the ejaculate enters the bladder instead of continuing further down the urethra and exiting the meatus.

The intraoperative and perioperative complications of TURP are robust and complex and thus should be managed promptly to prevent further damage and rapid worsening of symptoms. Bleeding in the larger arteries may be compressed with a resectoscope as well as by careful coagulation of the lumen using a loop.[5] Balloon catheter compression is a popular method that may also be used in cases of venous bleeding.

If not treated emergently and swiftly, TUR syndrome may progress to severe pathology, most commonly bronchial or cerebral edema. A combination of intravenous hypertonic saline, along with a loop diuretic such as furosemide, is given in order to raise sodium levels throughout the body. A rate of increase of 1 mmol/L/h in sodium concentration is considered the gold standard when correcting a state of hyponatremia. Suprapubic catheters are inserted to drain urine in cases of urinary retention until the fossa is fully healed.

In addition, infection may develop after TURP. The rate of post-TURP infection is about 21.6%.[5] The mainstay of treatment for bacterial infections after TURP is antibacterial prophylaxis with both gyrase inhibitors and cotrimoxazole. After the procedure, a high-fluid regimen of 3 L per day is recommended for patients with hematuria who have clots that are visible in the urine. Once severe hematuria begins to subside, at least 2 L of fluid intake should be recommended during post-TURP recovery to keep the urine clear and free of clots.

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