Voiding DysfunctionHigh-yieldUpdated Aug 202626 min read

BPH — Non-Neurogenic Male LUTS

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Etiology & Basic Science

Embryological origin

Wolffian ducts develop into the seminal vesicles, epididymis, vas deferens, ampulla, and ejaculatory duct — the developmental growth of this group of glands is stimulated by fetal testosterone, not DHT
The prostate arises from the urogenital sinus, through DHT stimulation
The central zone of the prostate arises from the Wolffian duct
BPH inheritance — autosomal dominant

Predictors of disease progression

Age
PSA
Prostate size
IPSS
Flow rate
PVR

LUTS — Classification

Storage (irritative)
Voiding (obstructive)
Post-micturition

Differential — LUTS is a symptom complex, not a diagnosis

Category	Causes
Prostatic	BPH
Bladder	OAB, nocturia, bladder tumor, neurogenic bladder
Outlet / urethra	Urethral stricture, foreign body
Upper tract	Distal ureteric stone
Inflammatory	UTI, CPPS

Evaluation

Medical history & physical exam — including DRE
- History mnemonic — FUN WISE, plus hematuria, hesitancy, dysuria
Symptom score — IPSS
Voiding diary — frequency / volume
Urinalysis
Cytology — if severe irritative symptoms or dysuria
PVR — if high → assess upper tract
PSA
Ultrasound and uroflowmetry — if moderate to severe symptoms
Frequency-volume chart — if nocturia or irritative LUTS predominate

PVR and PSA are optional in some guidelines.

AUA 2021 splits this explicitly

Recommended (3)	Optional (3)
History & physical exam	Post-void residual (PVR)
Urinalysis	Uroflowmetry
IPSS	Urodynamics

Urinalysis → focus on glucosuria, proteinuria, hematuria, infection
Uroflowmetry → minimum interpretable voided volume 150 cc; don't Valsalva void
- Qmax < 10 mL/s for BOO → specificity 70%, PPV 70%, sensitivity 47%
PVR → no accepted "significant" threshold — follow the trend; > 300 mL is worth monitoring
- Correlation with degree of obstruction is weak; not a strong predictor of AUR
- Elevated PVR alone is NOT an indication for surgery
- In clinical practice a PVR < 30 mL is usually considered nonsignificant, whereas a PVR persistently > 50 mL could be regarded as important
DRE is unreliable for prostate size and cannot assess a middle lobe — image if size will drive the decision
Prostate specific gravity 1.05 → g = mL = cc interchangeably; growth ~1.6%/yr — imaging within 12 months preferred

Indications for upper tract imaging

UTI
High creatinine
Large PVR
Urolithiasis
Hematuria

IPSS — Scoring

Score	Severity
0–7	Mild
8–19	Moderate
20–35	Severe

The 7 domains

Frequency
Urgency
Nocturia
Weak stream
Intermittency
Straining
Incomplete emptying

Cystoscopy — Indications

Suspicious CIS
Hematuria
Query or history of stricture
History of TURP
Prior to surgical intervention

Urodynamics — Indications & Formulae

If no clear suggestion of obstruction (Qmax > 10)

A pressure-flow study is suggested before invasive treatment in:

Patients with previously unsuccessful invasive procedures
Patients who cannot void more than 150 mL
Patients with a PVR > 300 mL
Patients older than 80 with predominantly voiding LUTS
Patients younger than 50 with predominantly voiding LUTS

BOOI — Bladder Outlet Obstruction Index

BOOI = Pdet@Qmax − 2(Qmax)

BOOI	Interpretation
> 40	Obstructed
20–40	Equivocal
< 20	Unobstructed

BCI — Bladder Contractility Index

BCI = Pdet@Qmax + 5(Qmax)

BCI	Interpretation
> 150	Strong
100–150	Normal
< 100	Weak / acontractile

Detrusor underactivity alone (BCI < 100) with BOOI < 40 → significantly worse 12-month Qmax after surgery — counsel carefully before TURP

Management Algorithm

Click the algorithm to open it full size.

Step	Question / Action	If YES	If NO
1	Absolute indication? — recurrent retention/UTI/hematuria · large bladder stones · hydronephrosis or renal insufficiency	Prostate US → SURGICAL TREATMENT	→ Step 2
2	LUTS bothersome by symptom score? (IPSS)	→ Step 3	Surveillance
3	Voiding diary → polyuria? — polyuria 3 L/24 h; nocturnal polyuria 33% of 24 h output at night	Fluid restriction	→ Step 4
4	Uroflow + PVR + prostate US → LUTS compatible with BPH?	Alter non-BPH factors → discuss surgical vs medical → start medical therapy (see Medical Therapy)	Evaluate & treat non-BPH

Complicated LUTS → straight to specialized management

Suspicious DRE
Hematuria
Abnormal PSA
Pain
Infection (assess and start treatment before referral)
Palpable bladder
Neurologic disease

Two caveats on the recommended tests

Serum PSA is part of the recommended workup when life expectancy is > 10 years and if a diagnosis of prostate cancer would modify management
A frequency-volume chart is recommended when significant nocturia is a predominant symptom
Note the loop: the absolute indications at step 1 are the same list as the surgical indications (see Surgical Management — Indications) — minus therapy failure, which can only appear later. The algorithm asks the surgical question at the top, and again at the end of medical therapy once medical therapy fails.

Medical Therapy — Choice by Predominant Symptom

Click the algorithm to open it full size.

Predominant symptom	First line	If it crosses over
Obstructive, PV > 40	α-blocker + 5-ARI ± tadalafil	If LUTS become irritative after therapy → add OAB medication
Obstructive, PV < 40	α-blocker &/or tadalafil	(as above)
Irritative	Behavioral therapy + OAB medication	If LUTS remain obstructive → add α-blocker

→ Then reassess: Satisfaction?

YES → Surveillance
NO → Surgical therapy (= therapy failure — see Surgical Management — Indications and Surgical Choice)

Watchful Waiting & Lifestyle

Offer to men with mild/moderate symptoms who are minimally bothered — bother-based, not score-based
Offer lifestyle advice & self-care prior to, or concurrent with, treatment Components of watchful waiting & self-management

Education and reassurance

Discuss the causes of LUTS, including normal prostate and bladder function
Discuss the natural history of BPH and LUTS, including the expected future symptoms
Reassure the patient that no evidence of detectable cancer has been found

Fluid management

Advise a daily fluid intake of 1500–2000 mL (minor adjustments for climate and activity)
Avoid inadequate or excessive fluid intake — judge on the frequency-volume chart
Advise fluid restriction when symptoms are most inconvenient (long journeys, out in public)
Advise evening fluid restriction for nocturia — no fluid for 2 hours before retiring

Caffeine and alcohol

Replace caffeine with decaffeinated or caffeine-free alternatives
Avoid alcohol in the evening if nocturia is bothersome
Replace large-volume alcoholic drinks (a pint of beer) with small-volume ones (wine or spirits)

Concurrent medication

Adjust the timing of any medication affecting the urinary system to reduce LUTS at times of greatest inconvenience
Replace antihypertensive diuretics with suitable alternatives with fewer urinary effects — via the patient's GP

Toilet and bladder retraining

Double voiding — spend extra time on the toilet to try to empty completely
Urethral milking for post-micturition dribbling
Bladder retraining with distraction techniques (a predetermined mind exercise, perineal pressure, pelvic floor exercises)
- Aim to increase the minimum time between voids to 3 hours (daytime) and/or the minimum voided volume to 200–400 mL (daytime)
- Suppress the urge to void for 1 minute, then 5, then 10 — increasing on a weekly basis
- Use frequency-volume charts to monitor progress

Miscellaneous

Avoid constipation in men with LUTS
Control diabetes
Efficacy: ~85% with mild LUTS stable at 1 year; 5-year failure 21% (79% clinically stable)
Follow-up: 6 months, then annually — history, bladder diary, IPSS, uroflowmetry, PVR

Medical Management

α-Blockers

Drug	Class	Receptor	Key effect
Tamsulosin	Uroselective	α1A + α1D	Retrograde ejaculation
Alfuzosin	Uroselective	—	Least ejaculatory dysfunction
Silodosin	Uroselective	α1A	Most retrograde ejaculation
Naftopidil	Uroselective	α1D	—
Terazosin	Selective	α1	Hypotension — titration necessary
Doxazosin	Selective	α1	Most hypotension — titration necessary
Phenoxybenzamine	Non-selective	α1 + α2	(not used in modern BPH practice — the classification anchor)

α1A receptors found in → prostate, bladder neck, distal ureter
Uroselective agents cause more ejaculatory dysfunction — this does not apply to alfuzosin
Silodosin → improvement in urinary flow within 8 h
Tamsulosin → improvement within 24 h
Alfuzosin → least retrograde ejaculation — < 1%
The five standard agents (alfuzosin, doxazosin, silodosin, tamsulosin, terazosin) are equally effective — IPSS improvement 4–7 points vs placebo
- Switch α-blocker for side effects → worthwhile
- Switch for insufficient response → not recommended — drug type doesn't change effectiveness

Choosing by side-effect profile

Concern	Prefer
Ejaculatory dysfunction	Alfuzosin, doxazosin, terazosin (no difference vs placebo) — avoid silodosin/tamsulosin in young sexually active men
Orthostatic hypotension / syncope	Alfuzosin, tamsulosin, silodosin
On sildenafil/vardenafil	Avoid terazosin & doxazosin (potentiate hypotension); tamsulosin 0.4 mg does not

Side-effect superlatives

Least painful ejaculation → alfuzosin
Most dizziness → terazosin and doxazosin (both long-acting, both need titration)
Most retrograde ejaculation → silodosin, then tamsulosin
Most hypotension → doxazosin

Starting an α-blocker

Monitor blood pressure closely in the first week of treatment
Ask whether the patient is already taking an α-blocker for hypertension — if so, don't add a second one

Tamsulosin (Omnic) — full side-effect profile

Blocks α1A and α1D
Postural hypotension, dizziness, retrograde ejaculation, priapism, rhinitis, palpitations, syncope, intraoperative floppy iris syndrome
IFIS — Intraoperative Floppy Iris Syndrome
- Tamsulosin has the highest risk — 40× alfuzosin; all α-blockers raise it somewhat
- Ask about planned cataract surgery before starting; delay initiation until after
- Stop tamsulosin 4–7 days pre-op is routine — doesn't fully eliminate the risk
- 1 serious complication per 255 men on tamsulosin in the immediate pre-op window
α-blocker for AUR → prescribe before a voiding trial; at least 3 days of therapy first
- A successful trial still leaves them at increased risk of recurrent retention — say so
- Delay the voiding trial if there's an active UTI

5α-Reductase Inhibitors (5-ARI)

Drug	Inhibits
Finasteride	Type 2
Dutasteride	Type 1 + 2

Indications to start a 5-ARI:

Prostate volume > 40 cc
PSA > 1.5

Effects:

Reduce prostate size by 30%
Improve symptom score by 30%
Reduce risk of urinary retention by 50%
Reduce need for surgical intervention by 50%
Decrease PSA by 50% after 9 months → double the PSA for the actual result
Help stop chronic hematuria related to the prostate (consider a 5-ARI to reduce intra-operative bleeding / transfusion before TURP)
Increase Qmax — only ~2 mL/s
Decrease serum and prostatic DHT

Finasteride

For prostate > 40 cc + moderate-to-severe symptoms
Side effects — low libido, ejaculatory problems, depression, ED 5%
Long-term data show a 51% reduction in the risk of either AUR or surgery

Dutasteride

For prostate > 40 cc + moderate-to-severe symptoms
ED 6%, low libido 3.7%, depression, ejaculatory dysfunction

PDE5 — Tadalafil

Tadalafil 5 mg daily — discuss for LUTS/BPH irrespective of comorbid ED
Mean IPSS drop 1.7 points; similar to tamsulosin 0.4 mg at 3 months
Does NOT improve urodynamic profiles
AEs: headache, nasopharyngitis, back pain

Phytotherapy

Serenoa repens (saw palmetto) is the most widely investigated phytotherapeutic agent for LUTS
Recommended dose — 320 mg daily, taken with food

Combination Therapy

Combination	When
α-blocker + 5-ARI	Only with demonstrable enlargement — PV >40 cc / PSA >1.5
α-blocker + anticholinergic	Moderate–severe storage-predominant LUTS — check PVR before and during
α-blocker + β₃-agonist	Moderate–severe storage LUTS, esp. older patients where anticholinergics are inappropriate

α-blocker + PDE5 inhibitor — possible, but not preferable

Antimuscarinics

For moderate-to-severe irritative LUTS, with no history of AUR and PVR < 200 cc
Contraindications: closed-angle glaucoma, bladder outlet obstruction
Anticholinergics may be safely given in bladder outlet obstruction to reduce frequent voiding provided PVR is < 200 mL and the patient does not report increasing hesitancy or show a rising PVR on therapy

Mirabegron

For moderate-to-severe irritative LUTS
Side effect — hypertension
Combination beats dose escalation. Adding mirabegron 50 mg to solifenacin 5 mg is superior to escalating solifenacin from 5 mg to 10 mg — better efficacy with fewer side effects. Combination therapy overall outperforms either agent alone, with a safe side-effect profile.

Follow-up on Medical Therapy

Reassess at 4–12 weeks: α-blocker / PDE5 / β₃ / anticholinergic → as early as 4 weeks; 5-ARI → wait 3–6 months
Assess → adverse effects + IPSS (every visit); consider PVR & uroflow
Reasonable trial length → 4 weeks (α-blocker or PDE5), 6–12 months (5-ARI)
Failure → think detrusor underactivity (urodynamics clarifies), lack of efficacy, or LUTS not actually from BPH

Nocturnal Polyuria & Desmopressin

Nocturnal polyuria = nocturnal output > 20% of 24-h output (young) or > 33% (age > 65)
Age < 65 → start 0.1 mg/day, escalate weekly to max 0.4 mg/day
Age > 65 with nocturia ≥ 2×/night → low dose only; do not use if serum Na is below normal (EAU: Weak)
No fluids 1 h before and 8 h after dosing
Na monitoring: baseline, day 3, day 7, 1 month, then periodically; if normal → every 3 months; more frequent if > 65; restart the sequence after any dose escalation
Clinically significant hyponatremia → 11% in men ≥ 65 vs 0% in men < 65 (50 mcg)
Exclude sleep apnea before prescribing

Trials

CombAT vs MTOPS — design at a glance

	CombAT	MTOPS
Treatment groups	Dutasteride 0.5 mg · Tamsulosin 0.4 mg · Combination	Finasteride 5 mg · Doxazosin 4 or 8 mg · Combination · Placebo
n	4844	3047
Location	International	US only
Age	≥ 50	≥ 50
PV (cc)	≥ 30	None
PSA (ng/mL)	≥ 1.5 and ≤ 10	≤ 10
IPSS	≥ 12	8–30
2-year endpoint	Improvement in IPSS	None
4-year endpoint	Reduction in risk of AUR or surgery	Composite endpoint of BPH clinical progression

CombAT = dutasteride + tamsulosin — marketed as the fixed-dose combination (dutasteride 0.5 mg / tamsulosin 0.4 mg)
Overall, both MTOPS and CombAT support the therapeutic advantage of combining a 5-ARI + α1-blocker in men with moderate-to-severe LUTS at high risk of clinical progression — PV ≥ 30–40 mL and PSA ≥ 1.5 ng/mL

PLESS (Proscar Long-term Efficacy & Safety Study)

Finasteride vs placebo
→ Improved symptom score, flow rate, decreased prostate volume
→ 50% reduction in AUR
→ 50% reduction in BPH surgery

CombAT (Combination therapy)

Daily tamsulosin vs dutasteride vs combination — no placebo arm
→ Improved symptom score, flow rate, decreased prostate volume
→ Combination has the same effect on reducing AUR & surgery compared with dutasteride alone
→ More side effects with combination

MTOPS

Placebo vs doxazosin vs finasteride vs combination
→ Dual therapy reduced progression significantly more than either drug alone
→ Finasteride & combination reduced risk of AUR & surgery
→ Reduce PSA 50% & volume

OAB & BPH

75% of men with BPH have OAB — due to the overworked bladder
19% have persistent OAB after surgical therapy
Management discussed later in neuro-urology

Acute Urinary Retention

Recognized predictors of AUR

Older age
Severe LUTS
Low peak flow rate
High PVR volume
Large prostate volume
High serum PSA

Trial of void (TOV)

Give the TOV after 3–8 days (median 5 days)
Up to 3 TOVs may be given before planning surgery

Attempt	Success rate
1st TOV	60%
2nd TOV	29%
3rd TOV	26%

Surgical Management — Indications

Recurrent retention
Recurrent infection
Recurrent hematuria
Renal insufficiency / hydronephrosis
Therapy failure
Bladder stones

Antibiotic coverage

Fluoroquinolone or trimethoprim-sulfamethoxazole
If the patient is catheterized, consider broader coverage

Surgical Choice

Depends on → size · anticoagulation · preservation of ejaculation

Patients with a peak uroflow > 15 mL/s have significantly less improvement in prostate symptom scores after TURP than patients with a peak uroflow < 15 mL/s

By prostate size

Volume	Options
< 30 cc	TUIP, TURP, HoLEP, ThuLEP, PVP
30–80 cc	TURP, HoLEP, ThuLEP, PVP, TUVP, Rezum, UroLift
> 80 cc	HoLEP, ThuLEP, simple prostatectomy

HoLEP and ThuLEP are size-independent — they can be used for a prostate of any size
Men concerned about preserving erectile and ejaculatory function should consider UroLift or Rezum — these have the least impact on sexual function

By special circumstance

Scenario	Choice
Anticoagulated, > 80 cc	HoLEP, ThuLEP
Anticoagulated, < 80 cc	PVP, HoLEP, ThuLEP
Wants to preserve erection & ejaculation	Rezum & UroLift

Cannot do UroLift in a median-lobe prostate

Comparison of Treatments — Outcomes

BPH therapy	Symptom score improvement*	Flow rate improvement*	Urinary retention	BNC	SUI	Retrograde ejaculation	ED	Blood transfusion	Secondary procedure rate‡
α-Blocker	6	2–3	0–4%	—	Rare	≤ 28%	—	0%	—
5α-Reductase inhibitor	3.4	1.7	2%	—	0%	†	3%†	0%	†
TUMT	9–11	3	6–17%	3%	1%	5%	1%	≤ 2%	10–16%
TUNA	9	4	20%	3%	1%	4%	3%	3%	23%
UroLift	9	3–4	1%	< 1%	0%	0%	0%	0%	13.6%
Rezum	11	4–5	4%	< 1%	< 1%	3%	3%	Low	4.4%
Aquablation	17	11	8%	3%	Low	10%	Low	2%	2.6%
Holmium enucleation	18	11	8%	5%	1%	59%	3%	2%	1–7%
PVP	14	11	13%	3%	3%	42%	7%	3%	8–12%
TUVP	16	13	12%	5%	3%	65%	8%	1%	8%
TUIP	15	7	6%	6%	2%	18%	13%	1%	18%
TURP	15	11	5%	5%	4%	65%	10%	3%	2–8%
Simple prostatectomy	10	14	1%	8%	6%	61%	?	27%	3%

* At > 10 months after beginning treatment. AUA symptom score improvement is in points; flow rate improvement is in mL/s. † 5α-reductase inhibitors carry a low risk of reversible ED, decreased libido and decreased ejaculate volume. They reduce the need for surgery by 50%. ‡ The rate of needing re-operation for recurrent or persistent BPH-related voiding symptoms.

Reading the table — the patterns worth remembering

Biggest symptom-score gains → holmium enucleation (18) and Aquablation (17)
Highest retrograde ejaculation → TUVP and TURP (65%), simple prostatectomy (61%), HoLEP (59%) — vs 0% for UroLift and 3% for Rezum
Highest transfusion rate → simple prostatectomy (27%)
Highest re-operation rate → TUNA (23%), TUIP (18%), UroLift (13.6%)
Highest ED rate → TUIP (13%), TURP (10%)

Newer / Minimally Invasive Options

Technique	Size	EAU position
UroLift (PUL)	< 70 mL, no middle lobe	Strong — offer if preserving ejaculatory function
Aquablation	30–80 mL	Weak — alternative to TURP; Strong: counsel on bleeding risk & lack of long-term data
PAE	no size limit given	Weak — accept less optimal outcomes vs TURP; only with trained interventional radiology
Rezum (WVTT)	30–80 cc (AUA)	No EAU rating — narrative only
iTind	25–75 cc (AUA)	No EAU rating — under investigation

PAE is not recommended by the AUA
UroLift → requires cystoscopy both to check for a median lobe and to perform the procedure
- Complications — dysuria, hematuria, pelvic pain
- No retrograde ejaculation
Rezum → requires cystoscopy; for men > 50 years old
- Water vapor injected into the prostate causes cell necrosis leading to atrophy
- Maximum benefit takes up to 3 months
- Good choice if the patient wants to preserve ejaculation
Rezum can be used with a median lobe — an advantage over UroLift
- With a large median lobe, water vapor therapy is a better choice than UroLift in terms of ejaculatory function
Rezum → 52% meaningful QoL response at 12 months; surgical retreatment 4.4% over 5 years
iTind → device left in situ 5 days, then removed by outpatient urethroscopy; no new ejaculatory or erectile dysfunction reported

Mechanisms worth a line each

UroLift (PUL) → transprostatic suture implants pull the urethral lumen toward the capsule — no tissue ablated; urethral side epithelializes within 12 months; PSA unchanged
WVTT / Rezum → convective radiofrequency steam into the transition zone, denaturing the adenoma
PVP / GreenLight → 532 nm side-firing, absorbed by hemoglobin; penetration 0.8 mm; saline → no TUR syndrome; use 120 W or 180 W (the 80 W platform had higher retreatment)
- Two crystals in use — KTP (potassium titanyl phosphate) and LBO (lithium borate) — both called green light lasers
- Complication — epididymitis
HoLEP / ThuLEP → chromophore is water; penetration 0.4 mm holmium / 0.2 mm thulium → superficial + strongly coagulative = ideal for enucleation
RWT / Aquablation → robotic waterjet with TRUS mapping, sparing the verumontanum; hemostasis afterwards by cautery/tamponade/traction
- Not truly a MIST — requires general anesthesia
- A cystoscope inserts the transurethral probe containing the water jet nozzle; intraoperative TRUS designates the ablation zone
- The robot delivers a pulsating, high-velocity, heat-free saline jet
- No tissue chips are produced — so there is no need to manually evacuate prostate tissue
TUMT → microwave heating to ≥ 45 °C → coagulation necrosis; higher retreatment than TURP; being displaced by newer MISTs
- Delivered through a catheter with an antenna; causes retrograde ejaculation

TUNA — transurethral needle ablation (1996)

Radiofrequency waves heat the prostate and cause thermal necrosis
Requires a cystoscope
Contraindicated in bladder neck contracture
Not recommended by the AUA
Complications — dysuria, sexual dysfunction, perineal pain, UTI
Also not recommended in: active UTI, a metallic pelvic prosthesis (e.g. artificial hip), cardiac implants (defibrillator or pacemaker), or a high bladder neck

TUIP — Transurethral Incision of the Prostate

Using cutting current, 1 or 2 endoscopic incisions are made in the prostatic urethra at 5 and/or 7 o'clock
Incisions extend from the bladder neck to a point immediately cephalad to the verumontanum
Depth of the incision should be down to the fibrous prostatic capsule
No ED, but causes retrograde ejaculation

Transurethral Laser & Vaporization Therapies

Laser is used either to enucleate (resect) or to vaporize (ablate) prostate tissue.

HoLEP — complications

Morcellator-mediated bladder injury
Ureteric orifice injury
Capsular perforation
Bleeding
Retrograde ejaculation
Urethral stricture and bladder neck contracture

ThuLEP

Requires a longer operative time — about 10 minutes more than HoLEP

TUVP — Transurethral Electrovaporization of the Prostate

Prostate tissue is vaporized using electrical (cutting) current delivered through a blunt probe
High rate of retrograde ejaculation

TURP

Gold standard for glands of 30–80 g
The apex is resected at the end
Monopolar → glycine (hypotonic) → TUR syndrome
Bipolar → normal saline (isotonic)
Intra-operative erection → give phenylephrine
Post-operatively → give laxatives and avoid activities involving perineal pressure

Complications

Bleeding
TUR syndrome (Na < 125)
ED
Rectal injury
Retention — the most common post-operative complication is failure to void
UTI / sepsis
Bladder neck contracture — attempt office dilatation first
Retrograde ejaculation
Ureteric orifice injury

Extravasation & perforation of the prostatic capsule

→ Abdominal distension
Management:
- Control bleeding & stop the procedure
- Urethral catheter drainage

TUR Syndrome — (brain edema)

Definition: Na < 125 + 2 symptoms
A serum sodium < 120 mEq/L indicates significant dilution and may lead to coma or seizures

Symptoms

Vomiting
Bradycardia
Chest pain
Mental confusion
Visual disturbance
Hypertension
Headache
Pulmonary edema

Risk factors

Monopolar
Gland size > 45 g
Long resection time > 90 min
Deep resection / capsular perforation — open veins
Large volume of irrigant used
Height of irrigant > 60 cm
CHF
Liver failure
Raising the irrigant 10 cm above 60 cm increases pressure in the prostatic fossa and produces a greater than twofold increase in systemic fluid absorption

Management

Stop the TURP as soon as hemostasis is achieved; 3-way Foley on traction + CBI with NS
ABC, 100% O₂, vitals q2h, labs stat + q4h
Lasix 40 mg IV, 200 cc hypertonic 3% NS over 1–2 h — only if creatinine is normal; otherwise hemodialysis. Don't over-correct → osmotic demyelination
If seizures → Lorazepam 4–8 mg IV

Severe Bleeding After TURP

Intraoperative

General measures

ABCs — if hypotensive, bolus with crystalloid/NS or colloid/albumin
Type & cross, stat CBC and coagulation profile
2 large-bore IVs

Local measures

Arterial bleeding → fulguration
Venous bleeding → fulguration
Insert a catheter, inflate the balloon and tamponade → Foley on traction for 10 minutes + irrigate → if the bleeding is venous, the color should improve

Systemic

Correct any coagulopathy
Transfuse — pRBC, cryoprecipitate, platelets, FFP

Postoperative