BPH — Non-Neurogenic Male LUTS

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

Cowper's (bulbourethral) glands

• Lie within the external urethral sphincter in the deep perineal pouch, above the perineal membrane
• Only their 2–3 cm ducts pierce the perineal membrane → open into the proximal bulbar urethra

Predictors of disease progression

• Age
• PSA — the strongest predictor
• Prostate size
• IPSS
• Flow rate
• PVR
• Age, symptom severity, Qmax, prostate volume and serum PSA → predict AUR and BPH-related surgery
• Gross hematuria → a complication of BPH, not a predictor of progression

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LUTS — Classification

• Storage (irritative)
• Voiding (obstructive)
• Post-micturition

Differential — LUTS is a symptom complex, not a diagnosis

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Evaluation

Mandatory

• Medical history & physical exam — including DRE
  • History mnemonic — FUN WISE, plus hematuria, hesitancy, dysuria
• Symptom score — IPSS
• Urinalysis
  • Dipstick or microscopy — before starting any LUTS treatment (EAU, Strong)
• Voiding diary / frequency-volume chart

Optional

• PSA — if he is a candidate for prostate cancer screening
• PVR — if high → upper tract imaging
• Cytology — if severe irritative symptoms or dysuria

Before any intervention

• Uroflowmetry and ultrasound — mandatory
  • Exam answer: before laser prostatectomy for refractory LUTS (history, DRE and symptom score already done) → urinalysis is the only routinely recommended test
    • A PSA normal within the past year need not be repeated

AUA 2021 splits this explicitly

• Urinalysis → focus on glucosuria, proteinuria, hematuria, infection
  • Any of these (incl. microhematuria; glucosuria → diabetes) → redirect the workup away from benign prostatic obstruction
• 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 — some guidelines take 150 mL, others 300 mL as elevated; follow the trend
  • Correlation with degree of obstruction is weak; not a strong predictor of AUR
  • Elevated PVR alone is NOT an indication for surgery

Prostate size

• 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

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
  • LUTS persisting despite tamsulosin → assess prostate size and configuration (e.g. a median lobe) by cystoscopy or TRUS before discussing surgery such as prostatic urethral lift (UroLift) or TURP

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Urodynamics — Indications & Formulae

• Invasive urodynamics (pressure-flow) = gold standard for bladder outlet obstruction — the diagnosis rests on urodynamics, not uroflowmetry, TRUS, cystoscopy or cystourethrogram
• Pressure-flow is not routine before prostate surgery (costly, invasive) — reserve for diagnostic doubt / uncertainty in male LUTS
  • E.g. younger men with small prostates and severe LUTS, or suspected neurogenic detrusor dysfunction
  • UPSTREAM: routine urodynamics in uncomplicated LUTS did not significantly reduce surgery rates and was non-inferior for IPSS → use selectively
  • Before BPH surgery, cystoscopy and uroflowmetry are optional (cystoscopy when prostate size or configuration is in doubt, e.g. too large for endoscopic surgery or a median lobe)
• If no clear suggestion of obstruction (Qmax > 10)
  • EAU: surgery considered + bothersome, predominantly voiding LUTS + a valid Qmax > 10 mL/s (voided volume > 150 mL) → pressure-flow study (weak recommendation)
• If Qmax < 10 mL/s → obstruction likely; pressure-flow not necessarily needed

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
  • An elevated PVR alone should not justify outlet surgery — detrusor underactivity mimics obstruction
  • Pressure-flow separates them: obstruction = high pressure + low flow · underactivity = low pressure + low flow
• 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)

BCI — Bladder Contractility Index

BCI = Pdet@Qmax + 5(Qmax)

• Detrusor underactivity alone (BCI < 100) with BOOI < 40 → significantly worse 12-month Qmax after surgery — counsel carefully before TURP
• Diabetics — typical urodynamics: impaired bladder sensation · increased cystometric capacity · decreased contractility · impaired uroflow · later, increased residual urine — though some suggest detrusor overactivity is the predominant pattern

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Management Algorithm

Click the algorithm to open it full size.

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.

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Medical Therapy — Choice by Predominant Symptom

Click the algorithm to open it full size.

→ Then reassess: Satisfaction?

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

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Watchful Waiting & Lifestyle

• Offer to men with mild/moderate symptoms who are minimally bothered — bother-based, not score-based
  • High score and high bother (e.g. IPSS 25, bother 5) → watchful waiting inappropriate — offer intervention
• Offer lifestyle advice & self-care prior to, or concurrent with, treatment
• 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

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

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Medical Management

α-Blockers

Receptors

• α1 + α2 blockade → phenoxybenzamine and phentolamine; prazosin, terazosin, doxazosin, alfuzosin and tamsulosin are all α1-selective
• α1A receptors found in → prostate, bladder neck, distal ureter
  • Predominant subtype in prostatic stroma, bladder neck and prostatic urethra → mediates smooth muscle tone → blockade relaxes it → ↓ dynamic component of outlet obstruction
  • A highly selective α1A antagonist improves flow rate but not symptom scores
• α1D blockade (as with tamsulosin) → improves bladder-based storage symptoms
• α1B → vascular smooth muscle → blockade causes dizziness and orthostatic hypotension
  • Tamsulosin, silodosin and naftopidil → higher affinity for α1A/α1D than α1B

Ejaculatory dysfunction

• Uroselective agents cause more ejaculatory dysfunction — this does not apply to alfuzosin
  • Alfuzosin → least retrograde ejaculation — < 1%

Improvement in urinary flow

• Silodosin → improvement in urinary flow within 8 h
• Tamsulosin → improvement within 24 h
  • Exam answer: flow parameters change within only a few hours; symptom relief after about 1 week

Effectiveness

• 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

• Bothersome LUTS + worried about ejaculation → alfuzosin — α-blockers are first-line regardless of prostate size

Side-effect superlatives

• Most common class side effect → dizziness (2–10%)
  • Five most common → dizziness, orthostatic hypotension, headache, nasal congestion, retrograde ejaculation
• Least painful ejaculation → alfuzosin
• Most dizziness → terazosin and doxazosin (both long-acting, both need titration)
• Most retrograde ejaculation → silodosin, then tamsulosin
  • Ejaculatory risk rises with α1A selectivity → silodosin (OR 32.5) > tamsulosin (OR 8.57) > alfuzosin
• 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
• Warn every patient about first-dose hypotension — any α-blocker (silodosin, tamsulosin, alfuzosin, terazosin), even uroselective agents with their lower vascular risk
  • Non-uroselective agents (e.g., terazosin) → titrate the dose over the first few weeks — high first-dose hypotension risk
• An orthostatic BP drop without postural symptoms is not a contraindication to an α-blocker

Tamsulosin (Omnic) — full side-effect profile

• Blocks α1A and α1D
• Postural hypotension, dizziness, retrograde ejaculation, priapism, rhinitis, palpitations, syncope, intraoperative floppy iris syndrome
• Most common side effect → abnormal ejaculation — strongly dose-dependent: 6% at 0.4 mg vs 18% at 0.8 mg
  • Adverse events and withdrawals rise with dose → 0.4 mg is the formulation of choice for LUTS
• vs terazosin/doxazosin → retrograde ejaculation and rhinitis commoner with tamsulosin; dizziness and asthenia commoner with terazosin/doxazosin

IFIS — Intraoperative Floppy Iris Syndrome

• Tamsulosin has the highest risk — 40× alfuzosin; all α-blockers raise it somewhat
  • Incidence 30–88% on tamsulosin — α1A blockade of the iris dilator → iris billowing, prolapse toward the incisions, progressive miosis
• 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
  • Exam answer: stopping before cataract surgery does not significantly reduce the risk — IFIS can occur years after discontinuation → ask about current or previous α-blocker use
• Already on tamsulosin + cataract surgery → inform the ophthalmologist so the surgeon can anticipate IFIS and modify technique
• 1 serious complication per 255 men on tamsulosin in the immediate pre-op window

AUR

• 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
  • Delay the voiding trial if there's an active UTI

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5α-Reductase Inhibitors (5-ARI)

• Type 2 → predominant prostatic isoenzyme, localized mainly to stromal cells (interstitial fibroblasts)
• Type 1 → chiefly extraprostatic — skin and liver
• Finasteride 5 mg (type 2 only) → serum DHT ↓ 70%; dutasteride 0.5 mg (both) → serum DHT ↓ 94%
  • Yet prostate volume reduction at 1 year is similar

Indications to start a 5-ARI:

• Prostate volume > 40 cc
• PSA > 1.5

Effects:

• Reduce prostate size by 30%
  • Exam answer: 15–30% volume reduction after 6–24 months of treatment
• 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
  • Applies to finasteride 1 mg or 5 mg — e.g., 1.8 → 3.6 ng/mL; adjusted PSA > 3 ng/mL → multiparametric MRI or a biomarker
    • ConfirmMDx → tissue-based biomarker, indicated only after a previously negative biopsy; standard biopsy sampling = 12 or more cores
• 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
  • Also ↓ semen volume, with variable falls in sperm concentration and motility
  • Infertile man on tamsulosin + finasteride with low semen volume and poor sperm parameters → stop both — ejaculatory and semen effects are reversible
    • Pseudoephedrine or imipramine → only for retrograde ejaculation that persists after the drugs are stopped

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
• Mechanism → ↑ nitric oxide signaling → relaxes prostate and bladder neck smooth muscle
• 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

• α-blocker + PDE5 inhibitor — possible, but not preferable
  • Adding tadalafil to an α-blocker does not improve storage LUTS

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
• Bothersome storage LUTS persisting on tamsulosin + small prostate + low PVR → treat as OAB → add an antimuscarinic (solifenacin)
  • Antimuscarinic over mirabegron here — mirabegron is relatively contraindicated in uncontrolled hypertension
  • Not finasteride (larger prostates only) and not a higher tamsulosin dose (targets voiding, not storage LUTS)

Mirabegron

• For moderate-to-severe irritative LUTS
• May be preferred in older men with prevalent storage symptoms — more favorable tolerability than antimuscarinics
• 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

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Nocturnal Polyuria & Desmopressin

Polyuria

• Nocturnal polyuria = nocturnal output > 20% of 24-h output (young) or > 33% (age > 65)
  • Nocturnal polyuria index (NPi) = nocturnal urine volume ÷ 24-h voided volume → > 0.33 = nocturnal polyuria (e.g. 1000 / 2000 mL = 0.5)
  • The nocturnal share of urine output rises with age → about 14% of 24-h volume under age 25 vs about 34% after 65
• Global (24-h) polyuria = urine output > 40 mL/kg/24 h

Nocturia

• First investigation for bothersome nocturia
  • → 3-day bladder diary (frequency-volume chart) — sorts it into 24-h polyuria · nocturnal polyuria · diminished bladder capacity · sleep disorder before desmopressin or antimuscarinics are started
• Heart failure with dependent leg edema → third-spaced fluid mobilized on lying down → nocturnal polyuria that resists bladder therapy → optimize heart failure + compression stockings
  • Nocturia from edema → diuretic such as hydrochlorothiazide in the mid-afternoon (about 6 h before sleep) → pooled fluid is cleared while awake, not overnight

Dosing

• 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)
• Females need lower doses → greater sensitivity to desmopressin
• No fluids 1 h before and 8 h after dosing

Hyponatremia

• 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
  • Check at 1 and 4 weeks after starting; stop immediately if hyponatremia develops
• Clinically significant hyponatremia → 11% in men ≥ 65 vs 0% in men < 65 (50 mcg)
  • Independent risk factors for Na < 130 mmol/L →
    • Age ≥ 65
    • Baseline Na < 135 mmol/L
    • Creatinine clearance < 60 mL/min
    • Above-approved doses

Before prescribing

• Contraindications:
  • Hyponatremia
  • Conditions that impair water excretion (severe liver disease, hydronephrosis)
  • Type IIB or platelet-type (pseudo) von Willebrand disease → risk of platelet aggregation & thrombocytopenia (yet therapeutic in type 1)
• Primary nocturnal enuresis → oral desmopressin preferred (lower risk of symptomatic hyponatremia)
  • After hyponatremia cases with intranasal use, the FDA & EMA removed the enuresis indication from all intranasal preparations
• Exclude sleep apnea before prescribing
  • Obstructive sleep apnea → hypoxia ↑ right atrial transmural pressure → ↑ atrial natriuretic peptide (ANP), ↓ ADH → nocturnal diuresis & secondary nocturnal enuresis; CPAP improves the enuresis
  • Elderly man with nocturia + OSA → avoid desmopressin — treat the apnea at its source; desmopressin-induced hyponatremia risk is highest in older patients

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Trials

CombAT vs MTOPS — design at a glance

• 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
• → AUR risk rises near-linearly across ascending serum PSA thresholds — for both spontaneous and precipitated AUR

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
• → Dutasteride monotherapy reduced the risk of surgical treatment more than tamsulosin monotherapy

MTOPS

• Placebo vs doxazosin vs finasteride vs combination
• → Dual therapy reduced progression significantly more than either drug alone
  • Doxazosin alone still significantly reduced the risk of clinical progression vs placebo
• → Finasteride & combination reduced risk of AUR & surgery
• → Reduce PSA 50% & volume
• → PSA > 4 is the strongest predictor of AUR
  • Exam answer: serum PSA is the strongest predictor, with AUR risk already rising above PSA 1.4 ng/mL in pooled placebo data (figures under Acute Urinary Retention)

VA Cooperative Study

• Placebo vs alpha-blocker vs finasteride vs combination — 1229 patients
• → Alpha-blocker alone was superior for symptoms & peak flow rate
• → Adding finasteride only further reduced prostate volume — no significantly greater symptom relief

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OAB & BPH

• 75% of men with BPH have OAB — due to the overworked bladder
• 19% have persistent OAB after surgical therapy
• Urgency / urge incontinence without significant obstruction (e.g. elderly man, Qmax 14 mL/s, PVR 50 mL)
  • → start bladder retraining / timed voiding before any antimuscarinic
• Conservative OAB measures (weight loss, smoking cessation, less caffeine / fluid / alcohol, pelvic floor training, bladder retraining)
  • → give at least 6 weeks, ideally 3 months, before judging them a failure
• Urgency incontinence with urodynamic obstruction (e.g. diabetic man, Qmax 8 mL/s, voiding pressure 88 cm H2O)
  • → TURP — it treats the obstruction; neuromodulation is not indicated with outlet obstruction
• Management discussed later in neuro-urology

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Acute Urinary Retention

Recognized predictors of AUR

• Older age
• Severe LUTS
• Low peak flow rate
• High PVR volume
• Large prostate volume
  • > 40 mL → AUR 1.6% → 4.2% (about threefold) (PLESS and pooled placebo-arm data)
• High serum PSA
  • Strongest predictor (MTOPS) → above PSA 1.4 ng/mL, AUR 0.4% → 3.9% (about eightfold) (same pooled data)

Precipitated vs spontaneous AUR

• Classic precipitants → anticholinergic or antihistaminic drugs (e.g. chlorpheniramine) — impair detrusor contractility on top of obstruction — and alpha-sympathomimetics
• After precipitated AUR → only 9% have a later spontaneous episode, 26% need surgery
• After spontaneous AUR → 15% have a later spontaneous episode, 75% need surgery

Trial of void (TOV)

• Give the TOV after 3–8 days (median 5 days)
  • AUR with an enlarged prostate → replace the catheter + start an alpha-blocker (tamsulosin) before a TOV in 3 days; catheter or SPT alone is not recommended
  • Adding a 5-ARI (finasteride) may be reasonable in some men — but it is contraindicated in hepatic impairment (e.g. avoid after liver resection)
• Up to 3 TOVs may be given before planning surgery
  • Exam answer: 2 failed TOVs on maximal medical therapy → already an absolute indication for surgery (see Surgical Management — Indications)

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Surgical Management — Indications

• Recurrent retention
  • Retention despite maximal medical therapy after 2 failed TOVs → absolute indication for surgery
• Recurrent infection
• Recurrent hematuria
• Renal insufficiency / hydronephrosis
  • Oliguric man awaiting renal transplant → delay outlet obstruction treatment until after transplant — up to half improve once oliguria resolves
    • Surgery pre-transplant raises bladder neck contracture & stricture risk
• Therapy failure
• Bladder stones

Antibiotic coverage

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

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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

• HoLEP and ThuLEP are size-independent — they can be used for a prostate of any size
• Monopolar TURP suits 30–80 mL → an uncomplicated man with a 40 mL gland whose LUTS have failed medical therapy goes straight to TURP
• Exam answer: large glands rule out several alternatives → prostatic urethral lift ≤ 100 g (beyond the table's 30–80 cc UroLift band) · water ablation ≤ 80 g · TUIP < 30 g

By special circumstance

• Anticoagulated (e.g. warfarin) → laser prostatectomy (KTP/PVP, HoLEP, ThuLEP) gives better hemostasis than TURP — even bipolar TURP; TURP bleeds more
  • KTP 532 nm light → selectively absorbed by hemoglobin

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Comparison of Treatments — Outcomes

* 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%)

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Newer / Minimally Invasive Options

• PAE is not recommended by the AUA

UroLift

• UroLift → requires cystoscopy both to check for a median lobe and to perform the procedure
  • Complications — dysuria, hematuria, pelvic pain
  • No retrograde ejaculation
  • Exam answer: usually reserved for prostates < 80 mL (EAU table above: < 70 mL); recently FDA-approved for larger glands
  • Not evaluated in men in urinary retention

Rezum

• 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
  • Classic case: LUTS + bothersome retrograde ejaculation on maximum medical therapy + large median lobe → Rezum, not UroLift
• Rezum → 52% meaningful QoL response at 12 months; surgical retreatment 4.4% over 5 years
  • Retreatment 3.7% at 24 months; a large median lobe causes no apparent loss of efficacy

Ejaculatory function

• UroLift and Rezum → both preserve sexual and ejaculatory function — AUA conditional recommendation (Grade C evidence)
  • By contrast, TURP, HoLEP and transurethral vaporization → significant ejaculatory dysfunction

iTind

• 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
  • Implants placed anterolaterally — avoiding the neurovascular bundles (posterolateral) and the prostatic veins (anterior); they compress the transition zone to open the urethral lumen
• WVTT / Rezum → convective radiofrequency steam into the transition zone, denaturing the adenoma
  • Controlled penetration depth with minimal effects beyond the transition zone; the prostatic urethral epithelium is preserved
• 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
  • Exam answer: holmium → 2140 nm, pulsed; zone of thermal injury 0.5–1.0 mm → injury beyond the tissue in direct contact with the tip is unlikely
• 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

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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
  • Exam answer: retrograde ejaculation in up to 37% (outcomes table: 18%)
  • Unilateral incision may carry a lower risk than bilateral — controversial, but the majority view
• Short procedure, suited only to small prostates (generally < 30 mL)
• No adenoma is removed; does not cause TUR syndrome

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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

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TURP

• Gold standard for glands of 30–80 g
• The apex is resected at the end
• Monopolar → glycine (hypotonic) → TUR syndrome
  • Needs a non-conducting irrigant — if normal saline is hung, current spreads through the fluid → cutting and coagulation suddenly fail
• Bipolar → normal saline (isotonic)
• Intra-operative erection → give phenylephrine
  • Persistent erection restricts the resectoscope and intracavernosal injections fail → perineal urethrostomy for access
• Long penis — resectoscope can't reach the bladder neck → perineal urethrostomy to shorten the route, rather than abandoning the resection
  • Same access route in HoLEP for a very large adenoma or morbid obesity
• Post-operatively → give laxatives and avoid activities involving perineal pressure
• Oliguric / anuric man after TURP or TUIP → cycle the bladder for 6 weeks — via SPT or CIC, instill water or saline 4–5 times daily and void per urethra
  • Prevents a dry urethra → bladder neck contracture and obliterative urethral strictures

Complications

• Bleeding
• TUR syndrome (Na < 125)
• ED
  • Cavernous nerves run posterolaterally beside the capsular prostatic artery and vein → the vessels are the visible landmark for these fine nerves
  • Near the apex the neurovascular bundle lies at 5 and 7 o'clock → deep resection or capsular perforation there risks ED
• Rectal injury
• Retention — the most common post-operative complication is failure to void
  • Exam answer: failure to void after catheter removal → retention in 4.5–7.1% after monopolar TURP — more common than transfusion (2.0%) or TUR syndrome (0.8%) (outcomes table: transfusion 3%)
  • Drivers → detrusor underactivity, prostatic fossa edema and clot; persisting beyond a few weeks despite an adequate resection → urodynamics for detrusor underactivity
• UTI / sepsis
• Bladder neck contracture — attempt office dilatation first
• Retrograde ejaculation
• Ureteric orifice injury
• Retreatment → incomplete resection, poor patient selection (glands > 80 mL) or technical error; revision risk rises with larger glands and preoperative retention
  • New AUR 3 months after TURP in a man who had been voiding freely → most likely incomplete resection — residual adenoma at the apex or anteriorly

Extravasation & perforation of the prostatic capsule

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

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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
  • Check serum sodium after monopolar TURP; bipolar resection in normal saline largely eliminates the risk
• 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
  • 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
• CHF
• Liver failure

Management

1. Stop the TURP as soon as hemostasis is achieved; 3-way Foley on traction + CBI with NS
2. ABC, 100% O₂, vitals q2h, labs stat + q4h
3. 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
   • Na < 120 mEq/L + neurologic symptoms → add central venous access to the regimen above — not isotonic saline or fluid restriction
   • Exam answer: 3% saline as 100 mL boluses every 10 min (max 300 mL) → target a Na rise of 4–6 mEq/L + symptom resolution; never > 12 mEq/L in 24 h
4. If seizures → Lorazepam 4–8 mg IV

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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

General measures

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

Immediate bleeding in PACU = faulty intraoperative hemostasis

• Manual catheter irrigation to declot, then high-flow CBI
• Full balloon (50 cc) on traction
  • Traction tamponades the bladder neck + prostatic fossa; with CBI it treats stable hematuria after TURP or simple prostatectomy — exchange the catheter only if it won't drain
  • Never inflate the balloon within the prostatic fossa → severe spasms, paradoxically worse bleeding
• Double-balloon catheter
• Iced saline irrigation
• Alum and/or silver nitrate and/or formaldehyde irrigation
• Amicar intravesically or systemically — no longer available

Return to theatre if that fails

• Second look to declot, coagulate and rollerball
  • Bleeding despite large-bore catheter traction, irrigation, transfusion and clot evacuation (after TURP or simple prostatectomy) → cystoscopy of the prostatic bed + bladder neck with fulguration
• Open attempt at hemostasis if transurethral management fails:
  • Suture ligation at the bladder neck
  • Malament stitches — nylon purse-string at the bladder neck, brought out through the anterior abdominal wall and removed 1–2 days later
  • O'Connor stitches — plicate the posterior prostatic capsule with O-chromic
  • Pack the prostatic fossa
  • Place a suprapubic tube
  • Ligate the internal iliacs
• Radiologic embolization of the bleeder
  • Not routinely used after prostate surgery

Systemic measures

• Amicar 5 g IV loading dose over 1 h, then 1 g/h × 8 h (up to 30 g/24 h) — not available
• Correct systemic coagulopathy — cryoprecipitate, platelets, FFP, vitamin K, protamine

Delayed bleeding = sloughing of tissue rendered ischemic during the initial procedure

• Ensure the patient is stable
• Irrigate the bladder + CBI
• Rule out other causes of hematuria (history, exam, labs) — treat if found
• Correct systemic coagulopathy
• If bleeding is from the prostate — traction on the Foley, Amicar, cystoscopy + fulguration

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Open Prostatectomy

• Retrograde ejaculation — the most common adverse outcome after open simple prostatectomy (~80–90%): enucleation leaves a wide-open prostatic fossa and an incompetent bladder neck

Retropubic (Millin's procedure)

• Excellent anatomic exposure
• Direct visualization of the adenoma
• Precise transection of the apex and urethra distally to preserve continence
• Clear visualization of the prostatic fossa to control bleeding
• Minimal to no trauma to the bladder
• DVC needs to be ligated
• Goes through the anterior prostatic capsule — the bladder is never opened → cannot reach a bladder stone; stones need the suprapubic (Freyer) route

Suprapubic (= transvesical)

• Allows access to a large median lobe
• Good for bladder stones or symptomatic diverticulum
  • Diverticulum that can't be everted → submucosal excision from within its fibrous capsule; the adherent capsule stays behind → avoids dissecting inflamed perivesical tissue near the ureter
  • Submucosal technique: circumferential mucosal incision ~0.5 cm around the neck → sac dissected out → two-layer bladder wall closure with a secure seromuscular layer to prevent recurrence
• Glands > 80–100 mL with any of these → suprapubic preferred over retropubic — direct exposure of the bladder neck + bladder mucosa
• Freyer — adenoma enucleated by finger from inside the opened bladder
• Retropubic and suprapubic both work in the space of Retzius, but suprapubic needs no DVC control before enucleating the adenoma

Perineal Prostatectomy

• Radical perineal approach suits men with prior renal transplantation or morbid obesity
• Contraindication: hip or spine ankylosis — can't tolerate the exaggerated lithotomy position
• To reach the apex: release Lowsley traction first (tenting the rectum raises rectal injury risk), then divide the rectourethralis sharply — never bluntly

Robotic

• Robotic simple prostatectomy has a role in prostates larger than 80 cc
• Difficult apical adenoma → extend the cystotomy distally toward the apex, opening the detrusor apron, for visualization — not conversion to open

Methods to control bleeding after open prostatectomy

1. 4-0 suturing of the bleeders
2. Two sutures at 5 and 7 o'clock
3. Malament sutures — 2 nylon sutures around the bladder neck brought out and tied on the skin, removed after 2 days
4. O'Connor sutures — transverse sutures in the posterior capsule

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Post-operative Follow-up

• Review 4–6 weeks after catheter removal
• Assess → IPSS, uroflowmetry, erectile & ejaculatory function, PVR
• If symptomatic relief and no adverse events → no further re-assessment necessary
  • Exception: bladder diverticulum that drains well after TURP
    • → still needs annual cystoscopy + urine cytology — natural history unknown, and premalignant change may have occurred while it was not draining