CLINICAL CONSIDERATIONS
“I cannot pass urine”
A very large number of men over the age of fifty have enlarged prostate. Some of them may seek your advice for their symptoms but a significant number of them report only when acute retention develops. Younger people who have stricture of the urethra may also come to you when they develop retention. Therefore, you should realize that this is one of the common urological problems you may face in general practice. The condition can be quite agonizing and if properly managed, patients are most grateful.
Common Pitfalls
- There is a curious pitfall into which doctors keep on falling with amazing frequency. Typically, a patient who is on the verge of acute retention passes small amounts of urine with a lot of straining. As the distended bladder starts bothering him (distention of bladder is very painful), he reports to his doctor and says that he is passing “less urine”. Translated into medical terminology, it implies oliguria. If the doctor does not palpate the abdomen to feel the distended bladder or if the patient is talking on the phone, he (the doctor) prescribes a tablet of a diuretic (e.g. Lasix). (This happens far more often than you would now be willing to believe. It happens even when the patient says that he cannot pass urine at all). As a result, the patient has brisk diuresis; the bladder distends further and you convert a mild discomfort into an agony.2When a patient makes a complaint like this, it is safer to find out whether he has retention of urine. Even if a distended bladder is not palpable, as may be the case in an obese patient, it is advisable to get an ultrasound examination or pass a disposable, sterile urinary catheter to confirm whether the patient has retention. To give a diuretic such as Lasix to a patient who has retention of urine can make him miserable. On the other hand, even if you are dealing with a patient of acute renal shut down, catheterization done with strict aseptic precautions would do no harm.
- The second pitfall is just the reverse of the first. Many such patients have a chronically distended bladder with more than a litre of residual urine in the bladder all the time. They keep on passing very small amounts of urine at frequent intervals. The patient, however, comes and says that “he is passing excess urine”. On the face of it, it sounds like ‘cystitis—frequency of urination with some discomfort. As a result, the patient is prescribed an antibiotic and an alkalizer and sent home. Whenever you think that an adult or elderly male has urinary tract infection, ask yourself: why does he have infection? Then you are less likely to misdiagnose the problem.
- There is a third pitfall. A patient with a chronically distended bladder, especially if he is very old and feeble and bed-ridden due to some other problem like a fracture of the hip, will keep on passing small amounts of urine involuntarily. This is not true incontinence but overflow dribbling and needs to be treated on the same lines as retention of urine. (Please see —Incontinence in Elderly Male).Moral: Count ten before you make a diagnosis other than acute retention of urine.
Can acute retention be prevented?
Let us see how acute retention develops and accordingly, what can be done to prevent it.
The classic example is that of a man about 60 years of age, sitting with his friends, enjoying a drink on a chilly evening. 3After consuming alcohol, he comes out in the cold weather to go home. Just before going to bed he goes to the bathroom but finds that he cannot pass urine or can pass only a small amount with great difficulty. The problem worsens during the night and becomes so agonizing that he wakes up in the middle of the night with a distended bladder and seeks your help.
What has happened? Alcohol promotes diuresis and coupled with the amount of water/soda consumed with it, causes the bladder to fill-up rapidly. Even though he might have felt the urge, the patient did not bother to pass urine (again, another effect of alcohol). Coming out in the cold weather causes congestion of the prostate, thus increasing the obstruction which finally leads to acute retention. As the effect of alcohol wears off, the pain of the distended bladder becomes unbearable (Fig. 1.1).
The second common precipitating cause of acute retention is the use of some drugs especially ephedrine/antihistamine combinations prescribed for common cold, and anticholinergic drugs like Pro-Banthine used in peptic ulcer disease.
A lot of widely used antidepressant drugs such as tricyclic agents (Amitriptyline etc.) can also precipitate acute retention of urine. These drugs weaken the contractile power of the bladder (by their anticholinergic effect) and precipitate acute retention.
Lessons Learnt
- A person who is in the age group in which prostatic problems are common should be advised not to consume large amounts of liquids over a short period of time, especially the kind of liquids that promote diuresis, e.g. tea, coffee and alcohol. Similarly, you should be careful in prescribing such a patient drugs for common cold and antidepressants as mentioned above and the patient should be cautioned not to indulge in self-medication with these drugs.
- He should be advised not to postpone urination. If the bladder is allowed to remain distended, it loses its tone and power to contract and cannot evacuate itself. The old man should void when he feels the urge.
- To avoid getting up frequently at night to pass urine, he should be advised not to consume large quantities of liquids in the late evening. Less urine will, thus be formed during the night.
- As we shall see later, a few drugs are now available that reduce the chances of a patient developing acute retention (please see ). Their use should be considered judiciously.
Must a patient wait for treatment until he develops acute retention?
For a number of decades, open prostatectomy was the only effective treatment available for an enlarged prostate causing obstruction to the flow of urine. This procedure was painful, messy and associated with significant morbidity and mortality. Every old man had seen his father, a relative or a friend pass through the agony of this operation and was naturally inclined to postpone his own operation until it became absolutely necessary, i.e. acute retention developed.5
Figs 1.2 and 1.3: This patient complained of night time frequency only and said that his stream was normal. Uroflometry revealed marked degree of obstruction (Fig. 1.2). Uroflometry done earlier would have unmasked the condition and need for treatment. Postoperative graph (Fig. 1.3) of the same patient shows marked improvement.
However, this picture has now been totally altered by the following developments:
- Since the symptoms of enlargement of prostate develop slowly, many patients consider them as part of the normal aging process and do not bother about them even though they have significant obstruction. With the help of simple tests like uroflometry (see “Uroflometry” in Chapter 15) it is now possible to objectively assess the degree of obstruction (much like a treadmill stress test which reveals the presence of coronary artery disease). The patient can thus be advised as to whether he needs treatment even if he is not much troubled by his symptoms (Figs 1.2 and 1.3).
- Many drugs and minor procedures which can help patients with early obstruction are now available. They are also useful in patients who are temporarily unfit for surgery, e.g. after a recent myocardial infarction. (see: Medical Treatment of Enlarged Prostate; ).
- As stated earlier, open surgery for prostate was associated with significant morbidity and mortality and this was what scared the patients. At present, however, almost all cases can be managed by TUR-P (Transurethral Resection of Prostate). This operation is much safer and causes minimal 6discomfort to the patient. Thus, if a patient has significant obstruction, TUR can be recommended as an elective surgery and the patient can be assured that the experience would not be unpleasant like an open prostatectomy. In recent years, many procedures which are variants of TUR-P, such as microwave thermotherapy, laser prostatectomy, TUNA (Transurethral needle ablation), etc have also become available.
It is, therefore, evident that a patient who is experiencing symptoms of enlarged prostate need not be afraid of and wait for treatment until he develops acute retention. Now let us look at the other side of the coin and therein is an important question:
Is there any harm in delaying treatment?
You will invariably be asked this question and the answer is “yes”. A lot of harm can occur by delaying treatment. This can happen in many ways.
- In some cases, the bladder muscle has to keep on exerting more and more to expel urine against the obstruction, and therefore, it becomes thick and irritable (Figs 1.4a and b). As a result, it loses its capacity to accommodate sufficient quantity of urine. If surgery is performed at this late stage, frequency of micturition persists postoperatively and is interpreted both by the patient and the referring doctor as failure of the operation. In fact, it is the result of thickened, noncompliant bladder from delaying treatment unduly.
- An obstructed bladder usually has some amount of residual urine in it. As every medical student knows, this predisposes to infection (cystitis) and stone formation. Infection itself can precipitate acute retention and these two—obstruction and infection—form a deadly combination leading to septicaemia which may prove fatal (Figs 1.5a and b).
- Another serious trouble can creep in insidiously. As the obstruction persists year after year, it takes its toll on the kidneys which become hydronephrotic and the patient develops uraemia (Fig. 1.6). He may not notice any ill effects apart from a feeling of generalized asthenia.It is only when some other illness forces him to seek medical advice and a blood urea or serum creatinine estimation is done that the extent of renal damage is noticed. In early stages, it might be reversible with a few days of catheter drainage but in later stages, it may not be so.
- Another important fact that must not be ignored is that enlarged prostate may have foci of carcinoma. Proper evaluation and treatment at an early stage offers the best chance of cure.
- At a more general level also, delaying treatment of prostatic obstruction can be harmful. If a patient is straining all the time to pass urine, he runs the risk of development or aggravation of an already existing hernia and/or haemorrhoids. If he suffers from coronary insufficiency with angina, this also will worsen.
To sum up, a patient of enlarged prostate is well advised to seek proper treatment and not to delay it unduly. Thus, if an old man comes to you with angina, it would be a good policy to enquire if he has any urinary symptoms and in a doubtful case, to get a uroflometry done because if he keeps on straining to pass urine, you will find it difficult to control his angina. Also, it must be impressed on the patient who wants to delay his treatment for any reason that he should at least get himself periodically and regularly examined so that cancer of the prostate can be detected at an early stage.
‘Near normal—sized gland: Does the patient need treatment?
In earlier days, rectal examination was the only clinical method to assess the size of the prostate gland. However, with the ready availability of ultrasound, it is now a common practice that a patient who reports with symptoms of bladder outlet obstruction is advised to get this examination done to estimate the size of the prostate. Often you may get a report like this: “Approximate weight of the prostate: 20 grams. Insignificant residual urine”. This is usually interpreted as a normal report but may not be so. You must remember that the size or weight of the gland bears no relationship to the degree of obstruction. A small gland can produce more severe degree of obstruction than a large gland (Figs 1.7a and b).9
Similarly, absence of significant amount of residual urine does not mean that the patient has no obstruction. It may only mean that so far, the bladder has been able to overcome the obstruction by undergoing compensatory hypertrophy. Under these circumstances, it is preferable to get a uroflometry done which will give a much better assessment of the degree of obstruction and the need for treatment. (To be deceived by the near normal size of the prostate and to do nothing about it is, unfortunately, so common in general practice that one cannot help, even at the risk of repetition, to impress upon the family physician not be misled by the “normal” size of the gland). As already mentioned, if this state of affairs is allowed to drift, the patient may go into chronic retention with all its ill-effects.
(What is the normal weight of prostate? The prostate remains a very small gland in the whole of prepubertal age. At puberty, it undergoes a rapid increase in weight. Many studies have shown that the maximum weight of a normal adult prostate is about 26 grams at the age of 30 years. This again remains more or less steady till the age of 50 after which, there is a gradual increase in its weight the rate of which varies from person to person. It is not clear why some people have a faster growth rate than others).10
Medical (nonoperative) Treatment of Enlarged Prostate
For a number of years, some drugs were used for symptomatic relief in cases of enlarged prostate. These drugs had no scientific basis for their action and the relief, if any, was most likely due to placebo effect. Presently, however, drugs are available which can relieve the symptoms of an enlarged prostate on a scientific basis and can, thus be used in patients who have mild to moderate symptoms. The availability of these drugs has greatly widened the role of the family physician in dealing with a vast number of these patients. It is, therefore, important to understand their action as well as potential side effects in detail.
The obstruction to the flow of urine in the cases of enlarged prostate is considered to be caused by two factors:
- Mechanical factor: This is produced by increase in the size of the prostate gland, which narrows down the urethra.
- Dynamic factor: This is caused by the presence of smooth muscle fibres in the bladder neck and the substance of the prostate gland. The contraction (tone) of these fibres causes functional obstruction to the flow of urine.
It therefore follows that two types of drugs can give symptomatic relief: (1) Those that can reduce the size of the gland, and (2) those that can reduce the tone of smooth muscle fibres and cause their relaxation.
The first type of drug, i.e. one that can reduce the size of the prostate gland is known as ‘5 alpha reductase inhibitor’. The generic name of such a drug is “Finasteride” (Brand names: Fincar, Finast). It has been observed that after the use of this drug for about twelve weeks, the size of the prostate gland comes down by nearly 25% in many of the patients. The main drawback is its slow action and the fact that the effect cannot be achieved in all patients. The patients with prostate glands which are of relatively bigger size, i.e. ≥ 35 grams are more likely to benefit from it. This drug is available as a 5 mg tablet and the dose is one tablet a day.
There are some side effects of this drug. Main among them are a decrease in libido, difficulty in achieving a satisfactory erection and ejaculation and gynaecomazia. These side effects 11tend to diminish with prolonged use of the drug but the patient may need to be counseled about them. A positive side effect is the revertion of male type balding which many patients may appreciate. The latest addition to this group of drugs is Dutasteride (Duprost, Durize). It is considered to be more potent than Finasteride and the dose is 0.5 mg cap. once daily.
The second group of drugs are those which produce smooth muscle relaxation in the prostate and are called “alpha blockers”. Quite a few drugs in this category are available by the generic names of Prazosin and Terazosin (Brand names: Minipress XL and Hytrin respectively). In contrast with the drugs of the first category, these drugs have a much more rapid action of onset (3–5 days) and most of the patients who use these drugs show a significant beneficial effect as regards their symptoms. Most patients report a decrease in the frequency and improvement in the flow of urine. The main side effect of these drugs is postural hypotension. This means that the patient has a fall in his blood pressure when he gets up from a lying position. The effect is seen at the beginning of the treatment or later when the dose is increased. The patient should be expressly warned to be careful of this side effect. He should take the drug before going to bed. When he gets up from a lying position, he should do so very slowly and not abruptly. The other side effects usually reported by the patients are feeling of dizziness, headache, nasal stuffiness and asthenia, i.e. a feeling of tiredness and lethargy. The patient should be reassured that these are normal, though unpleasant effect of the drug.
Dosage: Prazosin is available as a 2.5 and 5 mg tablet. One should start with 2.5 mg daily. The drug should be taken at night to minimize the incidence of postural hypotension. If a beneficial effect is observed, the dose can be increased to 5 mg per day.
Terazosin is a long acting drug. Start with 1 mg tablet per day at bed time and slowly increase the dose (upto 5 mg per day).
The latest addition to this class of drugs is Tamsulosin (Urimax, Veltam, Contiflo). It is claimed by its manufacturers 12to be ‘prostate specific’ and therefore, it does not cause hypotension which is the unpleasant side effect of other drugs in this category. However, in clinical use, this claim has not always been found to be true and it's worthwhile to warn the patients about this. Tamsulosin is available as 0.2 and 0.4 mg capsules. Start with lower dose and take it upto 0.4 mg (and no further).
In a patient with a gland of moderate size, i.e. ≥ 35 grams, it seems an attractive preposition to give the patient both the drugs for the maximum beneficial effect. Such combination therapy is available in many preparations, e.g. Veltam-F, Urimax-F. It is claimed that combination therapy significantly reduces the risk of acute retention of urine and need for surgery.
The Changed Role of Family Physician
The discussion above shows that medical treatment has a definite role to play in the management of BPH. As such, the role of the family physician in the management of this common problem has become very important. To play this role satisfactorily and successfully, the family physician has to share the whole responsibility with the urologist. Also, before the family physician assumes this role, he must learn about the treatment options as well as gain expertise in some procedures. The latter would include:
- A careful assessment of the patient's problem so as to be able to decide that medical treatment will help the patient.
- Digital Rectal Examination (DRE): This simple procedure needs some training so that the patient does not feel undue discomfort. The following technique works well:
- Ask the patient to remove his trousers and lie in left lateral position
- Wear a glove on your right hand. Apply a liberal amount of xylocaine jelly on the pulp of index finger.
- Do not insert the finger in the anal canal directly. Keep the pulp of the terminal phalanx of the ring finger over which you have already applied jelly at the anal verge at right angle to the direction of anal canal. Gently exert increasing pressure with the pulp on the 13anal verge. Slowly the finger will slide into the anal canal. This causes minimum discomfort to the patient.
- Once your finger is in the anal canal, you can move it around to feel various landmarks. With the help of a urologist, learn to differentiate between benign and malignant prostate.
- The family physician should follow up the patient (who is on medical treatment) carefully. The follow up may include:
- A digital rectal examination by a urologist
- An ultrasound examination
- PSA estimation (see more about PSA on and ).
Can enlargement of prostate be prevented?
This is a question that many patients experiencing symptoms of prostatic enlargement will ask you. Till recently, the answer was simple: enlargement of prostate is part of the normal aging process, like developing grey hair or baldness and there is little you can do about it. Most will have it, any time after the age of forty. As described above, now we have drugs like ‘Finasteride’ and ‘Dutasteride’ which can reduce the size of the gland and/or reduce further growth. The difficulty is to decide whether these drugs can be given to all males above the age of 50 as a prophylactic measure and be continued indefinitely. At present, urologists are not using this approach and the drug is given only to patients who have symptoms of enlarged prostate.
Acute retention: What to do?
Let us now assume that you are confronted with a patient who has a distended bladder and is crying with agony. What to do?
Conservative Measures: Are They of any Use?
Conservative measures like fomentation with a hot water bottle over the abdomen or in the perineum and use of intravenous antispasmodics are usually unsuccessful in relieving acute retention except that they give you enough time to collect your 14things for catheterizing the patient and give the patient a feeling that something is being done.
Pitfalls with Antispasmodics
If you use antispasmodics to relieve the pain of acute distention, two things must be kept in mind. The first is that they reduce the pain temporarily but the antispasmodic effect causes further atony of the bladder and thus worsens the obstruction. The other thing you should remember is that many patients feel dizzy after an intravenous injection of an antispasmodic and can have a syncopal attack. You should be careful that the patient does not immediately stand up after receiving the injection.
Catheterization
This minor procedure is so vitally important and frequently required that every GP should know the technique of safe and easy catheterization. With a little care, it is possible to catheterize a patient in a sterile way without much equipment.
Steps of Catheterization
- A patient in acute retention is usually in severe agony. Give him a good analgesic (Inj. fortwin/morphine/pethidine) so that he allows you to proceed. Also, give him an intravenous shot of a good, broad-spectrum antibiotic, e.g. inj. gentamicin 80 mgm. Any manipulation on the urinary tract carries the grave risk of causing bacteraemia and the this is especially true of catheterization.
- Clean the genital area with an antiseptic solution (Savlon/Betadine). There is no need to shave the pubic hair but do retract the prepuce and clean the smegma. (Do not forget to pull the prepuce back after catheterization; otherwise, paraphimosis may result).
- Take a tube of Xylocaine jelly. It comes with a nozzle. Fit the nozzle on the tube, clean it with the same antiseptic solution that you have used to clean the genitalia, insert the nozzle into the meatus, hold the penis upright and squeeze the whole of the tube into the urethra. Pinch the urethra at the 15meatus for about 2–3 minutes so that the jelly does not escape and the effect of local anaesthesia is achieved.
- Take a Foley's catheter no.14 or 16. Peel off the outer cover. The inner cover is sterile and has a perforation towards the tip. If you pull here, the terminal 4–5 cm of the catheter will protrude outside the cover. Without touching it, insert it into the urethra, holding only the sterile paper cover and holding the penis with the other hand. Slight obstruction may be encountered at the level of external sphincter. Ask the patient to take a deep breath and you will usually be able to negotiate this area. Keep on inserting the catheter even after the urine starts flowing so that the catheter is well within the bladder. Inflate the balloon with 10 ml of sterile water (e.g. Water for Injection) and connect the catheter to a bag. Gently withdraw the catheter so that the balloon rests on the bladder neck.
In the above steps, you will notice two things:
- No mention is made of wearing sterile gloves or using sterile sheets to cover the genital area. This does not mean that these things are redundant. Ideally all aseptic measures should be adopted. The point that must be made is that even if you are working in less than ideal conditions, it is still possible that by observing simple precautions and adopting a “no touch” technique as described above, catheterization can be successfully performed without harming the patient.
- It is better to use an indwelling catheter like Foley's rather than a straight, disposable one. If you use the latter, you may evacuate the bladder and send the patient home only to find that he develops retention again within 4–5 hours.
Pitfalls in Catheterization
- Sometimes you will find that the catheter has gone in smoothly and easily, still the urine does not start draining. What happens is that the eye of the catheter gets blocked by the jelly that you had used for local anaesthesia and lubrication. There is no need to panic. Do not start fiddling with the catheter. The jelly gets dissolved in a few seconds and the urine starts flowing.16Figs 1.8a to c: (a) The eye of the catheter is in the bladder but the balloon is still lying in the prostatic urethra. Inflating the balloon may injure the urethra. (b) Insert the catheter well into the bladder and inflate the balloon. (c) Withdraw the catheter gently so that the balloon rests on the bladder neck.
- The reverse of the above situation occurs at times. When you are inserting the catheter, its eye is the first to enter the bladder. The urine may start flowing and if you do not insert the catheter any further, the balloon will still be in the urethra. If you inflate it here, urethral injury can occur. Therefore, keep on inserting the catheter even after the urine flow starts. Inflate the balloon only when the catheter is well within the bladder (Figs 1.8a to c).
- Be sure to use only distilled water to inflate the balloon. If you use some other liquid like saline, it will later block the inflation channel and it then becomes difficult to deflate the balloon while taking out the catheter.
- In a patient who has acute on chronic retention, sudden decompression of the bladder by catheterization can result in two problems:
- Patient may develop hematuria.
- Patient may develop postobstructive diuresis.
It is therefore, essential to decompress the bladder gradually. Take the advice of a urologist.
When you fail to pass the catheter
If you are unable to pass the catheter, bear two things in mind.
- Do not use force.
- Do not use a harder catheter like Gibbon's.
In both cases, urethral injury can occur which can later form a stricture. Failure to pass the catheter can be because of the presence of a urethral stricture, a stone impacted in the urethra or some other cause. You should leave these problems for the specialist to tackel. However, if you are, for some reason, unable to contact a specialist and the patient is in real agony, you can attempt either of the following two things:
- Using a long needle like a lumbar puncture needle, aspirate the bladder just above the symphysis pubis in the midline. First clean the suprapubic area with an antiseptic solution. Using a thin needle, give a little local anesthetic (Xylocaine 2% without adrenaline) in the midline, just a finger above the pubic symphysis. Insert the lumber puncture needle through the same place vertically downwards. As the urine starts flowing, aspirate with a syringe (Fig. 1.9). This way you can temporarily relieve the obstruction and then send the patient to a nearby specialist.It is important that you don't just let the patient go home and thus allow the bladder to refill. Urine will leak through the puncture hole and collect outside the bladder (Fig. 1.10).
- In a similar way, you may use a readymade kit like Supracath. This has a Foley type catheter with a long needle in the lumen. It is inserted exactly the same way as the lumbar puncture needle in the above procedure. As the catheter enters the bladder, you will feel a distinct sensation of resistance giving way. Remove the needle and inflate the catheter balloon. Thus you can perform a percutaneous suprapubic cystostomy (Fig. 1.11).
Both these techniques are easy to carry out and it would be a wise policy to include them in your armamentarium.
Caution: Do not attempt either of the above two procedures in a patient who has a scar of a previous surgery in the lower abdomen.
Leaking of urine around the catheter
Sometimes, you may catheterize a patient and send him home pending further investigations and treatment. In the meantime, he comes back and complains of severe spasms and pain in the region of the bladder and urethra. During these spasms, some amount of urine may leak around the catheter or the patient may get a sensation that urine is not “coming out” even though he can see it accumulating in the bag.
These spasms are probably due to irritation of the trigonal area by the catheter. In the wards, when a patient makes this complaint of urine leaking around the catheter, the nurse or the resident doctor inflates the balloon of the catheter with a little more distilled water to plug the leak. It never works. On the other hand, reducing the amount of water in the balloon may help. When faced with this problem, you should reassure the patient that there is nothing seriously wrong; make sure that the catheter is draining well and is not blocked; that the tubing connecting the catheter with the bag is not kinked and also explain to the patient that he should take care that while he sits or lies, the tube does not come under his body and get kinked. Try simple antispasmodic drugs and analgesics. The condition usually resolves by itself after a few days.
Choice of Surgery: Open prostatectomy vs TUR-P
This is a question that many patients will ask you: whether they should undergo the old type of operation, i.e. open prostatectomy or the new one of the drilling type, i.e. TUR-P. TUR-P is considered the gold standard against which the results of open prostatectomy or any other medical or minimally invasive procedure are compared. The battle for supremacy of 20TUR-P has now been virtually won, yet there still are physicians and surgeons and members of lay public who are not convinced about the benefits of TUR-P. The following discussion is meant to clear that air of uncertainty:
- The chief criticism of TUR-P is the mistaken notion that it is an incomplete removal of prostate, that only a small amount of adenoma is removed to open the passage and thus the procedure will have to be done again. This is not true. If performed properly, the resection is as complete as with open prostatectomy. Limited resection is done in certain situations. If the patient has retention due to carcinoma of the prostate (Fig. 1.12), open prostatectomy has no role. However, a limited amount of tissue can be removed with TUR-P to make a channel. The other situation is when the patient has severe heart or lung disease as well as a large prostate gland causing obstruction.One knows that such a patient will not be able to withstand the trauma of an open operation. A limited amount of tissue may be removed by TUR-P to make a channel to enable the patient to pass urine and get rid of the indwelling catheter (Fig. 1.13). That, after all, is the aim of the operation.
- Similarly some surgeons believe that TUR-P is meant for only very old and feeble patients who cannot withstand open surgery. One must ask that if the operation is so much safer in these high-risk patients, why should its advantages be denied to a patient who is otherwise in good health.
- TUR-P is also criticized on the assumption that it often causes incontinence. However, statistics have shown that a well trained urologist can easily avoid this complication.
- The only drawback of TUR-P is from the surgeon's point of view. It requires long apprenticeship and is technically more difficult to perform than an open enucleation. From the patient's point of view, he has everything to gain by undergoing TUR-P vis-a-vis open prostatectomy provided it is done by someone trained adequately. It does not hurt the patient much in the postoperative period, the hospital stay is much shorter and so is the convalescence period. There is no absolute contraindication to TUR-P. Only if the 22gland is very big (and these cases are not more than 1–2% of all cases) or if the patient has a bad urethral stricture, one may opt for open surgery. (Some options for the surgical management of enlarged prostate, other than TUR-P are discussed in Chapter 16, ).Please also see for more on TUR-P.
Recurrence of symptoms following TUR-P
At times, you might have referred a patient to a urologist for TUR-P. Everything goes smoothly and the patient starts passing urine normally. However, after a few weeks, the patient comes back, complaining that his problem is back to where it was before surgery. One tends to feel that the urologist did not do a good job and must have left some gland inside. In fact, most of these patients have what is called submeatal stenosis, i.e. they develop a narrowing in the urethra just inside the external urethral meatus (Fig. 1.14). All that is needed is a gentle dilatation, may be more than once and the problem resolves. Some patients develop a soft stricture in the urethra. This can happen following any type of prostatectomy (Fig. 1.15). Again, it responds to dilatation a couple of times or to internal urethrotomy. Therefore, when a patient comes with recurrence of symptoms, the wise thing to do would be to advise him to see his surgeon.
BPH and Sexual Function
Patients are usually concerned about the effect any treatment—medical or surgical—will have on their sexual potency. BPH on its own has no effect on sexual function except the usual decrease in libido and erectile function that occurs with age. Out of the medical agents used in treatment, alpha blockers seem to somewhat improve the sexual function, probably by relaxing the smooth muscle of corpora cavernosa. However, the other group, i.e. 5 alpha reductase inhibitors - Finasteride and Dutasteride - both cause a decrease in libido, difficulty in achieving a good erection and trouble with ejaculation. All these issues should be discussed appropriately with the patient before starting medical treatment. TUR-P has no effect on sexual function except retrograde ejaculation.
Acute retention in Females
In females, acute retention of urine is not common. If and when it does occur, most of these patients report to a gynaecologist. Child-birth is a common cause of this condition. A common pitfall in these cases is that the diagnosis is missed because the pain is attributed to after-pains and the distended bladder is confused with the uterus which has not yet undergone complete involution.24
Another cause of acute retention in females is a retroverted gravid uterus. This happens around the fourteenth week of pregnancy when the uterus gets trapped under the sacral promontory.
Whatever the cause of retention in females, the diagnostic pitfall remains because usually these patients present with symptoms of abdominal pain (due to the distended bladder) and frequent dribbling of urine rather than complete retention and thus are likely to be treated as cases of UTI. The only clue to the correct diagnosis is keeping the possibility of this condition in mind in such situations. The management remains the same, i.e. catheterization and the steps of catheterization are also the same. There is usually no difficulty in catheterizing a female patient because the urethra is short and straight. One essential requisite is that the genital area should be properly exposed and there should be adequate light. Often one has seen nurses fiddling to find urethral opening because the patient does not spread her legs out of embarrassment and modesty and the nurse cannot locate the urethral orifice in the poor light. Many a time, they end up pushing the catheter in the vagina.
Acute retention in Children
Parents may bring children of all ages and even neonates with acute retention due to conditions such as a stone impacted in the urethra and posterior urethral valves. The difficulty in children is not the diagnosis because this will be volunteered by the parents by saying that the child has not passed urine for a day or so. The difficulty is in obtaining the patient's cooperation as the child is in pain and is frightened by the presence of strangers. One will need the help of an anesthetist to give a small dose of ketamine. A small, well lubricated feeding tube (no. 4 or 5) is usually adequate to catheterize a child. One has to be extremely gentle; any trauma caused to a struggling child's urethra may later from a stricture which will be a life-long tragedy. Therefore, children with difficulty in passing urine with doubtful retention of urine should be referred to a urologist as soon as possible.25
Cancer of the Prostate
Cancer of the prostate is also common in the same age group as benign hyperplasia. In fact, the main risk factor for developing carcinoma of prostate is age—the older a person is, higher is the risk of his having this cancer. However, it may not cause any symptoms and the patient may die a natural death or of some other disease such as myocardial infarction or cerebrovascular accident before he develops any symptoms of cancer. On the other hand, it might cause symptoms similar to benign hyperplasia such as difficulty in passing urine or even acute retention of urine. These symptoms are managed by doing a limited TUR-P so as to make a channel in the urethra which allows the patient to pass urine without straining.
The importance of carcinoma of prostate from the point of view of the general practitioner is that these patients are in the older age group and as a result of aging, may feel weak and lethargic. They go to their family physician and ask for a tonic. It is not uncommon to see such a patient being given anabolic hormones, either oral or as an injection. If this patient has carcinoma of the prostate, nothing could be worse for him because these hormones flare up the carcinoma. Therefore, while prescribing these hormones, you should do a rectal examination to see if there is any hard nodule in the prostate (you may have to seek the help of a urologist). Another thing that you can do is to get the patient's blood estimated for PSA (prostatic specific antigen) level. In fact, you should, as a matter of routine, get the PSA estimation of all your patients who are above the age of forty five, every year. This way, it would be possible to detect cancer of the prostate in its early stage and a radical, curative treatment can be carried out by the urologist. The normal blood value of PSA is 0–4 ng/ml. Some patients with a very big benign prostate have a slightly high PSA level. This is true of some other conditions also. However, a general practitioner will do well to treat 4 ng as the upper limit and if the PSA is higher than this, a urologist should be consulted. (see more on PSA in Chapter 15, ).26
Another important thing to remember is that if a patient undergoes prostatectomy for benign hyperplasia of the prostate, a small posterior part of the gland remains intact. This is true regardless of the fact whether the patient has undergone a TUR-P or open surgery. This posterior part is the common site for the development of cancer. Physicians and patients often assume that after undergoing surgery for benign hyperplasia, the prostate has been completely removed and there is no risk of any further problem as regards prostate. Evidently, this is not true. Some years after an open prostatectomy or TUR-P, a patient can develop cancer of the gland in the residual posterior part of the gland.