Mr P is a 68 year old farmer who has long-standing lower urinary tract symptoms (LUTs) which significantly deteriorated over the past year. Upon further questioning he suggested that the symptoms may have started up to 10 years ago. He had significantly reduced flow rate (weak stream) and urgency and at times minor leakage of urine. He also complained of nocturia (waking up to 5 times per night), hesitancy (difficulty starting urination), intermittency (stop-start urination) and incomplete emptying (needing to void frequently). He suffers from high blood pressure, high cholesterol, well controlled diabetes, mild obesity and is an ex-smoker. He previously had three coronary artery stents and has atrial fibrillation (heart arrhythmia) for which he takes blood thinning medications Xarelto and Aspirin.
Mr P had seen two previous GPs in the past but did not attend an arranged Urologist consultation. The first GP 7 years ago, had made the diagnosis of Benign Prostatic Hyperplasia (BPH) as a cause of his lower urinary tract symptoms (LUTs) and commenced him on Prazosin (alpha blocker) which made a minor improvement to his symptoms. The second GP had further assessed him with an ultrasound of his kidneys and bladder. This showed an enlarged prostate of 120cc and retained volume of 250ml. Subsequently he was referred to a Urologist and commenced on combination medical therapy with Duodart. Due to concerns of the possible side-effect profile he ceased this medication a few months later and did not attend the Urologist consultation. He ‘put up’ with the symptoms for another 18 months along with a few more embarrassing situations with urgency and small volume urinary incontinence. After reading a local paper article on prostate cancer awareness and speaking with a friend who had treatment, he requested a referral to Melbourne Urology Centre.
Prior to his appointment Mr P had consulted our website melbourneurologycentre.com.au and was familiar with BPH and its treatment options. He had read about Transurethral Resection of Prostate (TURP), Homium Laser Enucleation of Prostate (HoLEP), Greenlight laser, Urolift and Rezum treatment. His other concern however was also prostate cancer.
On examination Mr P was mildly overweight. He did not have a palpable/distended bladder. His genital and scrotal examination showed a normal urethral opening but mild foreskin closure (phimosis). His digital rectal examination confirmed a large benign smooth prostate with no concerning nodules
Mr P had normal blood tests for kidney function (UEC) and his PSA was 3 which is normal for his age. His previous readings had also been stable. He had a urine test (MSU) that did not show any blood or sign of infection. A renal tract ultrasound showed a 120cc prostate, normal kidneys and ureters. His initial bladder volume was 480ml and he retained 300ml after voiding.
His International Prostate Symptom Score (IPSS) was 28 indicating significant bother. Flow studies demonstrated a 140ml void which took 1min 20sec with a maximum flow rate of only 5mls/sec and retention of 280ml.
Following an in-depth discussion of management options Mr P decided on HoLEP surgery. Urolift and REZUM may not be as effective for a very large prostate and have higher failure rate. TURP may also not be as effective for a large prostate and would require his blood thinner Xarelto to be withheld for longer period of time. Greenlight laser may also not be as effective in achieving an adequate cavity. Using a high powered 120W laser machine the prostate could be very efficiently enucleated with minimal bleeding. At times the procedure can be done with minimal interruption to the blood thinning medications.
The procedure was performed under general anaesthetic and took around 90 minutes to complete. Following surgery there was a mild burning sensation and the need to void despite having a catheter in-situ due to bladder irritation. He had the catheter removed the following day and was discharged after three voids of 250-400ml and each time not leaving more than 50mls behind on bladder scan. Prior to discharge he was educated on what to expect and advised to minimise any strenuous activity or lifting (>3-5kg) for up to four weeks. Peri-operatively he was off his Xarelto blood thinning medication for only three days and continued Aspirin throughout.
Mr P contacted our practice nurse two weeks following discharge concerned about blood stained urine. He was reassured that this is not uncommon as long as there are no fevers, large clots or difficulty urinating. He was also once again reminded to avoid any strenuous activity.
At six week follow up he had recovered well and was very happy with his flow rate and improved bladder emptying. He was back to his usual work on the farm. He still had to wake 2-3 times per night and had rush to toiled when he felt the urge to urinate. He in fact had a few more accidents where he couldn’t make it to toilet on time. His international prostate symptom score (IPSS) was now 10 with some bother. On his flow he voided 350ml over 45 seconds with a maximum flow rate of 22mls/sec and only retained 8mls. He maintained his normal sexual function. He was reassured that the urinary frequency, urgency and nocturia will take up to nine months to settle down. The bladder muscle that had built up to push against the blockage now has to re-adjust to lack of resistance and obstruction. I commenced him on anti-cholinergic tablets (bladder relaxants), pelvic floor exercises and a bladder retraining program.
Mr P returned for his four month follow up still very pleased with the results. His International Prostate Symptom Score (IPSS) was now 4 with no bother. On his flow study he voided 420ml over 40 seconds with a maximum flow rate of 25mls/sec and only retained 10ml. His urinary frequency, urgency and nocturia had resolved by this point. therefore his anti-cholinergic medication was ceased and he was discharged back to his GP. He will have his annual PSA check with his GP and seek consult whenever necessary.
Take Home Messages:
- Most men delay treatment and may need encouragement from their partner
- Medical therapy and minimally invasive treatment options for BPH may not be appropriate for all patients
- In the hands of an appropriately trained Urologist, high powered laser may be the most appropriated treatment for some patients
- The recovery process from HoLEP is usually very smooth particularly if post operative instructions are adhered to closely
- It is not uncommon to get transient deterioration of some urinary symptoms initially following any treatment for BPH including after HoLEP