BPH Treatment, Repeat TURP and Incontinence After Surgery

BPH treatment is matched to the severity of the problem the enlarged prostate is causing: lifestyle measures for mild symptoms, a single alpha blocker for bothersome symptoms, and surgery once it is damaging the kidneys or causing other complications. Surgery versus a long-term catheter depends on fitness, not age, and transurethral resection of the prostate (TURP) can be repeated when the gland regrows, at a rising risk of complications.

Benign prostatic hyperplasia (BPH) is the non-cancerous enlargement of the prostate that becomes common as men age, obstructing the flow of urine from the bladder. It shares its symptoms with prostate cancer, infection and stones, which is why the diagnostic work-up described in the complete guide to prostate cancer early detection comes first. Once cancer has been considered and BPH is the working diagnosis, management becomes a series of practical decisions. Dr. Nitin Shrivastava, a urologist and uro-oncologist, addressed those decisions in detail in response to doctors' questions: how to treat BPH, when surgery is preferable to a catheter, how many times TURP can be repeated, and how continence and quality of life are restored after surgery for prostate and bladder cancer.

BPH treatment options: the best method of managing BPH

There is no single best method of managing BPH; treatment is chosen according to what the enlargement is doing to the patient. Dr. Shrivastava sets out a clear order of priorities.

1. Protect the kidneys first. The first task is to make sure the BPH is not damaging the kidneys. Obstruction at the bladder outlet can transmit back pressure to the kidneys, and once that is happening the decision changes.
2. Mild symptoms: lifestyle management only. No medicine is needed.
3. Bothersome symptoms: one alpha blocker. A single medicine of this class, which relaxes the smooth muscle of the prostate and bladder neck to ease the flow of urine, is his choice for symptoms that trouble the patient.
4. Kidney damage or other complications: surgery. If the BPH is causing damage to the kidneys, or complications such as recurrent urinary retention, recurrent infection or bladder stones, or if symptoms do not respond to medicines, the patient needs an operation.

The structure is deliberately simple. It keeps most men on the least invasive treatment that controls their symptoms, and reserves surgery for those in whom the gland is causing harm.

BPH surgery or a catheter: fitness matters more than age

When a man with BPH reaches the point of needing either a long-term catheter or surgery, the deciding factor is his fitness for the procedure, not his age. Doctors asked Dr. Shrivastava what age range makes surgery preferable to urinary diversion (rerouting urine out of the body by another path) or catheterisation. His answer rejected the premise: age does not decide it.

He illustrated the point at both extremes. His team has operated on a man who was 100 years old. Conversely, some patients who are only 60 have so many other illnesses that they are at very high risk for any procedure, and those men may need to remain on a catheter.

A decision shared with the patient

Dr. Shrivastava does not regard catheterisation as an easy default. Living with a catheter is, in his words, a difficult decision and very uncomfortable for anyone. Where a patient has a very large prostate that would need a long operation, and many other diseases that make him high risk, the choice becomes the patient's: remain on a catheter, or go ahead with surgery understanding that it carries high risk.

How many times can TURP be repeated?

There is no fixed limit on the number of times TURP can be performed on the same patient, but every repeat procedure carries a higher chance of complications. TURP removes the obstructing prostate tissue from inside, using an instrument passed along the urethra, so that no external incision is needed. Details of the procedure and its cost are on the TURP treatment cost page.

Dr. Shrivastava gave a specific figure for how often a second operation is needed: about 10 patients in every 100 will require another TURP within 10 years. Several situations lead to a repeat procedure:

• Regrowth. Sometimes the prostate grows back quickly, and the surgeon has to go in again.
• Staged resection. In some patients the operation is deliberately done in stages, with half of the prostate resected in one operation and the other half in a second.

The trade-off is cumulative risk. The more times TURP is done, the more the chance of complications rises. In his own practice, the most times he has performed TURP on one patient is twice.

Incontinence after prostate cancer surgery

Urine leakage, or urinary incontinence, is a recognised consequence of surgery to remove the prostate for cancer, and the first and best remedy is pelvic floor rehabilitation. Dr. Shrivastava describes Kegel exercises, which train the pelvic floor muscles that help control the flow of urine, as the most practical and the best treatment for post-operative leakage.

If the exercises do not restore continence, the next option is surgery to implant an artificial urinary sphincter, a device with an inflatable cuff placed around the urethra that the patient opens with a small pump when he wants to pass urine. Dr. Shrivastava regards this as the last resort. Information on the cost of prostate removal itself is on the robotic radical prostatectomy cost page. The operation is described in the guides to robotic radical prostatectomy and recovery by Dr. Shafiq Ahmad and to robotic, laparoscopic and open prostatectomy by Dr. Amit Goel.

Where physical medicine and rehabilitation fits

A doctor from the Democratic Republic of the Congo, where physical medicine and rehabilitation exists as a separate specialty, asked whether it has a role in treating prostate cancer. Dr. Shrivastava's answer drew a precise line. Rehabilitation does not treat the cancer itself. It is nonetheless an integral part of the whole treatment process, because after prostate surgery patients need to do Kegel exercises to regain continence.

Neobladder and ileal conduit: bladder cancer, not prostate cancer

A neobladder and an ileal conduit are ways of reconstructing urine drainage after removal of the bladder; they are treatments for bladder cancer, not for prostate cancer. Dr. Shrivastava made this distinction when a question about these procedures and quality of life was put to him.

The two options differ in how urine leaves the body:

A neobladder is the more complex procedure. Dr. Shrivastava offers it to a patient who has limited disease and is fit enough to undergo the more demanding operation; choosing which patients are fit for it is part of the surgical decision.

Quality of life after a urinary diversion

Dr. Shrivastava's view of quality of life after bladder cancer surgery is direct. What matters most is that the cancer comes out of the body completely; once it has, it becomes history. Whether a patient passes urine through the normal passage or into a bag, he has seen everyone adjust to it well, and in the long term, in his experience, the route does not matter much.

Diet and the wider team in BPH care

Nutrition is part of BPH management as well as cancer prevention. Dr. Shrivastava's advice to control weight, cut quick sugars, take adequate vitamins preferably from food and plan a balanced diet with a dietician applies to men with BPH as much as to men with prostate cancer; the evidence behind it is set out in the complete guide. He would place a dietician and a physiotherapist in every urology team.

For the decisions that come before treatment, including when to biopsy a man with a raised PSA, see the article on prostate biopsy decisions. Doctors' questions on BPH, TURP and post-operative leakage are recorded in the Live Discussion from this masterclass, and further urology content is on the urology hub.