Surgery chapters
Lower urinary tract symptoms (terminology), BPH and prostate investigations
The standard terms for lower urinary tract symptoms (storage, voiding, post-micturition) and their causes, benign prostatic hyperplasia (zones, effects, assessment, drugs and surgery including TURP), the investigations used for benign prostatic disease, and how BPH differs from prostate cancer and prostatitis.
- LUTS are grouped into storage (frequency, nocturia, urgency, urge incontinence), voiding (hesitancy, poor stream, intermittency, straining) and post-micturition (incomplete emptying, dribble) symptoms; "prostatism" is an outdated term.
- BPH arises in the transition zone under DHT drive; assess with symptom score, DRE, urine dipstick, creatinine, flow rate and residual, and PSA after counselling.
- Treat with α-blockers (fast) and 5α-reductase inhibitors (large glands, slow), and TURP (gold standard) for retention, renal impairment, stones, bleeding or failed drugs.
On this page
Overview
Lower urinary tract symptoms (LUTS) are very common in older men. They are not always due to the prostate: an overactive bladder, a weak detrusor, nocturnal polyuria, a stricture or neurological disease can give the same picture.
The exam tests the correct terminology, the causes of LUTS, the work-up of benign prostatic disease and the treatment options for benign prostatic hyperplasia (BPH).
Terminology of lower urinary tract symptoms
The International Continence Society defines the standard terms.
Storage symptoms (bladder filling)
| Term | Definition |
|---|---|
| Frequency | Voiding more often than the person considers normal |
| Nocturia | Waking at night one or more times to pass urine |
| Urgency | A sudden compelling desire to void that is hard to defer |
| Urge incontinence | Leakage immediately preceded by urgency |
| Stress incontinence | Leakage with a rise in abdominal pressure (cough, sneeze, exercise), typically after vaginal delivery |
| Nocturnal enuresis | Involuntary loss of urine during sleep; in an older man, think of chronic retention |
Voiding symptoms (emptying)
| Term | Definition |
|---|---|
| Hesitancy | Delay in starting to void |
| Reduced (poor) stream | Weaker flow than before or than others |
| Intermittency | Flow that stops and starts during voiding |
| Straining | Using abdominal effort to start or keep the stream |
| Terminal dribble | Prolonged final part of voiding with a slow trickle |
Post-micturition symptoms
| Term | Definition |
|---|---|
| Incomplete emptying | A feeling that the bladder is still full after voiding |
| Post-micturition dribble | Leakage just after finishing; urine left in the bulbar urethra; common with age; not cured by TURP |
Other terms
- Strangury: a distressing, constant urge to void with little output; typical of lower UTI, bladder stones or tumours.
- Dysuria: pain or burning on voiding.
- Overactive bladder: urgency, usually with frequency and nocturia, with or without urge incontinence, without infection or other pathology.
- "Prostatism" is an outdated term; use LUTS.
Storage = "FUN" (Frequency, Urgency, Nocturia). Voiding = "SHIP" (Straining, Hesitancy, Intermittency, Poor stream).
Storage symptoms point to the bladder (overactivity, infection, CIS, stones). Voiding symptoms point to the outlet (BPH, stricture). A man with obstruction often has both, because the thick obstructed detrusor becomes overactive.
Causes of LUTS in men
| Group | Causes |
|---|---|
| Outlet obstruction | BPH, prostate cancer, bladder neck stenosis or dyssynergia, urethral stricture, meatal stenosis, phimosis |
| Bladder | Overactive bladder, underactive (weak) detrusor, CIS, stones, UTI, interstitial cystitis |
| Neurological | Diabetes, stroke, Parkinson disease, multiple sclerosis, spinal cord or cauda equina disease, dementia |
| Polyuria | Diabetes mellitus or insipidus, diuretics, nocturnal polyuria (heart failure, high evening fluids, caffeine, alcohol) |
| Drugs | Anticholinergics, antihistamines, opioids, decongestants |
| Prostate inflammation | Acute or chronic prostatitis |
Applied anatomy of the prostate
| Zone | Share of normal gland / notes | Disease |
|---|---|---|
| Peripheral zone | Largest part in young men; posterior and lateral; felt on DRE | Most cancers |
| Transition zone | Small, around the urethra above the verumontanum | BPH |
| Central zone | Around the ejaculatory ducts, at the base | Few cancers |
| Anterior fibromuscular stroma | No glands | — |
- BPH in the transition zone forms the lateral lobes; subcervical glands can form a median (middle) lobe that projects into the bladder like a ball valve. A small prostate on DRE can therefore still obstruct.
- Growing BPH compresses the peripheral zone into a false (surgical) capsule. This plane is used in enucleation, and the peripheral zone left behind can still develop cancer after TURP.
- The verumontanum marks the upper end of the external (striated) sphincter; it is the distal limit of resection in TURP.
- The bladder neck (internal) sphincter closes during ejaculation; removing it causes retrograde ejaculation.
Benign prostatic hyperplasia (BPH)
Definition and epidemiology
Non-malignant hyperplasia of the glandular and stromal tissue of the prostate (it is hyperplasia, not true hypertrophy). Seen from about 50 years; by 60, about half of men have histological BPH. It is the commonest cause of bladder outflow obstruction in older men.
Aetiology
- Dihydrotestosterone (DHT): testosterone is converted to DHT by 5α-reductase in the prostate; BPH does not develop in men castrated young.
- Ageing and a relative rise in oestrogen effect as testosterone falls; local growth factors.
- Smooth muscle tone, controlled by α1-adrenoceptors, adds a dynamic component to obstruction.
Effects
| Site | Changes |
|---|---|
| Prostatic urethra | Lengthened and distorted (not narrowed anatomically); exaggerated curve may need a curved catheter |
| Bladder | Detrusor hypertrophy, trabeculation, saccules and diverticula; later decompensation with residual urine |
| Upper tracts | In high-pressure chronic retention: bilateral hydroureteronephrosis and renal impairment |
| Complications | Acute retention, chronic retention, UTI, bladder stones, haematuria (fragile veins at the bladder base), overflow incontinence |
Symptoms, gland size and urodynamic obstruction correlate poorly: a big prostate may cause no symptoms, and a small one may obstruct.
Investigations for benign prostatic disease
Essential
| Test | Purpose |
|---|---|
| Symptom score (IPSS) with a bother / quality-of-life question | Severity and response to treatment |
| Frequency–volume chart | Nocturnal polyuria, small frequent voids, fluid habits |
| Abdominal examination | Palpable bladder (chronic retention) |
| Digital rectal examination | Size, shape, consistency; BPH: smooth, firm-rubbery, symmetrical, median sulcus preserved, rectal mucosa mobile; anal tone and perianal sensation |
| Urine dipstick (± culture) | Infection, blood, glucose |
| Serum creatinine / eGFR | Renal function (chronic retention) |
| Urinary flow rate | Qmax above 15 mL/s normal; 10–15 equivocal; below 10 suggests obstruction (voided volume should be at least 150–200 mL) |
| Post-void residual by ultrasound | Incomplete emptying; repeat if high |
Additional (selected patients)
- PSA, after counselling, when finding cancer would change management (e.g. men expected to live long enough to benefit, or with a family history or an abnormal DRE). Useful also to estimate prostate size.
- Pressure-flow urodynamics: suspected neurological disease, predominant storage symptoms, near-normal flow (around 15 mL/s), low voided volumes, before surgery in uncertain cases, or after failed surgery.
- Ultrasound of kidneys and bladder: haematuria, infection, raised creatinine, chronic retention.
- Transrectal (or abdominal) ultrasound: prostate volume before choosing drugs or surgery; TRUS biopsy if cancer is suspected.
- Cystourethroscopy: haematuria, suspected stricture or bladder tumour; immediately before prostatectomy.
An inability to reach the upper border of the prostate on DRE suggests a gland of at least 50 mL. A big residual urine pushes the prostate down and makes it feel bigger than it is.
Before starting an antimuscarinic for storage symptoms in a man, measure the post-void residual. A large residual means the drug may tip him into retention.
A small prostate on DRE does not exclude obstruction. A median lobe or bladder neck stenosis can obstruct without much lateral lobe enlargement.
BPH versus prostate cancer versus prostatitis
| Feature | BPH | Prostate cancer | Prostatitis (acute bacterial) |
|---|---|---|---|
| Zone | Transition | Peripheral | Whole gland |
| DRE | Smooth, rubbery, symmetrical, sulcus present | Hard, craggy, nodular, sulcus may be lost, may be fixed | Exquisitely tender, warm, boggy |
| PSA | Normal or mildly raised | Often raised | Markedly raised (temporarily) |
| Other | LUTS | Often silent; bone pain (osteoblastic metastases) | Fever, perineal pain, dysuria, retention |
| Next test | Flow rate, residual | Multiparametric MRI, biopsy | Culture; avoid vigorous DRE and biopsy; antibiotics for weeks (quinolone or trimethoprim) |
Management of BPH
Conservative (watchful waiting)
For mild symptoms with good flow (over 10 mL/s) and small residual (under 100 mL): reassurance, review, reduce evening fluids, caffeine and alcohol, double voiding, urethral milking for dribble, bladder training.
Drug treatment
| Class | Examples | Action | Points |
|---|---|---|---|
| α1-blockers | Tamsulosin, alfuzosin, doxazosin, terazosin, prazosin | Relax smooth muscle of the prostate and bladder neck (dynamic component) | Work within days; side effects: postural hypotension, dizziness, retrograde ejaculation, floppy iris syndrome in cataract surgery |
| 5α-reductase inhibitors | Finasteride (type 2), dutasteride (types 1 and 2) | Block conversion of testosterone to DHT; shrink gland | Slow (at least 6 months); best for large glands; prostate shrinks about 25% in a year; reduce retention and need for surgery; halve PSA; sexual side effects, gynaecomastia; reduce BPH bleeding |
| Combination | α-blocker + 5α-reductase inhibitor | — | Large glands with bothersome symptoms |
| Antimuscarinics | Oxybutynin, tolterodine, solifenacin | Reduce detrusor overactivity | Storage symptoms; check residual first (risk of retention) |
| β3-agonist | Mirabegron | Relaxes detrusor | Storage symptoms |
| PDE-5 inhibitor | Tadalafil | — | LUTS with erectile dysfunction |
Drugs improve flow by only about 2 mL/s and symptoms by about 20% more than placebo, whereas TURP roughly doubles flow (from about 9 to 18 mL/s) with about 75% symptom improvement.
Indications for surgery
- Acute retention after failed catheter removal (about a quarter of prostatectomies).
- Chronic retention with renal impairment or upper tract dilatation.
- Complications of obstruction: bladder stones, recurrent UTI, diverticulum.
- Recurrent haematuria from the prostate.
- Bothersome symptoms not helped by drugs (the commonest indication), especially with low flow (under 10 mL/s) and a significant residual.
Operations
| Procedure | Notes |
|---|---|
| TURP (transurethral resection of the prostate) | Gold standard; resectoscope with a diathermy loop removes "chips" from bladder neck to verumontanum; monopolar uses glycine irrigation (limit about 1 hour), bipolar uses saline; three-way catheter irrigation afterwards |
| TUIP (bladder neck incision) | Small prostates (no median lobe), bladder neck stenosis or dyssynergia; less retrograde ejaculation |
| HoLEP (holmium laser enucleation) | Enucleates the adenoma along the capsule plane; any gland size; good haemostasis |
| Laser vaporisation (e.g. green light/KTP) | Very haemostatic; possible on anticoagulants |
| Open prostatectomy | Retropubic (Millin) or transvesical (Freyer); very large glands, or with a big bladder stone or diverticulum |
| Prostatic stent or long-term catheter | Very unfit men |
Complications of TURP
| Complication | Details |
|---|---|
| Retrograde ejaculation | Commonest (well over half); bladder neck removed |
| Haemorrhage | Primary (at operation); secondary after discharge, often with infection; clot retention |
| TUR syndrome | Absorption of hypotonic glycine irrigant → dilutional hyponatraemia, fluid overload, confusion, visual disturbance, hypertension then hypotension, haemolysis; prevented by bipolar saline TURP and short resection time; treat with fluid restriction (± hypertonic saline if severe) |
| Infection and sepsis | Bacteraemia is common; antibiotic prophylaxis |
| Incontinence | Damage to the external sphincter (resection beyond the verumontanum) |
| Urethral stricture | At the meatus or bulbar urethra |
| Bladder neck contracture | After over-resection of a small gland |
| Erectile dysfunction | Uncommon (about 5%) |
| Perforation of capsule or bladder | Extravasation |
| Re-operation | About 15% within 8–10 years |
| Death | Under 0.5% |
Retrograde ejaculation after TURP is due to loss of the bladder neck mechanism. Incontinence is due to damage to the external sphincter below the verumontanum.
Expect: classification of LUTS into storage, voiding and post-micturition, definitions of nocturia, urgency, strangury and post-micturition dribble, transition zone BPH versus peripheral zone cancer, the median lobe, DHT and 5α-reductase, essential versus optional tests (flow rate cut-offs, residual, creatinine, PSA after counselling, urodynamics for neurological patients), DRE findings in BPH, cancer and prostatitis, α-blockers versus 5α-reductase inhibitors, floppy iris, indications for TURP, TUR syndrome, retrograde ejaculation and the verumontanum landmark.
Quick revision
- Storage: frequency, nocturia, urgency, urge incontinence. Voiding: hesitancy, poor stream, intermittency, straining. Post-micturition: incomplete emptying, dribble.
- Post-micturition dribble is not helped by TURP.
- BPH: transition zone, DHT, from about 50; half of men by 60.
- Essential tests: symptom score, DRE, dipstick, creatinine, flow rate, residual.
- Qmax: above 15 normal, below 10 obstructed.
- α-blocker = quick (α1); 5α-reductase inhibitor = slow, large glands, halves PSA.
- TURP gold standard; limit at verumontanum.
- TUR syndrome = glycine absorption → hyponatraemia; bipolar saline TURP prevents it.
Written by The House Job from standard references (Bailey & Love; Kumar and Clark's Clinical Medicine).
FAQ
What is the difference between storage and voiding symptoms?
Storage symptoms (frequency, nocturia, urgency, urge incontinence) arise while the bladder fills and suggest bladder overactivity. Voiding symptoms (hesitancy, poor stream, intermittency, straining) arise while emptying and suggest outlet obstruction.
Which tests are essential for a man with LUTS?
A symptom score, abdominal and rectal examination, urine dipstick, serum creatinine, a urinary flow rate and an ultrasound measure of residual urine. PSA is offered after discussion.
Why do α-blockers work faster than finasteride?
α-blockers relax prostatic smooth muscle within days. Finasteride works by shrinking the gland through blocking DHT, which takes six months or more.
What causes TUR syndrome?
Absorption of large volumes of hypotonic glycine irrigation fluid into open prostatic veins during monopolar TURP, causing dilutional hyponatraemia and fluid overload.