Benign prostatic hyperplasia. Part 4
Complications
Almost 30% of men who go on to have prostatectomy, present with acute urinary retention. Birkoff felt this presentation to be independent of the degree of prostatism (n = 26). In an East Anglian practice in 1969, Craigen found symptom duration of <3 months in acute retention (n = 89). A follow-up of those who had not presented in this way (n = 129) found <10% developing acute retention over the next seven years. These findings were replicated by Powell who found little evidence of symptoms warning of retention.
Bladder outflow obstruction (BOO) can lead to recurrent urinary tract infection (UTI) and pyelonephritis or chronic urinary retention, dilatation and hydronephrosis. Reporting on acute renal failure, Feast noted an incidence of 172 million in adults, with 25% (n = 31/125) due to prostatic disease. For this prostate group the survival rate was 84% at three months. Chronic renal failure, where prostatic causation accounts for a lesser proportion (12%), may be entirely preventable through early detection by general practitioners. Elevated urea/creatinine is associated with precipitant admission and is more likely in the United Kingdom (UK) to result in transurethal resection of prostate (TURP) being undertaken by surgeons in training grades. Such elevations are associated with more post-operative complications and mortality.”
Bladder stones were reported as a reason for prostatectomy in 1-2% of cases. Grosse, in a large necropsy study (n = 19 863), found the prevalence of stones in men over the age of 60 at a rate eight times higher in those with BPE (3.4%) than either non-BPE men (0.4%) or women (0.3%).
Current pathways to diagnosis/tests
Shared care of benign prostatic hyperplasia is still in its infancy, although clinicians generally favour this approach. By 1995 in the UK, 62% of urology centres operated a prostate-specific clinic, allowing efficient ‘fast tracking’ of severe cases. An increasing number of these clinics are being run by nurse practitioners, however, management decisions are still determined by consultants, with true sharing with primary care still to be developed. Almost three quarters of the remaining 38% of urology centres, with traditional urological outpatient services, wished to change to a prostate-specific clinic.
The UK British Prostate Group, the WHO-sponsored International Consensus Committee (ICC), and the American Guidelines Group concur that mandatory investigations should include:
• full medical history,
• urinary symptom review,
• digital rectal examination (DRE),
• urine analysis, and
• serum creatinine.
In the UK these can readily be carried out in primary care. There is less agreement about other tests, such as:
• Prostatic Specific Antigen (PSA): if suspicion of cancer or positive family history of prostatic cancer in men aged <75 is noted,
• uroflometry: currently assessed in only 40% of UK prostatectomy patients,
• residual urine (RU): despite wide variation in individual patients, RU is used as an indication for surgery, though it may reflect bladder dysfunction rather than obstruction, and
• pressure flow studies: arguably helpful in predicting poorer outcomes from operation, by establishing detrusor hypotonicity.