Benign Prostatic Hyperplasia ( BPH)

Prostate Enlargement

BPH – NON CANCEROUS ENLARGEMENT OF THE PROSTATE

Non cancerous enlargement of the prostate is one of the commonest male urology problems after the age of 50 years. The prostate is a pear shaped gland lying below the bladder through which passess the water passage – urethra. When the prostate enlarges it constricts the urethra and cause difficutly In passing urine.

Common Symptoms

Difficulty to initiate urination in spite of having the urge to do so.
Passing urine in a poor stream
Breaking of the urinary stream
Feeling if incomplete emptying of the bladder
Having to pass urine more than twice at night

Diagnosis

Besides clinical history and physical examination which will include a per rectal examination, the Urologist may require specific tests such as blood examination , Ultrasound scan and a measurement of the rate of flow of urine – uroflowmetry ( a simple test where you pass urine on to a machine).

Treatments

The majority of patients can be treated with medications with regular follow up as these medications are required long term.
If the obstruction is severe, or if complications such as complete blockage of urine requiring catheterization or recurrent infections, or the fucntion of the urinary system has been affected the doctor is likey to advice surgery.
The majority of glands can be operated endoscopically under anaesthesia, by passing a telescope through the water passage . Sometimes the gland is so large that multiple endoscopic procedures will be required to remove adequate quantitiy of enlargement. In this case the doctor may advice a single stage open procedure.

Endoscopic surgery of the prostate is called TURP – Trans Urethral Ressection of the Prostate.
TURP

 The prostate is a gland present in males. It is situated, just outside the bladder. The urethra, the tube connecting the bladder to the outside, through the penis, passes through this gland. When the gland enlarges abnormally, this tube gets squeezed producing obstruction to the urethra. When the obstruction is not severe, the condition can be treated by medications. In more severe obstructions, TURP surgery has to be performed. TURP produces much more relief than medications. However, there is a small percentage of complications such as bleeding, infection, retrograde ejaculation and impotence.
 In this operation, a telescope is passed through the urethra to visualize the prostate. The enlarged obstructing prostate is then carved from within, to enlarge the urethra to its original calibre.
 The procedure is done using a special telescope linked to a video system. This enables x10 to x15 magnification enabling superior surgical techniques.
Appearance of the obstructed water passage due to the enlarged prostate. A diverticulum in the bladder. This is a pocket in the bladder formed due to high pressures in the bladder resulting from obstruction to the flow of urine.
 
The final view of the prostate after TURP
    
ROUTINE FOR OPERATION
 MEDICAL FITNESS
Before final decision for surgery is made, medical risk factors and fitness is assessed. This will involve-
1.     Blood tests, Blood group, ECG, Chest X-ray.
2.     Medical checkup.
 
 ADMISSION
1.     Come for admission at the time of appointment, the day before surgery, if medically fit. Other wise, the doctor will advise admission earlier.
2.     You will sometimes be advised to book for 2 units of blood the day before surgery at IMA blood bank.
3.     Preparation for surgery is under taken the day before surgery, and will consist of  – Shaving of private parts,Fasting from 6 hours before surgery and an enema/laxatives the night before or early morning on the day of surgery.
4.     The anesthetist will do a routine pre operative check up and arrange for medications, to allow you to sleep well before surgery.
 
DAY OF SURGERY
1.     Time of surgery will be intimated the day before surgery.
2.     The surgery time may be delayed by about an hour, depending on when the previous surgery in the theatre finishes.
3.     The surgery is preferably done under Spinal Anesthesia. An injection is administered to the spine causing the lower half of your body to loose both sensation and muscle power. This is temporary and will last about 3 hours.
4.     The surgery is done using the TV monitor. There fore you have the option of being able to watch the surgery on the TV screen while the surgery is going on. You should inform the surgeon and anesthetist  your wish, so that the anesthetist will avoid any sedation during surgery.
5.     After surgery you will have a catheter (tube, through the penis, into the bladder). This tube will be removed usually within 2 days.
6.     You will not return to your room on the day of surgery. You will be looked after in our postoperative intensive care room. As soon as you recover, your relatives will be informed and one person will be allowed to meet you briefly inside the postoperative room. As the intensive care room is maintained sterile, request for more relatives to meet you should not be made.
 
1ST POST OPERATIVE DAY
1.     You will be allowed to go back to your room.
2.     You will have a catheter, which will be connected to a bag.
3.     Strict bed rest is NOT REQUIRED. You can move about with the bag.
4.     YOU SHOULD NOT STRAIN- especially when trying to pass motion. Straining will cause bleeding from the operation site. The blood will clot and block the catheter. You will then have to be taken back to theatre to wash the bladder. THERE FORE DO NOT STRAIN- FOR 6 WEEKS FROM THE DAY OF SURGERY.
5.     You should DRINK ABOUT ONE GLASS OF WATER EVERY HOUR when you are not sleeping. This prevents the blood that comes from the operation site to be washed down by the urine before it clots.
 
2ND POST OPERATIVE DAY
1.     Normally the catheter will be removed today.
2.     The urine will continue to be light red colour for another couple of days.
3.     DO NOT STRAIN.
4.     DRINK A GLASS OF WATER EVERY HOUR WHEN AWAKE.
5.     Maintain strict intake output chart with each voided volume as instructed by the ward sister. In the initial 2 or 3 days after catheter removal, due to the operation wound inside, you may have urgency to pass urine. This  may be so severe, that you may not have time to get to the toilet. You should therefore have a urinal by your bedside.
6.     For the same reason, you may wet the bed at night.
All these problems will settle down rapidly, even though occasional episodes can occur up to 6 weeks, the time taken for the wound inside to heal.
 
4th POST OPERATIVE DAY
1.     Normally you will be allowed to go home today. Urinary infection is the commonest reason for any delay in sending you home.
 
 AT HOME
1.     As the surgical wound inside takes 6 weeks to heal, you are advised to
a. Not be constipated for 6 weeks
b. DO NOT STRAIN
c. Drink 10 glasses of water every day.
2.     You may notice some blood in your urine, during the 6 weeks it takes for the prostate to heal. Do not worry. On such days, drink 1 glass of water every hour. Once the blood clears, drink 10 glasses of water every day.
3.     It is better that you confine yourself to within the 4 walls of your compound during the 6 weeks, after surgery, to avoid inadvertent strain.
4.     You should not sit continuously for more that 30 minutes. This will avoid congestion and bleeding from the operation wound.
5.     You should come for review in about 10 days. At this time the pathology report would be ready.
 
LONG TERM SIDE EFFECTS OF PROSTATE SURGERY.
1. There is a small incidence of impotence.
2. Decrease or absence of semen on ejaculation due to the semen flowing into the bladder at the time of ejaculation. It is later passed out in the urine. (Retrograde ejaculation)