Q. Is surgery necessary for a mild benign prostatic hyperplasia?

Answered by
Dr. Shahil Khant
and medically reviewed by iCliniq medical review team.
Published on Aug 28, 2017 and last reviewed on: Oct 09, 2018

Hello doctor,

I am a 58 year old male. Except for low blood pressure, I am in generally perfect health with mild benign prostatic hyperplasia (BPH) that has not been getting noticeably worse lately but, has been present for years. While my stream is certainly not like when I was younger, I have no difficulty in voiding other than it takes more time and I do not have to urinate frequently (considering the amount of liquid intake). The stream is enhanced to relatively normal with low-dose saw palmetto and 5 mg Tadalafil. I do drink plenty of water.

On following a dietary shift away from red and white meat (still consuming fish and eggs) with plenty of fruits and vegetables, I began producing sand in my urine which prompted me to see a urologist. The urologist insists this condition is caused by excessive urinary retention due to BPH. On my volition, I had the sand analyzed to determine it was 100 % carbonate apatite, which I know from basic chemistry, precipitates in alkaline pH. With a pH meter, I learned my urine was often 8+ which I have corrected with dietary changes (based on PRAL score) and L-methionine if needed and monitor throughout the day to keep it mildly acidic. This has alleviated the stone formation.

A digital exam at the routine physicals with multiple doctors has elicited no concerns, stating either no or mild enlargement felt. However, CT scan reportedly reveals lateral enlargement. Multiple ultrasounds show that my bladder retention currently is not excessive (9 to 30 cc) but, a recent UroCuff test indicates a bladder pressure of 260" H20 (with the meds mentioned above) with no accompanying abdominal muscle activity (no pushing). My flow is quite good with what I am presently taking, something I would characterize as pretty normal for a healthy adult male. It is just that apparently to achieve that flow my bladder is quite muscular. I do not feel like I am straining at all when voiding, just relaxed.

The urologist insists that a prostate surgery (microwave) is needed to correct the BPH and alleviate the higher than normal bladder pressure and he thinks I will still have future stone formation if it is not corrected. He says that an elevated bladder pressure is damaging on the bladder. He states he is supported by cystoscopy that reveals pronounced striations on the interior wall, which for all I know are rugae. He characterized it as visually the bladder of an 80 year old.

I do not wish to subject myself to unnecessary surgery with all its associated risks and side effects. What is the risk, (if any) associated with elevated bladder pressure? Is surgery really warranted considering the present lack of significant impact on my lifestyle? My main concern is, in the case of no perceived functional problems, is the elevated bladder pressure actually harmful to the bladder or kidneys? Or is it just like any other muscle that simply develops in response to use and is harmless compensation.

Dr. Shahil Khant

Andrology General Surgery Urology
#

Hello,

Welcome to icliniq.com.

I have gone through your history.

  • If possible, send me a graph of your bladder pressure study and flow. If the bladder pressure is high, then it is better to get operated for the prostate enlargement.
  • A high power or pressure in the detrusor suggests a bladder outflow obstruction and in your case a prostate obstruction. A chronic high bladder detrusor pressure will damage it by causing fibrosis which has already started in your case in the form of trabeculations.
  • Unlike other muscles in the body which get stronger with constant stretching, the bladder muscles would get fibrosed and eventually will become hypo or acontractile, which is not reversible.
  • So, it is really important that you need to go ahead with the prostate surgery.

For more information consult a urologist online --> https://icliniq.com./ask-a-doctor-online/urologist

Hello doctor,

Thanks for the reply. That is very interesting regarding the risk of fibrosis. I have not yet noticed any symptoms of hypo or acontractile. Is this promoted by inflammation? Are there other ways to counteract the inflammation? I have attached the requested penile cuff test results, showing high pressure, and high (normal) flow. Is Tamsulosin a viable and effective alternative to surgery for this particular situation?

Dr. Shahil Khant

Andrology General Surgery Urology
#

Hello,

Welcome back to icliniq.com.I have seen the penile cuff test graphs sent by you (attachment removed to protect patient identity).

  • Let me tell you that the graph is not normal. The bladder pressures are also high. Cystoscopy shows trabeculations which means your bladder is asking for help. But, your flow is good at present.
  • As your age is 58 years, your bladder may get damaged later in your life. Nobody can predict when. But, once it is damaged, it is impossible for it to recover and you may require a permanent catheter.
  • There are many theories to explain bladder damage like a neurogenic inflammation, stress on the muscle, C fiber activation, etc.
  • You can take Tamsulosin for one or two years. It cannot be said right now if you will completely benefit from it.
  • It is not an emergency where you need to undergo a surgery right away. Take your time and make the decision.
  • For now, you could take Tamsulosin and keep a strict vigilance on your bladder by regularly doing post void residual urine test, urine flow test and if required a cuff test. If any of above deteriorates, then go ahead with the surgery.

For further queries consult a urologist online --> https://icliniq.com./ask-a-doctor-online/urologist

Hello doctor,

Thanks for the information and advice. I have obtained a copy of the urodynamics study performed early this year (attached). At this point in time, I had started the 5 mg Tadalafil but not yet the Saw Palmetto and the max flow was only 9 ml/s. Whereas, at present, it is 12 ml/s. Interestingly, although present bladder pressure is 126" H2O per Urocuff, the January urodynamics measurement of peak pressure was 86" H2O. This would imply that flow has improved significantly but pressure has gone up a lot at the same time. However, I am told that the two different measuring techniques are not directly comparable for pressure with roughly a 30" difference even though theoretically they should be about the same. So, I am inclined to take your second suggestion and monitor it for a while and see how it trends over time. I am just a little skeptical of the accuracy and consistency of the UroCuff test. So, I have some reservations regarding an accurate trending. The urodynamics test, while I do not mind at all doing, it is considerably more expensive.

Dr. Shahil Khant

Andrology General Surgery Urology
#

Hello,

Welcome to icliniq.com.

  • You can go for the second option but, keep in mind all the possibilities that I explained and keep a careful vigilance on your bladder. If at any point in time you feel that your flow is decreasing, then it is an alarming sign.
  • Urodynamics is a better investigation than the cuff test.
  • As per your earlier reports (attachment removed to protect patient identity), your average flow is around 3. Moreover, BOOI (bladder outlet obstruction index) is 60, which is way above the cut off of 40. But, as you are emptying the bladder completely you can wait with your fingers crossed and hope your bladder does not get damaged further.
  • Tamsulosin would help in relaxing the bladder outlet. Saw palmetto extracts are not very helpful.
  • You can also take Dutasteride. It reduces the size of the prostate gland. Take it only if you are not sexually active as it causes side effects of low libido and erection problems in some patients.

For more information consult a urologist online --> https://icliniq.com./ask-a-doctor-online/urologist

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