A 65 year old diabetic male.
Presented with first time Acute urine retention.
A urethral catheter was fixed for 2 weeks and tamsulosin starte
DRE revealed large prostate of benign feeling
LAS is 3.6 ng/ml
Ultrasound showed large prostate 200 gm
After removal of the cather he can void
Urodynamic showed hypocontractile bladder but he can void using abdominal pressure
PVR is 85 cc
I think that a transurethral resection of prostate is a safe procedure that will decrease the risk of new urinary obstructions.
Hello,
I think that a good initial step for this patient would be to scope him in order to know if the gland is obstructing the urinary flow, if it is, TURP remains the gold standard and urinary retention it’s an indication, none the less, you might try to treat him first with alpha blockers and 5 alpha reductase inhibitors. Regarding bladder hypocontractility, Crede’s maneuver might increase the risk of ureteral reflux and thus infections, so follow up with PVR or clean intermittent catheterization could be good. Perhaps I will try to individualize based on patient’s expectations.
Best regards
I agree with Dr Basulto-Martinez. I would add Finasteride or Dutasteride to the Tamsulosin and reassess him in a few months. If failed medical therapy then I would suggest to consider HoLEP rather than TURP.
It is well known though studies that after acute urinary retention, almost 50-70% of the patients will develop a new episode of retention in the following weeks or months. Furthermore a low voiding detrusor pressure predict subsequent retention. The patient is also still relative young. If he has diabetes for less than 3-5 years and is unter control, it is unlikely to be responsible for the bladder unteractivity. I would recommend to the patient an operation for the prostate. TUR-P for this size of prostate would have a 40% probability of failure to void after catheter removal. I would suggest HoLEP/ThuLEP or classic open (simple) prostatectomy (Freyer or Millin).
Personally I think TUPR is not an optiob because thid patient according to UD is not obstructed. Consecuently I recomend Clean Intermitent Catheterism depending on postmicturition residual urine
A single measurement of PVR is not reliable as it showed wide variability in repeated measurements, therefore, it should be repeated. UDs may play a very limited role in detecting BOO in BPH patients with detrusor underactivity (DA), and surgical intervention should not be arbitrarily excluded simply based on UDs findings, despite DA is a poor prognostic sign in men who do not void spontaneously pre-operatively. Considering that the patient is diabetic and able to void after catheter removal, I guess no surgical treatment is currently recommended and CIC may be a good alternative option, if needed. Renal function and status of the upper urinary tract may affect the subsequent decision.
Best Regards
I believe monitoring is enough at this stage. I would add Dutasteride to Tamsulosin.
I think it’s better to think about surgical intervention in this case because of hypotonic bladder due to D M &retention chance of re retention is high. T u R is gold estandard but with 200 gram open surgery is better .
With a diabetic patient procrastination will only lead to urinary infections. Eventually to a septic shock. There is a very high chance of renewed episodes of obstruction. Surgery is the best option wether classical prostatectomy or TURP.
I recomend previously ,in this pt surgical intervension T U R P or because of size 200 mg open prostatectomy is better because chance of repeated retention is high .
Monitoring for now, if he has high IPSS, high QOL with bothersome LUTS that are mainly obstructive, HoLEP is the best option
IPSS score + monitoring. alpha-blockers +/- Finasteride but one must take into account the patient's BMI. Very possibly in BMI>29 patient will not respond to the Finasteride treatment (appr. 30%) Ref: Article Age and Obesity Promote Methylation and Suppression of 5-Alp...
Consider TURP x2 stages or HoLEP as alternative
It is interesting to read the variety of suggested approaches, testifying to the difficulty in treating such patients! I would consider decreasing outlet resistance by offering surgery with such a large prostate and if he is otherwise fit. It might help him empty the bladder better. Such patients are prone to develop retention again if simply monitored or treated by drugs. Furthermore, self catherisation is not going to be easy or pleasant when a patient has such a large prostate.
What about the first feeling of urin in the bladder, and the first urg if any?
as the patient voids normally, my suggestion is to add dutasteride or fenasteride, and close observation for the building up or PVR. for early intervention.
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