CASE REPORT

BENIGN PROSTATE HYPERPLASIA

Author:
Mahek Monawar Patel
1102015125

Consulent:
dr.Herry Setya Yudha Utama, SpB, MHKes, FInaCS

CLINICAL CLERKSHIP OF SURGERY ROTATION

FACULTY OF MEDICINE YARSI UNIVERSITY
ARJAWINANGUN HOSPITAL
FEBRURARY 2020
 CHAPTER 1

CASE PRESENTATION

I. IDENTITY

Date of hospital entry : 27 January 2020

Name : Mr. Rastaka

Age : 51 years old

Gender : Male

Occupation : Entrepreneur

Address : Kaliwedi kidul, kabupaten Cirebon

Religion : Islam

Marital Status : Married

II. ANAMNESIS

Main complaint

Pain while urinating since 3 months before coming to the hospital

Additional complaints

Urination often feels incomplete, needs more effort while urinating (straining), and
frequencies of urinating becomes more often.

History of disease

Patient came to the urology polyclinic of Arjawinangun Hospital with the main complaint of
feeling pain while urinating since 3 months before coming to the hospital. The patient also
complained that he had to strain so that the urine came out, besides that, patient felt urination
was incomplete or unsatisfied. The patient states that the symptoms are felt to be increasing,
the patient feels that urinating becomes more frequent and urine comes out dripping and feels
painful. The patient also complained that he always wakes up at night because he wanted to
urinate. In the pubic area appear lumps which is not painful when pressed. These symptoms
are not accompanied by fever. Complaints of having blood or grains of sand in the urine is
denied by the patient.
Past medical history

History of the similar disease before : denied

History of hypertension : denied

History of diabetes mellitus : denied

History of Asthma : denied

History of Urinary tract infection : denied

History of Allergy : denied

Family history

History of the family with similar disease before : denied

History of the family with hypertension : denied

History of the family with diabetes mellitus : denied

History of the family with Asthma : denied

History of the family with Urinary tract infection : denied

History of the family with Allergy : denied

III. PHYSICAL EXAMINATION

a. Vital Status

Awareness : compos mentis

Blood pressure : 135/78 mmHg

Pulse rate : 91 x/minute

Respiratory rate : 18 x/minute

Temperature : 37, 1 oC

b. General Status

Head : Normocephal, symmetrical.

Eye : pupil isokor, light reflex (+/+), sclera icteric (-/-), conjunctival anemic (-/-)
Ear : normotia, secrete (-), tragus tenderness (-), tympani membrane intact (+).

Nose : normotia, septum deviation (-), secrete (-).

Mouth : dental caries (+), cyanosis (-), dry lips (-)

Neck : enlargement of thyroid gland (-), enlargement of lymph nodes (-), tracheal
deviation (-)
Thorax
Lung
Inspection : the chest symmetrical, the size ratio of anterior and transversal is 1:2
Palpation : fremitus tactil and fremitus vocal is symmetrical in both lungs, chest
tenderness (-), crepitation (-), palpable mass (-), rebound tenderness (-).
Percussion : resonance sonor sound in both lung fields
Auscultation : vesicular sound in all the lung fields, no additional sound like ronkhi or
wheezing.

Heart
Inspection : ictus cordis is no visible
Palpation : ictus cordis is palpable in linea midclavicular sinistra ICS 5
Percussion : within normal limits
Auscultation : heart sound 1 and 2 regular, no additional sound like murmur or gallob

Abdomen
Inspection : lump on the suprapubic region is visible, no hematom, or striae is visible.
Auscultation : bowel sound (+) frequency 15 x/minute
Palpation : palpable lump on the suprapubic region, tenderness (-), rebound ternderness
(-), palpable mass on other region (-), hepatosplenomegaly (-)
Percussion : tympani on each quadrant of the abdomen.

Extremities : Warm acral (+/+), edema (-/-), capillary refill time < 2 seconds

c. Local Status
Regio suprapubic
lump on the suprapubic region is visible, palpable lump on the suprapubic region, tenderness
(-), rebound ternderness (-).
IV. Extended Examination
a. Laboratory findings
Haematology
Test name Result Unit Reference value
Haemoglobin 14.3 g/dL 13.2 – 17.3
Leucocyte 21.2 103/uL 3.8 – 10.6
Thrombocyte 283 103/uL 150 - 440
Haematocrit 42.2 % 40 - 52
Erythrocyte 5.08 106/uL 4.4 – 5.9

Coagulation
Test name Result Unit Reference value
PT 13.4 seconds 11 - 15
INR 1.270 seconds
APTT 33.8 seconds 25 - 35

Clinical chemistry
Test name Result Unit Reference value
Current glucose 104 mg/dL 75 - 140
level
ureum 26.5 mg/dL 10 - 50
Creatinine 0.94 mg/dL 0.62 – 1.10

Immunology
Test name Result Unit Reference value
Anti HIV 0.2 Non reactive : < 1.0
Reactive : > = 1.0
HbsAG 0.1 Non reactive : < 0.9
Reactive : > = 1.0

b. ultrasonography findings
Impression:
Prostate hypertrophy (estimated volume is about 60 ml)
No visible abnormalities in the hepar, pancrease, lien, renal bilateral, and vesica urinaria.
No visible ascites.

V. Diagnosis
Benign Prostate Hyperplasia
VI. Differential Diagnosis
- Urethra Stricture
- Carcinoma Prostate
- Prostatitis

VII. Treatment
Operative:
Trans Urethral Resection of Prostate (TURP)

Non-operative:
- Cefixime 2 x 1
- Ketorolac 2 x 1
- Lansoprazole 3 x 1

VIII. Prognosis
Quo ad vitam: ad bonam
Quo ad functionam: ad bonam
Quo ad sanactionam: ad bonam

CHAPTER 2
LITERATURE REVIEW
ANATOMY OF PROSTATE

The prostate gland is located in the subperitoneal compartment between the pelvic diaphragm
and the peritoneal cavity. It is located posterior to the symphysis pubis, anterior to the rectum,
and inferior to the urinary bladder, thus allowing digital palpation for examination.
Classically described as “walnut-shaped,” it is conical in shape and surrounds the proximal
urethra as it exits from the bladder.

The prostate gland is composed of a base, an apex, anterior, posterior, and inferior- lateral
surfaces. The base is attached to the neck of the bladder and the prostatic urethra enters the
middle of it near the anterior surface, which is narrow and convex. The apex rests on the
superior surface of the urogenital diaphragm and contacts the medial surface of the levator
ani muscles. The posterior surface is triangular and flat, and rests on the anterior wall of the
rectum. The inferior-lateral surface joins the anterior surface and rests on the levator ani
fascia above the urogenital diaphragm.
Mc Neal (1976) divides the prostate gland in several zones, between others are: peripheral
zone, central zone, transitional zone, anterior fibromuscular zone, and periuretral zone. Most
prostatic hyperplasia is in the transitional zone proximal to the external sphincter on both
sides of the verumontanum and in the periuretral zone. Both zones make up only 2% of the
total prostate volume. While prostate carcinoma growth comes from the peripheral zone.

The human prostate is composed of glandular and stromal elements, tightly fused within a
pseudocapsule. The inner layer of the prostate capsule is composed of smooth muscle with an
outer layer covering of collagen. There are two anatomic defects in the prostatic capsule: at
the apex (anterior and anterolaterally) and at the site of entry of the ejaculatory ducts. In these
areas, it can be challenging to determine the pathologic stage of adenocarcinoma of the
prostate. Nerve supply to the prostate is derived from prostatic plexus and arterial supply by
the branches of the internal iliac artery. Lymphatics from the prostate drain predominantly
into the internal iliac nodes.
DEFINITON

BPH is the development of nodules within the prostate gland as a result of enlargement of
the stromal and epithelial components of the gland. As the BPH progresses, the entire
prostate enlarges in a process called benign prostatic enlargement, resulting in compression
of the prostatic urethra and development of bladder out ow obstruction. BPH is prevalent,
affecting approximately 70% of men between the ages of 60 and 69 years, making it one of
the most common conditions treated by urologists.

ETIOLOGY

Although the cause of BPH remains incompletely understood, it is clear that exces- sive
androgen-dependent growth of stromal and glandular ele- ments has a central role. BPH
does not occur in males castrated before the onset of puberty or in men with genetic diseases
that block androgen activity. Dihydrotestosterone (DHT), the ultimate mediator of prostatic
growth, is syn- thesized in the prostate from circulating testosterone by the action of the
enzyme 5α-reductase, type 2. DHT binds to nuclear androgen receptors, which regulate the
expression of genes that support the growth and survival of prostatic epithelium and stromal
cells. Although testosterone can also bind to androgen receptors and stimulate growth, DHT
is 10 times more potent. Clinical symptoms of lower urinary tract obstruction caused by
prostatic enlargement may also be exacerbated by contraction of prostatic smooth muscle
mediated by α1-adrenergic receptors.

There has been few theories that are suspected to be the cause of benign prostate hyperplasia:

a. Theory of dihydrotestosterone (DHT)

Dihydrotestosterone (DHT) is an adrogen metabolite that is essential for the growth of

prostate gland cells. Formed from testosterone in the prostate cells by the enzyme 5a-
reductase with coenzyme NADPH assistance. DHT with binds with androgen receptors (RA)
and will form DHT-RA complex in the cell nucleus which will stimulated the growth of
prostate cells. This cause the prostatic cells to be more sensitive toward DHT and cause
further cell replication.

b. Estrogen-testosterone imbalance
As the age increase, there will be changes in hormonal balance, which is between testosterone
hormone and estrogen hormone. Because testosterone production decreases and there is
conversion of testosterone to estrogen in peripheral adipose tissue with the help of the
aromatase enzyme, where the nature of this estrogen will stimulate the occurrence of
hyperplasia in the stroma, so there is a suspicion that testosterone is needed for the initiation
of cell proliferation but then estrogen is responsible for the development of stromal. Another
possibility is that changes in the relative concentrations of testosterone and estrogen will
cause the production and potentiation of other growth factors that can cause prostate
enlargement.

c. stromal-epithelial interactions

Cunha prove that the differentiation and growth of prostate epithelial cells are indirectly
controlled by stromal cells through a mediator (growth factor). Once the stromal cells of the
DHT-stimulated and estrogen, stromal cells synthesize a growth factor which in turn affects
the stromal cells themselves are intacrine and autocrine, as well as affect the epithelial cells in
paracrine. Stimulation caused the proliferation of epithelial cells and stromal cells.

d. Reduction in prostate cells apoptosis

Apoptosis in prostate cells is a physiological mechanism to maintain homeostatis of prostate

gland. Condensation occurs on apoptosis and subsequent cell fragmentation of cells
undergoing apoptosis which will be phagocytosed by surrounding cells, and then degraded by
lysosomal enzymes. On normal tissue, there is a balance between the rate of cells
proliferations and cells death. Reduced number of prostate cells undergoing apoptosis cause
prostate cell number as a whole to be increased hence the prostate becomes enlarged.
Estrogens are thought to be able to extend the life of prostate cells, whereas the growth factor
TGFb plays a role in the proses of apoptosis.

e. Stem cell theory

As in other organs, the prostate in this case the periuretral gland an adult is in a state of
"steady state" balance, between cell growth and dead cells, this balance is due to the presence
of certain testosterone levels in prostate tissue that can affect stem cells so that they can
proliferate. In certain circumstances the number of stem cells can increase so that the
proliferation occurs faster. Abnormal proliferation of stem cells results in the production or
proliferation of stromal cells and epithelial cells of the prostatic periuretral glands to be
excessive.

PATHOPHYSIOLOGY
In BPH there are two components that influence the occurrence of symptoms, known as
mechanical components and dynamic components. This mechanical component is related to
the enlargement of the periurethral gland which will press the prostatic urethra so that
disruption of urine flow (infra vesical obstruction) while the dynamic component includes
prostate smooth muscle tone and its capsule, which are alpha adrenergic receptors.
Stimulation of alpha adrenergic receptors will result in prostate smooth muscle contraction or
increased tone. This dynamic component depends on sympathetic nerve stimulation, which
also depends on the severity of the obstruction by the mechanical component.
These various conditions cause increased urethral pressure and resistance. Furthermore this
will cause urinary obstruction. To overcome the increased urethral resistance, the detrusor
muscles will contract to pass urine. This continuous contraction causes anatomic changes in
the bladder in the form of detrusor muscle hypertrophy, trabeculation, formation of selula,
sacula, and bladder diverticles. This detrusor muscle thickening phase is called the
compensatory phase.
Structural changes in the bladder are felt by the patient as a complaint in the lower urinary
tract or lower urinary tract symptom (LUTS) which was formerly known as prostatismus
symptoms.
With increasing urethral resistance, the detrusor muscle enters into the decompensation phase
and ultimately is no longer able to contract so that urinary retention occurs. Intravesical
pressure which is getting higher will be passed on to all parts of the bladder no exception at
the two ureteric estuaries. Pressure on the two ureteric estuaries can cause backflow of urine
from
bladder to the ureter or vesico-ureteric reflux. This situation if it continues will result in
hydroureter, hydronephrosis, and even eventually can fall into kidney failure.
CLINICAL MANIFESTATION

Symptoms and signs of bladder out ow obstruction (sum- marised in Box 35.1) are usually
gradual in onset. Benign causes are prostatic hyperplasia and the apparently independ- ent
disorder of bladder neck hypertrophy and brosis. Acute retention of urine may occur
suddenly at any time and is commonly precipitated by bladder over lling after excessive uid
intake. It is also a hazard of many general surgical or orthopaedic operations on older men
and also of any pelvic or perineal operations after adolescence. In some patients, the severity
of prostatic symptoms uctuates from month to month (and even perhaps with the season),
making it dif cult to decide whether an operation is necessary.

IPSS SCORE

The IPSS consists of seven questions to assess the occurrence of the following urinary
symptoms in the previous 4 weeks: incomplete emptying of the bladder, frequency,
intermittency, urgency, weak stream, straining and nocturia. The total score was calculated by
adding the score assigned to each individual question. Scores are assigned based on the
intensity of symptoms on a scale ranging from zero (absent) to five (strong), and the total
score varies from zero to 35. The severity of urinary dysfunction was categorised based on
the total score as follows: mild (one to seven points), moderate (eight to 19 points) and severe
(20 to 35 points).
MADSEN IVERSAN SCORE
DIAGNOSIS

A detailed history is needed to be taken to assess the nature of the symptoms and how much
they interfere with the patient’s life. The International Prostate Symptom Score sheet helps in
assessing the overall impact of symptoms in a standardised way. This, and the patient’s
general condition, are the principal factors determining whether treatment is needed. The
abdomen is examined for an enlarged bladder and the prostate palpated rectally. These
clinical examinations, however, reveal only gross abnormalities.

Digital rectal examination can give a picture of the state of anal sphincter, bulbo cavernosus
reflex, rectal mucosa, other abnormalities such as lumps in the rectum and of course palpable
prostate. On the touch of the prostate must be considered:
1. Prostate consistency (in prostate hyperplasia the consistency is springy)
2. Are there asymmetries
3. Are there any nodules on the prostate
4. Is the upper limit palpable
5. Sulcus medianus prostate
6. Is there crepitus
Plugging the rectum in prostate hyperplasia shows a palpable prostate enlarged, consistency
of the supple prostate such as touching the tip of the nose, flat surface, symmetrical right and
left lobes, no nodules were found, and protruding into the rectum. The more severe the degree
of prostate hyperplasia, the upper limit is more difficult to be touched. Whereas in prostate
carcinoma, the consistency of the hard and or palpable prostate nodules and between the
prostate lobes is not symmetrical. While the prostate stones will be palpable crepitus.
Upon examination of the abdomen, a full and palpable bladder of the cyst in the supra
symphysis area due to urinary retention and sometimes supra symphysis tenderness.
The next step is to investigate the effects of outlet obstruction on the bladder by measuring
urinary ow rate and estimating the volume of residual urine using ultrasound. This is
reliable, quick, non-invasive, safe and cheap. When urinary symptoms are severe but residual
volume is insignicant, the alternative diagnosis of an overactive bladder should be
considered. Urodynamic studies are more complex and involve measuring the lling and
emptying pressures of the bladder, but may be invaluable if diagnostic doubts remain.

Renal function is assessed by estimating plasma urea, creatinine and electrolytes. If these are
abnormal, further metabolic investigations may be necessary and renal tract ultrasound is
mandatory.

A midstream specimen of urine should be examined by microscopy and culture as urinary

infection alone may be responsible for the symptoms or may have precipitated an episode of
urinary retention. In addition, if surgery is intended, it is important that infection is eradicated
to minimise risk of perioperative infection and secondary haemorrhage.

If the prostate feels nodular on palpation, cancer should be suspected, particularly if the
serum prostate specific antigen (PSA) is elevated. Transrectal ultrasound scanning (TRUS)
and needle biopsy should be performed even if prostatectomy is planned because a
preoperative diagnosis of cancer is likely to alter the plan of management. Marked elevation
of serum PSA is diagnostic of prostatic cancer but a mildly elevated PSA may be due to
benign disease or infection. A normal result does not, however, exclude cancer.

BNO is useful for looking for opaque stones in the urinary tract, prostate calculus / stones and
sometimes can show a shadow of urine filled with urine, which is a sign of a urine retention.
It also can show the presence of hydronephrosis, bladder diverticles or the presence of
metastases to the bone from prostate carsinoma.

Prostate hyperplasia that has provided clinical complaints will usually cause the patient to
come to the doctor. The severity of clinical symptoms is divided into four gradations based
on the findings in digital rectal and residual urine volume, namely:

• Degree one, if prostatismus complaints are found, in the digital rectum prostate protrusion is
found, the upper limit is palpable and the residual urine is lacking of 50 ml.
• Degree two, if signs and symptoms are found the same as degrees one, the prostate is more
prominent, the upper limit is still palpable and the urine remains more than 50 ml but less
than 100 ml.
• Degree three, like degree two, only the upper limit of the prostate is no longer palpable and
the remaining urine is more than 100 ml
• Degree four, if total urinary retention has occurred.

TREATMENT

The world health organization (WHO) recommends classification for determine the weight of
micturition disorder called WHO PSS (WHO Prostate Symptom Score). This score is based
on the patient's answers to eight questions about proxy. Non-surgical therapy is
recommended if the WHO PSS remains below 15. For this reason it is recommended to
control by determining WHO PSS. Surgical therapy is recommended if WHO PSS 25 and
above or if obstruction develops.

The mainstay of treatment for LUTS due to BPH is α 1- adrenergic receptor blockers. As
previously discussed, α-adrenergic receptors are the most common adrenergic receptors in the
bladder, and α1 is the most common subtype in the lower urinary system, prostate, and

urethra. e action of α1 blockers is to relax the smooth muscle in the bladder neck and prostate
and to reduce out ow resistance. is class of drugs has become progressively more selective to
the α1 subtypes, and many now target the α 1a subtype receptor speci cally. e most common
side e ects of these drugs are dizziness related to orthostasis, retrograde ejacula- tion, and
rhinitis. A second category of pharmacologic therapy is the 5α-reductase inhibitors that target
the glandular component of the prostate. ese drugs block the conversion of testosterone to
dihydrotestosterone in the prostate and subsequently reduce the prostate volume, thereby
reducing out ow resistance. is class of drugs also alters the serum PSA level (reduces it about
50%), which must be kept in mind with regard to prostate cancer screening. In addition, these
drugs can be used in combination because of their di ering mechanism of action, and studies
show superior results to either drug used independently.

When medical therapy is ineffective, symptoms remain bother- some, or an objective surgical
indication arises (e.g., acute urinary retention, bladder calculi, azotemia, recurrent UTI, or
recurrent hematuria), surgical intervention is considered. e standard approach to surgical
treatment of BPH is transurethral resection of the prostate (TURP) using various
electrosurgical options (monopolar, bipolar, or laser). Minimally invasive treatment options,
such as microwave thermotherapy and radiofrequency ablation, can be performed in an o ce
setting but do not have equivalent long term outcomes compared to standard surgical
procedures. When the adenomatous growth is particularly large, open simple prostatectomy is
performed to enucleate the adenoma surgically. Outcomes of the transurethral procedures
show dramatic improvement in International Prostate Symptom Score numbers, urinary ow
rates, and post-void residual volumes. Procedures such as simple prostatectomy have such a
long historical use that objective data have not been measured or compiled, but outcomes are
similar to those of TURP. Complications of TURP procedures include persistent bleeding,
dilutional hyponatremia from liquid absorption of the glycine irrigation, UTI, urinary
incontinence, and urethral stricture. With newer electrosurgical systems (bipolar and laser),
normal saline irrigation is used and dilutional hyponatremia has been eliminated. In addition,
visualization is improved, with a significant reduction in bleeding com- plications and a
lower incidence of urinary incontinence.

Drug treatment

Finasteride and dutasteride block the enzyme 5-alpha reductase from converting
testosterone to dihydrotestosterone and thus reduce the size of hyperplastic prostate glands. A
6-month trial of treatment is required; if successful, symptoms may improve to the extent that
surgery can be delayed or avoided. Some herbal remedies such as saw palmetto contain
naturally occurring 5-alpha reductase inhibitors. Alpha-adrenergic A1 receptors are present in
the bladder neck and prostate and selective alpha-adrenergic blocking drugs may enable the
prostatic urethra to open more readily, relieving symptoms. Newer drugs, e.g. tamsulosin or
alfuzosin, have fewer side-effects than older drugs such as pra- zosin. Combination therapy
with alpha-adrenergic blockers and 5-alpha reductase inhibitors may be more bene cial in
patients with larger glands.

Transurethral resection of prostate (TURP) and other transurethral treatments

Transurethral prostatectomy has lower postoperative mortal- ity and morbidity than open
retropubic prostatectomy and requires a shorter hospital stay. Holmium laser enucleation of
prostate (HOLeP) yields at least equivalent results to TURP with the added bene t of
reduced blood loss. In addi- tion, larger glands can be enucleated than could reasonably be
resected, thus avoiding the need for open retropubic prostatectomy. Laser ablation
techniques (using KTP-green light and holmium lasers) can be valuable in special cir-
cumstances, such as a patient on warfarin, and have shown promising results approaching
those of TURP. Nonetheless, TURP remains the standard therapy, while other physical
treatments have demonstrated lesser degrees of success. Cryo- prostatectomy (freezing the
gland), cold punch prostatectomy, microwave thermotherapy and transurethral needle
ablation (TUNA) are obsolete procedures. The aim of transurethral prostatectomy is to
remove the bulk of the prostate but leave the compressed normal peripheral tissue. This
protects the subcapsular venous plexus that might otherwise bleed catastrophically. In TURP,
a series of ‘chips’ or strips of tissue are excised with a resectoscope using a cutting diathermy
wire loop; the chips drift into the bladder. The enlarged gland is progressively sliced away as
shown in Figure 35.3, taking great care to preserve the sphincter mechanism immediately
distal to the veru montanum. The prostatic chips are always examined histologically and may
reveal unsuspected carcinoma. A transparent isotonic irrigation solution is used during the
process, which washes away blood and debris to allow continuous visibility. Since some
irrigation fluid is inevitably absorbed, sterile glycine solution is most often used instead of
water as it does not cause haemolysis. If large volumes are absorbed, this causes dilutional
hyponatraemia and hyperammonaemia along with drastic plasma electrolyte changes,
producing the TUR syndrome. Various isotonic sugar solutions can now be safely used as
alternatives.

When obstruction is caused by bladder neck hypertrophy, the prostate is not usually resected
but the bladder neck muscle is divided by making a longitudinal incision (bladder neck
incision, BNI) using a diathermy point via the resectoscope. This operation is also effective
where the obstruction is caused by a small prostate (<30 g).

Retropubic prostatectomy

Open prostatectomy, now rarely performed, is used mainly when the gland is so large that
transurethral resection is not practicable, or occasionally when there are accompanying
bladder diverticula or huge stones.

COMPLICATION

Prostate hyperplasia can cause the following complications:

a. Paradox incontinence
b. Bladder Stone
c. Hematuria
d. Cystitis
e. Pyelonephritis
f. Acute or chronic urinary retention
g. Hydroureter
h. Hydronephrosis
i. Kidney failure

Complications of TURP and open prostatectomy

Prostatectomy usually disrupts the bladder neck mechanism that normally prevents semen
entering the bladder during ejaculation. Patients therefore usually fail to ejaculate through the
penis after prostatectomy (retrograde ejaculation), although the sensation of orgasm is
unaffected. This affects 75% of patients. Maintaining fertility is not usually important in this
older age group, but should the need arise, urine can be altered to recover sperm for artificial
insemination. Erectile impotence follows TURP in 5–10%, a rate similar to other major
operations in the pelvis or perineal area. Urethral strictures develop in 1–10% of cases,
recreating the use of relatively large instruments and potentially harmful urethral catheters.

Minor haematuria can be expected during the rst few weeks after prostatectomy. Secondary
haemorrhage (due to infection or unsuspected cancer) can be more profuse and may cause
clot retention, i.e. retention of urine caused by obstructing blood clot. Recovery of complete
urinary continence is sometimes delayed following prostatectomy but permanent damage to
the sphincter mechanism is rare.

PROGNOSIS

The BPH prognosis is changing and cannot be predicted by each individual. BPH that is not
treated will show adverse side effects of the patient itself such as urinary retention, renal
insufficiency, recurrent urinary tract infections, and hematuria.
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