Complications with the Prostate Glands
In males, the urethra is the tube that runs from the bladder to the tip of the penis, carrying urine and at the time of ejaculation, sperm with seminal fluid.
The prostate is a small olive-sized structure that surrounds the urethra, located a short distance from the bladder. The prostate produces semen which is added to the ejaculate (the fluid it makes is slightly alkaline so increasing sperm survival in the more acidic conditions of the vagina).
With age, it can increase in size and cause symptoms as it presses against the urethra. This can lead to an increase in urinary frequency, a dribbling stream and an increased risk of urinary infection (owing to incomplete emptying of the bladder and so allowing bacteria to accumulate). There may be difficulty in initiating passing urine, a ‘stop-start’ sequence, and getting up frequently at night time to go to the toilet.
There may be pain and discomfort from not being able to empty the bladder; retention of urine is seen, being due to complete obstruction of the urethra. The prostate increases in size with age to cause these symptoms, usually as part of a benign process, called exactly that, ‘benign prostatic enlargement’. Methods that are used to treat this condition include resecting it via the urethra, called transurethral section of the prostate, or ‘TURP’ for short. This procedure re-bores the urethra.
Other causes of an enlarged prostate gland include cancer of the prostate. This may present with similar signs as described with the condition above, as these symptoms are due to the urethra becoming narrowed. It is one of the most common cancers in men with 35,000 being diagnosed with this condition every year. The outlook depends on the aggressiveness, i.e. has it spread? Secondary malignant cancers are found more commonly in the lungs, liver and bone, meaning that late presentations/diagnosis of prostate cancer may be due to involvement of these areas. The signs and symptoms therefore relate to the site with the metastases, e g bony pain, pathological fractures occurring owing to bone weakening, respiratory features from lung involvement.
How TURP is undertaken
The procedure to performing TURP involves passing a light source with a camera attachment up the urethra. This is called the retro-scope (to which is also attached a thin metal loop). This loop is heated by electric power which cuts away at the surrounding prostatic tissue through the wall of the urethra. This is conducted under either general anaesthetic or epidural, so it is not a painful process.
A urinary catheter is usually left in place a couple of days afterwards as the section of urethra that has been operated upon will be swollen - the catheter allows time for this to subside.
For patients with very enlarged prostate glands, or with clotting disorders (which includes those who are on medication such as warfarin to ‘thin the blood’) other techniques are used such as using a laser which is attached to the device inserted via the urethra.
The removal of the prostate by an approach through the abdominal wall (a radical prostatectomy) is now uncommon as there are greater risks associated with this procedure.
Complications of undergoing a TURP
- Pain on passing urine which subsides over a few weeks as the inflammation from the procedure decreases.
- Fertility may be affected as loss of the ability to ejaculate can occur.
- Difficultly with having erections of the penis – occurring in about 10% of cases. This can recover over time.
- Occasionally there may be incontinence, although this tends to resolve within a few weeks of the procedure.
- In an estimated 4% of cases, there may be stricture formation of the urethra (as a result of scarring)- this narrowing of the urethra can lead to symptoms of straining to pass urine, dribbling after the end of urination, and mild discomfort when urinating. – if this is mild, the urethra can be dilated to open it up again.
- About 2% of patients experience bleeding (and some even require a blood transfusion), and about 5% develop a urinary tract infection.
- Damage to the bladder neck (which is the controlling valve for the bladder to release urine) may be damaged, giving rise to urinary retention in the bladder. This occurs in about 1-2% and is usually only temporary. This may manifest as a sudden desire to pass urine (urge incontinence).
- A rare but life threatening condition is the absorption of the large amounts of fluid used in the procedure into the blood stream. This is called TURP syndrome and can have symptoms of shortness of breath, even seizures and coma.
All these complications should be made known to patients as part of the informed consent process.
The general postoperative advice given is that sex, heavy lifting and strenuous exercise should be avoided for a few weeks post operatively. Not a complication of the procedure but a biological inevitability is that in 10% of men, the prostate enlarges again ! Usually this takes a few years.
Medico-legal aspects of TURP
Consent that is taken should record that detailed discussions of the complications listed above took place, as although some of them are relatively uncommon, they nonetheless do occur.
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