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Keywords:

  • BPH;
  • acute urinary retention;
  • TURP;
  • demography

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Authors

Objective To evaluate, in a prospective study, the demographic profile of patients with benign prostate enlargement who presented in acute urinary retention (AUR).

Patients and methods The study comprised all patients admitted for transurethral resection of the prostate and categorised into two groups, i.e. those presenting in AUR or electively. The factors evaluated included the length of hospitalization, the patients' occupation, their duration of symptoms and reasons for not seeking treatment.

Results There was no significant difference in the mean age and occupational status of the two groups but those in AUR had more complications and a longer hospital stay after surgery; 60% of these men had had their urinary symptoms for > 1 year. When asked why they did not seek treatment earlier, 35% reported fear of surgery, while 41% thought that their symptoms were a normal part of ageing.

Conclusion There is a need to raise the level of public awareness of benign prostatic enlargement because those who present with AUR incur excess morbidity and longer hospitalization that could otherwise be avoided through earlier treatment and elective surgery.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Authors

BPH is a common condition that affects men from the age of 40 years; 50–60% of men aged 40–60 years will develop an enlarged prostate [1,2]. The condition causes obstruction of the urinary tract, leading to a spectrum of LUTS. One of the complications is acute urinary retention (AUR); in Singapore the incidence of patients with BPH presenting in AUR is higher than in the West [3–5]. Previous reports show that patients in AUR and undergoing TURP have a higher complication rate [6–8]. The total hospital stay is also longer because concurrent medical conditions like diabetes, hypertension and heart disease need to be controlled before surgery, and any associated UTI also needs to be treated. Our policy is to withdraw any aspirin for a week before TURP; all these considerations contribute to a longer preoperative stay. A longer stay is also expected after surgery because of a higher incidence of complications.

There have been no studies to evaluate why many patients with BPH present at this late stage. Factors that might account for the high local incidence are poor public awareness and perception of the condition and the treatment modalities available. Thus the aim of the present study was to evaluate the demographic profile and underlying reasons of those who presented in AUR.

Patients and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Authors

A prospective consecutive-case study was carried out from January 1999 to April 1999, including all men with BOO caused by BPH that required TURP. Patients with carcinoma of the prostate, transient urinary retention caused by medication or constipation were excluded. The study cohort was divided into two groups, comprising men who presented with AUR from BPH and those who were elective admissions. The period of hospitalization was taken to be from the time of admission to discharge after surgery. This included those who elected to go home with a catheter in place and return for elective surgery, and those who opted for a trial without catheter but were subsequently re-admitted for AUR. The patients in AUR were also interviewed to determine their reasons for not seeking earlier treatment. Other demographic data included race, age and social status. To prevent interobserver variation, the interviews were conducted by only one of the authors.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Authors

Of the 67 patients in the study period, 32 (48%) had presented in AUR and 35 (52%) were elective; their mean (range) ages were 70.6 (54–87) and 70.7 (52–95) years, respectively. As expected, most patients were retired (Table 1). There were more Malay men than in the general population, with proportions of Chinese, Malay, Indian and others of 75%, 22%, 3% and none in the study group, vs 77%, 14%, 8% and 1% (1999 census).

Table 1.  The demographics and other variables in the two groups
VariableAURElective
Number3235
Employment
 Retired2527
 Blue collar66
 White collar12
Histology (prostatic chips)
 BPH only1522
 Chronic prostatitis1312
 Acute-on-chronic prostatitis41
Morbidity, n (%)
 UTI8 (12.5)0
 Intraoperative bleed requiring   blood transfusion4 (13)2 (6)
 Secondary haemorrhage1 (3)0
 Death from urinary sepsis1 (3)0

The hospitalization stay for the AUR group (mean 11.5 days) was longer than that of elective patients (mean 6.6 days). The perioperative morbidity and mortality was higher in the AUR group (Table 1).

The main reasons given by men in the AUR group for not seeking early treatment included fear of surgery (35%) and accepting symptoms as normal ‘part of ageing’ (41%), the other reasons being no symptoms (9%), unfit for surgery (6%), inaccessibility (6%) and financial (3%). Interestingly, nine (28%) of the AUR group had a short history (< 1 week) of LUTS before admission, with four and 19 reporting symptoms for 1 week to 1 year or > 1 year, respectively.

There was no significant difference in the histological findings between the groups that could account for the men presenting with AUR (Table 1).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Authors

In a study carried out in Singapore in 1994 [8], 54% of 175 men undergoing TURP presented in AUR; this incidence rate is higher than that reported in the West [6]. The mean duration of hospitalization for the present patients in AUR was longer than that of elective cases (mean 4.9 days more). A contributing reason for this was that many had concomitant medical conditions (especially diabetes, ischaemic heart disease and hypertension) that needed optimization and control before surgery, and associated UTI was treated first. These conditions could have been controlled on an outpatient basis if early consultation was sought. Another reason for the longer preoperative stay was logistical, as the surgeon had to wait for the next available operating list. Social reasons also contributed to the longer stay and included: (i) patients were unwilling to be discharged with an indwelling catheter; (ii) they wanted to be fully recovered before discharge; (iii) they tended to depend on family members to take them home and this was usually over the weekend when the caregiver was free.

More patients in the AUR group had significant blood loss; this was attributed to catheter cystitis and prostatitis. Patients with BPH admitted in AUR are more likely to require a second procedure for bleeding [6] and greater overall morbidity has also been reported in other studies [6,7].

When the men in AUR were asked why they did not seek earlier treatment a disturbing proportion (35%) admitted a morbid fear of surgery. Although the cause of this fear could not be ascertained, as far as the Malay population is concerned, their religious belief is that ‘fate’ lies in the hands of their deity and if they should die, they would want to do so at home and amongst family members. The concern over erectile and sexual dysfunction after TURP was not voiced in the study population. The present study was carried out in a district hospital which has a higher proportion of subsidised healthcare beds, and socio-economic factors may also underlie the reasons for not seeking treatment; LUTS is usually a bearable condition. Accessibility to a GP is not an issue in Singapore but healthcare costs as an outpatient are covered by the citizen. Thus the perception of LUTS as a trivial condition and an unwillingness to pay for long-term medication are plausible contributing factors, even though α-blockers are available in general practice.

One problem faced by the urologist is the psychological barrier in the patient in AUR; because they are unprepared for admission, many were reluctant or unconvinced of the need for TURP. Interestingly, 9% claimed to have no preceding LUTS to induce them to seek earlier treatment. A further 28% developed symptoms only in the week before AUR.

The present results highlight the misconception held by many men (41%) that their urinary symptoms are a normal part of ageing. There is still a need to raise public awareness about prostate disease and its treatment in Singapore, as more than half of TURPs during the present study period were in those men who presented in AUR.

References

  • 1
    Chaitow L. Prostate Troubles: a Drug Free Programme to Help Alleviate Prostate Problems. London: Thorsons Publishers, 1988
  • 2
    Burton Goldberg Group; Puyallup WA eds. Male Health. Alternative Medicine: the Definitive Guide. Future Medicine Publishing, Inc., 1993: 531533
  • 3
    Meigs JB, Barry MJ. Incidence rates and risk factors for acute urinary retention: The health professionals followup study. J Urol 1999; 162: 37682
  • 4
    Boyle P. Some remarks on the epidemiology of acute retention of urine. Arch Ital Urol Androl 1998; 70: 7782
  • 5
    Platz EA, Kawachi I, Rimm EB, Willett WC, Giovannucci E. Race, ethnicity and benign prostate hypertrophy in the health professionals follow up study. J Urol 2000; 163: 4905
  • 6
    Mebust WK, Holtgrewe HL, Cockett ATK, Peters PC. Transurethral prostatectomy. Immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3885 patients. J Urol 1989; 141: 2437
  • 7
    Malenka DJ, Roos N, Fisher ES et al. Further study of the increased mortality following transurethral prostatectomy: a chart-based analysis. J Urol 1990; 144: 2248
  • 8
    Wong MYC, Lim YL, Foo KT. Transurethral resection of the prostate for benign prostatic hyperplasia – a local review. Singapore Med J 1994; 35: 3579

Authors

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Authors

Sir-Young Loh, MD, Medical Officer.

Chong-Min Chin, MD, Consultant.

Abbreviations
AUR

acute urinary retention.

Chong-Min Chin, Department of Urology, Changi General Hospital, 2 Simei Street 3, Singapore 529889. e-mail: alfechin@singnet.com.sg