Prostate Enlargement

Lower Urinary Tact Symptoms (LUTS) caused by an enlarged prostate gland is a common condition. 21% of men above age 50 have LUTS caused by Benign Prostate Enlargement (BPE) and this peaks as a problem over the age of 70.

TURP remains the most commonly used surgical procedure for BPE, utilised in 76% of men undergoing surgery for BPE in Australia.

A/Prof Peter Royce and Mr Dennis King perform the treatments for prostate enlargement (BPH) below at Cabrini Hospital Malvern, Cabrini Brighton, Epworth Eastern Hospital Box Hill and St. John of God Berwick, Melbourne Australia.

Anatomy & Physiology

  • The prostate gland is shaped like an inverted pear and lies just below the neck of the urinary bladder. It is about 5cm long and 3-4cm wide. The urethra, which runs from the bladder through the middle of the prostate gland and through the penis, carries urine from the bladder.
  • The smooth muscle of the bladder neck is the internal urinary sphincter. Just below the prostate gland is a muscular valve that acts as the external urinary sphincter. This sphincter, which encircles the urethra, is under both reflex and voluntary control.
  • Along the back wall of the urethra in the prostate, there is an elevation called the verumontanum, and it is into this elevation that sperm (through the ejaculatory ducts) and spermatic secretions from the seminal vesicles and prostate enter the urethra during ejaculation.
Benign Prostate Hyperplasia


History & Examination

  • A patient with an enlarged prostate complains of symptoms that are related to obstruction of urine flow, irritation and other complications mentioned above.
  • Lower Urinary Tract Symptoms
    1. Hesitancy or delay in urine flow during attempted urination. There is a decrease in force and size of the urinary stream. There may be intermittency (pauses in flow of stream), dribbling of urine at the end of urination and a feeling of incomplete emptying of the bladder.
    2. Irritative symptoms include increased frequency and urgency of urination; nocturia; pain on urination from bladder stones; infection or muscle spasms and blood in the urine from infection, inflammation or bleeding veins at the surface of the prostate.
    3. Delayed symptoms are those of renal failure due to kidney involvement and the development of a hernia or haemorrhoids from constant straining during urination.
    4. Please self check your IPSS to gauge your level of LUTS.

      IPSS Assessment
  • During the physical examination, the prostate gland is examined. Digital Rectal Exam (DRE) is carried out by inserting a gloved finger into the rectum. The prostate gland lies just in front of the rectum and can be felt for size and nodules. DRE can help to detect a cancer of the prostate.

Diagnostic Testing

The symptoms of BPH may be mimicked by several conditions. These include: -

Medical Treatment

  • Medical therapy is appropriate for patients who have mild symptoms of urinary obstruction or are too old or sick to undergo a surgical procedure.
  • Relief from obstruction may not be immediate and usually necessitates life long medical treatment. Medical treatment may not be effective in men with high grade obstruction.
  • There are two main drug groups that are used to treat BPH: -
    1. Muscle Relaxants - This group of drugs blocks nerve impulses going to the muscles of the involuntary internal sphincter thus easing urinary flow. Side affects of these medications include low blood pressure, dizziness, fast heart rate, tiredness, nasal congestion and retrograde ejaculation (sperm goes into the bladder).
    2. Hormonal Agents - These drugs attempt to reverse the effect of testosterone on the prostate causing a decrease in size. This is accomplished by blocking the effect of testosterone on the prostate. Side effects of these drugs may include impotence and a loss of libido and breast enlargement.

Surgical Treatment (TURP)

Indications For Surgery

Transurethral Resection Of The Prostate (TURP)

Transurethral Resection Prostate (TURP)

Gyrus TURP

A newer technique currently being used by Urology Associates. This involves bipolar diathermy resection of the prostate which has the proven advantages of :-

  1. Allowing the use of normal saline irrigation fluid during the prostate surgery, which is safer than the glycine irrigation used with standard TURP.
    This allows safer resection of larger prostates which may otherwise require open surgery, and avoids the TUR syndrome associated with glycine irrigation.
  2. There is less bleeding both during and after the TURP surgery.
    Gyrus bipolar TURP forms a safer seal of bleeders than standard TURP.
  3. It allows superficial vaporisation of the prostatic tissue, while shaving away prostate chips, thus leaving less tissue debris at the end of the procedure. Prostate tissue is available for histopathology testing.

Urology Associates now routinely use this technique for prostate resection, backed up by several meta-analyses which prove the advantages of Bipolar TURP with saline.


Complications seen with TURP and their approximate rates of occurrence are: -

  • Bleeding (<5%) needing blood transfusion.
  • Infection (<2%) more likely if catheter insitu prior to TURP.
  • Inability to pass urine - usually due to bladder dysfunction with longstanding BPH (5%).
  • Stricture of the urethra from scarring (2%).
  • Urinary incontinence from damage to the sphincter (<1%).
  • Impotence (5%) in previously potent men. Please self check your SHIM score.

    SHIM Assessment
  • Retrograde ejaculation (passage of sperm) - because of the loss of the internal sphincter, spermatic secretions may go backwards into the bladder rather than down through the penis during ejaculation. These secretions will pass out later during urination. This may give rise to infertility due to reduced sperm emission. Retrograde ejaculation is noticeable in most men after TURP.
  • TUR Syndrome (<2%) - Extensive TURP, especially with very large prostates, may open up venous blood vessels during surgery. Fluid in the bladder may get absorbed into the blood causing fluid overload and electrolyte (salt) imbalance in the body. Fluid overload may be particularly a problem in a patient with heart or lung disease. Electrolyte imbalance may cause neurologic symptoms, including seizures and coma. TUR syndrome is minimised with routine use of saline fluid for irrigation during Gyrus bipolar TURP procedure.

Postoperative Care (TURP)

After The Operation

Post Operative Day 1

Post Operative Day 2

Post Operative Day 3

Recovering At Home

Urinary Symptoms

As a result of your operation, a raw area has been left exposed. This will heal over during the next 6-8 weeks. Until the healing process is complete you can expect to continue to experience some degree of needing to pass urine in a hurry and often, and you may expe rience urinary incontinence associated with this. These symptoms usually settle relatively quickly. You may also experience some burning on urinating, blood stained urine and small blood clots. This is only a concern if there is obstruction to your flow or if there is associated heavy bleeding.

Slow resolution of these symptoms will need to be discussed with your surgeon at your follow up appointment.

Secondary Bleeding

10-14 days after surgery, a scab within the healing area may lift and come away. Bleeding may be fresh and bright but usually settles with rest and increasing fluid intake. If bleeding is heavy or persistent or you are unable to pass urine, contact your surgeon, or go directly to the Emergency Department.

Diet and Fluids

You need to continue to drink between 2-3 litres of fluid a day at home for at least a week, especially if the urine is blood stained. When the colour of your urine is clear, you may return to your normal fluid intake.

Continue to follow a high fibre diet as straining and constipation can increase bleeding. You may need to take a laxative.


Ask your surgeon about alcohol consumption, as heavy drinking may increase your risk of bleeding.


  • Gentle exercise is encouraged for 3-4 weeks, such as walking. You must avoid heavy lifting and straining, gardening and more strenuous sporting activities such as golf, tennis and cycling. Such strenuous activity can increase the risk of bleeding.
  • Sitting for prolonged periods is not recommended as it places pressure on the healing prostate cavity and this can increase risk of bleeding.
  • You can drive your car the first week following discharge from hospital.
  • If you are planning to travel by plane please discuss this with your surgeon.
  • Sexual activity is not recommended within the first four weeks after surgery. Please discuss this with your surgeon at your follow up appointment. You should be aware that following a TURP the volume of semen ejaculated may be reduced or absent, however, in the majority of cases, sexual performance should remain unchanged.


You may continue to experience burning and stinging when passing urine. To relieve this, you can take Panadol or Ural as directed. These medications can be purchased ‘over the counter’ at your pharmacy. Slow resolution of these symptoms will need to be discussed with your surgeon at your follow up appointment.

What to Report

  • Fever ie: Shivering and shaking.
  • Excessive blood in urine that does not clear with drinking.
  • Cloudy or smelly urine.
  • Difficulty or inability to pass urine.
  • Worsening of any urinary symptoms.

Please ensure that before leaving hospital you have a follow up appointment with your surgeon.

Alternative Prostate Procedures

Special Comment

The choice of procedure for benign prostate enlargement will be discussed with you keeping in mind that TURP is regarded as the Gold Standard by which all other procedures are compared.

Some men will be more concerned with preservation of ejaculatory and erectile function, while others will be more concerned to have urinary function restored and urinary symptoms reduced.

Some men are on anticoagulation drugs for their heart condition, and need to remain on these drugs during prostate surgery.

Some men have very large prostate glands and may even have a urinary catheter insitu, which will limit the surgical options, in order to achieve the best outcome.

All of these factors will be carefully considered and discussed with you before deciding on the best option. Please feel free to ask questions about any aspect of your prostate surgery.


UroLift is a newer minimally invasive procedure suitable for treating BPH in some patients. It has been trialled since 2005 and been approved for use since 2013.

A cystoscope (small telescopic tube which allows visualisation of the urethra and bladder) is passed into the urethra under an anaesthetic. Small implants are used to tether the enlarged prostate tissue, holding it and therefore increase the bore of the urethra. The implants are left in place permanently but can be removed if required. The procedure takes about 30 minutes.

Enlarged Prostate

An enlarged prosate can narrow or even block the urethra.

Step 1

The UroLift Delivery Device is placed through the obstructed urethra to access the enlarged prostate.

Step 2

Small UroLift Implants are permanently placed to lift or hold the enlarged prostate tissue out of the way and increase the opening of the urethra. The permanent Implants are delivered through a small needle that comes out of the UroLift Delivery Device and into the prostate.

Step 3

The UroLift Delivery Device is removed, leaving an open urethra designed to provide symptom relief.


  • UroLift is minimally invasive requiring no cutting, heating or removal of tissue and can provide significant improvement in BPH symptoms within 2 weeks of the procedure. Transurethral resection of prostate (TURP) would give greater improvement in symptoms but is more invasive.
  • TURP can still be done later on after UroLift if required.
  • Generally a day stay procedure and often there is no need for catherization.
  • Preservation of sexual function (ejaculation of semen and erections).
  • UroLift does not affect subsequent PSA testing, or MRI scans for prostate cancer screening.
  • UroLift has 5 years of patient followup in USA studies, showing UroLift is durable in terms of patient satisfaction with relief of prostate symptoms and improved uroflow.
  • UroLift is FDA approved in USA and TGA approved in Australia for treatment of enlarged prostate symptoms.

Side Effects

There may be pain or burning wih urination, blood in the urine and frequency of urination and pelvic pain for 2-4 weeks after the procedure.

Follow Up

Review of prostate symptoms score and uroflow testing will confirm the success of UroLift procedure.