Analysis of the factors causing bladder irritation after transurethral resection of the prostate.

Abstract

Approximately 20% to 30% of patients with benign prostatic hyperplasia (BPH) require medication or supplementary treatment for their continuous irritative bladder symptoms after transurethral resection of the prostate (TURP). The purpose of this study was to identify any factors related to continuous bladder irritation in patients after TURP.
Of all patients who underwent TURP from January 2000 to December 2007, 160 who underwent long-term follow-up were selected for this study. The International Prostate Symptom Score (IPSS) was assessed 12 months after TURP, and the patients were divided into two groups: one group with an irritative bladder symptom score on the IPSS of 7 or less (non-irritative group) and another group with an irritative bladder symptom score on the IPSS of 8 or greater (irritative group). Preoperative urodynamic study variables, preoperative and postoperative IPSS, and the shape of the prostate upon transrectal ultrasonography (TRUS) were analyzed.
Of the 160 patients, 93 patients were assigned to the non-irritative group, and 67 were assigned to the irritative group. Initial irritative bladder symptoms were significantly different between the two groups (p<0.05). Also, a retrourethral enlarged prostate was more frequently observed upon TRUS in the irritative group. Symptoms of urinary frequency, incontinence, and urgency were significantly greater in the irritative group. Although there was no significant difference in the preoperative quality of life between the two groups, postoperative quality of life was significantly worse in the irritative group.
The shape of the prostate and the preoperative irritation score correlated significantly with the postoperative severity of irritative bladder symptoms. Therefore, physicians should be cautious when performing TURP in patients with a retrourethral enlarged prostate and severe irritative symptoms.

Full text

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Korean Journal of Urology
Ⓒ The Korean Urological Association, 2010
700
Korean J Urol 2010;51:700-703
www.kjurology.org
DOI:10.4111/kju.2010.51.10.700
Voiding Dysfunction
Analysis of the Factors Causing Bladder Irritation after
Transurethral Resection of the Prostate
Tae Im Kim, Jae Mann Song, Hyun Chul Chung
Department of Urology, Wonju Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
Purpose: Approximately 20% to 30% of patients with benign prostatic hyperplasia
(BPH) require medication or supplementary treatment for their continuous irritative
bladder symptoms after transurethral resection of the prostate (TURP). The purpose
of this study was to identify any factors related to continuous bladder irritation in pa-
tients after TURP.
Materials and Methods: Of all patients who underwent TURP from January 2000 to
December 2007, 160 who underwent long-term follow-up were selected for this study.
The International Prostate Symptom Score (IPSS) was assessed 12 months after TURP,
and the patients were divided into two groups: one group with an irritative bladder
symptom score on the IPSS of 7 or less (non-irritative group) and another group with
an irritative bladder symptom score on the IPSS of 8 or greater (irritative group).
Preoperative urodynamic study variables, preoperative and postoperative IPSS, and
the shape of the prostate upon transrectal ultrasonography (TRUS) were analyzed.
Results: Of the 160 patients, 93 patients were assigned to the non-irritative group, and
67 were assigned to the irritative group. Initial irritative bladder symptoms were sig-
nificantly different between the two groups (p＜0.05). Also, a retrourethral enlarged
prostate was more frequently observed upon TRUS in the irritative group. Symptoms
of urinary frequency, incontinence, and urgency were significantly greater in the irrita-
tive group. Although there was no significant difference in the preoperative quality of
life between the two groups, postoperative quality of life was significantly worse in the
irritative group.
Conclusions: The shape of the prostate and the preoperative irritation score correlated
significantly with the postoperative severity of irritative bladder symptoms. Therefore,
physicians should be cautious when performing TURP in patients with a retrourethral
enlarged prostate and severe irritative symptoms.
Key Words: Prostatic hyperplasia; Transurethral resection of prostate; Treatment
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial
License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Article History:
received 19 May, 2010
accepted 28 September, 2010
Corresponding Author:
Hyun Chul Chung
Department of Urology, Wonju
Christian Hospital, Yonsei University
Wonju College of Medicine, 162,
Ilsan-dong, Wonju 220-701, Korea
TEL: +82-33-741-0654
FAX: +82-33-748-3804
E-mail: chc7174@yonsei.ac.kr
INTRODUCTION
Benign prostatic hyperplasia (BPH) is a urologic disease
that affects males 50 years of age and older. It is a common
disease of the elderly that has rapidly increased in incidence
with the growing elderly population, economic growth, and
the ubiquity of the Western diet.
　A traditional surgical approach to BPH is transurethral
resection of the prostate (TURP). This operation is per-
formed if there is recurrent acute urinary retention, persis-
tent hematuria, urinary tract infection due to BPH, de-
creased kidney function due to impaired urine flow, or an-
other severe symptom [1-3].
　Complications arising after TURP are decreasing due to
recent improvements in both the resectoscope and surgical
techniques, but recent studies have reported that 20% to
30% of patients require postoperative medication to treat
continuous urinary symptoms. These complications are

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Korean J Urol 2010;51:700-703
Bladder Irritation Symtoms after TURP
701
TABLE 1. Patient characteristics
Nonirritative
group
Irritative
group
Parameters p-value
Age (yr)
IPSS
Prostate
volume (cm3)
Transition zone
volume (cm3)
Resection
volume (g)
Qmax (ml/sec)
67.97±5.99
21.26±7.74
47.99±20.25
68.88±6.84
24.96±7.57
52.09±25.55
0.423
0.281
0.122
24.93±16.23 29.89±20.21 0.324
14.66±14.13 11.07±9.460.212
8.44±7.60 7.60±4.290.386
IPSS: International Prostate Symptom Score, Qmax: maximal
flow rate
TABLE 2. Changes in clinical symptoms
ParametersPreoperativePostoperativep-value
IPSS
Prostate
volume (cm3)
Qmax (ml/sec)
23.5±4.14
51.28±21.04
11.6±3.57
29.75±11.64
0.017
0.025
7.6±8.4212.98±3.17 0.039
IPSS: International Prostate Symptom Score, Qmax: maximal
flow rate
important factors in the patients’ decreased quality of life
after surgery [4,5].
　In selecting patients for TURP, predicting the persis-
tence of irritative bladder symptoms is important, but
studies investigating the prognostic factors of bladder irri-
tation are uncommon. According to a recent report, post-
operative irritative bladder symptoms may remain if there
is a severe irritative bladder symptom before the surgery
or if there is frequent nocturia [6]. A domestic study also
investigated the factors leading to persistence of irritative
bladder symptoms, but this study involved the use of in-
vasive urodynamic studies and included patients without
bladder obstruction, thus limiting the clinical applicability
to our patient population [7].
　The present study investigated the factors influencing
the postoperative persistence of irritative bladder symp-
toms in patients who underwent TURP. Ideally, the results
of this study will be helpful in selecting appropriate pa-
tients for TURP and will provide information as to which
patients may require close attention during surgery.
MATERIALS AND METHODS
From January 2000 to December 2007, 400 patients visited
the urology department for treatment of bladder ob-
struction, and 160 were chosen to undergo TURP and were
included in this study. All subjects received treatment from
the same physician and could be followed up for at least 12
months. Patients whose urinary symptoms were affected
by a urologic tumor, neurogenic bladder, urinary tract in-
fection, bladder stones, or other diseases or anti-muscar-
inic medications were excluded.
　Patients were evaluated by using the International
Prostate Symptom Score (IPSS) before and 12 months after
surgery and were divided into two groups: the irritative
group (IPSS≥8) and the nonirritative group (IPSS≤7).
There are 3 categories in the IPSS that evaluate irritative
symptoms. Each category is assigned a maximum of 5
points, thus making the total score 15 for all 3 categories.
The irritative and nonirritative groups were divided on the
basis of a more than 50% improvement in irritative symp-
toms. In order to study the factors affecting the persistence
of irritative symptoms, the two groups were retrospectively
compared in the following categories: age, preoperative
and postoperative IPSS, preoperative shape and size of the
prostate as seen on transrectal ultrasonography (TRUS),
and volume of the resected prostate.
　A single physician reviewed all TRUS studies. The pros-
tate size was calculated by using the formula for an ellip-
soid (anteroposterior diameter calculated operative size of
the prostate), and the volume of the two groups was retro-
spectively compared with the following scheme set forth by
Wasserman: hyperplasia limited to the transition zone or
posterior urethral hyperplasia [8].
　Uroflowmetry was performed and compared by use of
Duet-logic G II (Dantect, Germany). The maximal flow rate
(Qmax) was measured in ml/sec, and the volume of the re-
sected prostate was measured after surgery.
　Statistical analysis was performed by using SPSS 12.0.
A paired t-test was used to evaluate the effects of TURP be-
fore and after surgery. To evaluate the postoperative per-
sistence of irritative symptoms, a chi-square test was used.
A p-value＜0.05 was set as the threshold for statistical
significance.
RESULTS
Of the 160 patients, 67 (41.8%) belonged to the irritative
group and 93 (58.2%) belonged to the nonirritative group.
There were no significant differences in age, prostate size,
Qmax before surgery, or the volume of the resected prostate
between the two groups (Table 1).
　The mean IPSS score was 23.5 before surgery and 11.6
at 12 months after surgery, suggesting an improvement in
symptoms. The Qmax increased from 7.6 ml/sec before sur-
gery to 12.98 ml/sec after surgery, and the prostate size de-
creased from 51.28 cm3 to 29.75 cm3. All of these factors in-
dicated a clear therapeutic effect of the surgery (Table 2).
　The IPSS score was not significantly different between
the two groups, but the irritative group had significantly
more severe preoperative irritative symptoms than did the
nonirritative group (10.55±3.45 vs. 8.69±3.69, p＜0.05).
　Both groups showed a decrease in severity of irritation
symptoms postoperatively, but the degree of change was
smaller in the irritative group, and three individual types
of irritative symptoms-urgency, urinary frequency, and
nocturia-constituted the majority of the IPSS in the irrita-

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Korean J Urol 2010;51:700-703
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Kim et al
TABLE 3. Clinical symptoms correlated to retention of irritative
bladder syndromes
Nonirritative
group
Irritative
group
Parameters p-value
Pre-op IPSS
Pre-op irritative
symptom score
Pre-op QoL
Post-op IPSS
Post-op irritative
symptom score
Post-op QoL
21.26±7.74
8.69±3.69
24.96±7.57
10.55±3.45
0.281
0.047
3.57±1.2
7.42±5.67
4.14±0.47
4.01±1.31
16.14±4.42
10.42±5.34
0.42
0.025
0.02
1.95±1.23.46±1.60.018
op: operation, IPSS: International Prostate Symptom Score, QoL:
quality of life
FIG. 1. Change in IPSS according to prostate shape. Type I is a
hyperplasia limited to the transition zone only and having no
retrourethral enlargement. Type II is a retrourethral enlarged
prostate. Both types showed a decrease in IPSS score postopera-
tively, but the degree of change was smaller in Type I. IPSS:
International Prostate Symptom Score, op: operation.
tive group. Quality of life was not significantly different be-
tween the two groups preoperatively, but was higher in the
nonirritative group postoperatively (Table 3).
　The individual types of irritative symptoms on the IPSS
(urgency, urinary frequency, and nocturia) were assessed
independently. The irritative group showed a significantly
higher degree of severity of each of the three categories of
specific symptoms.
　An analysis of prostate shape as seen on TRUS revealed
that enlargement of the retrourethral prostate correlated
with a significantly higher IPSS score compared with hyper-
plasia of the bilateral transition zone, which did not (Fig. 1).
DISCUSSION
BPH is the most common cause of micturition dysfunction
in elderly men. Bladder obstruction due to prostate hyper-
plasia causes a structural change in the bladder as part of
a compensatory mechanism, ultimately causing irritative
bladder symptoms. Bladder obstruction causes hypertro-
phy of the bladder wall and bladder stiffness. Hypertrophy
of the bladder wall leads to increased extracellular storage
of collagen, which leads to changes in the innervation pat-
tern and neurologic hypertrophy. It also activates un-
myelinated C nerve fibers, a phenomenon unseen in the
normal bladder, also causing bladder with irritative symp-
toms [9-11]. Treatment options for bladder obstruction
caused by BPH include medication and surgery, and TURP
is known to be the most effective of all the traditional surgi-
cal methods. Once the bladder is free from the obstruction,
the thickened bladder wall undergoes atrophy, and its elas-
ticity is restored, thus improving the irritative symptoms.
The degree of improvement is reported to be especially high
in patients with severe preoperative irritative symptoms
[12]. However, a recent study suggested that TURP does
not improve irritation symptoms in every patient, and 20%
to 30% of patients require medication postoperatively due
to persistent irritative symptoms, thus leading to a de-
crease in quality of life [13]. A study by Seki et al reported
that bladder irritation persisted more frequently in pa-
tients whose IPSS consisted mainly of irritative bladder
symptoms [14]. Of the irritative symptoms, frequent noctu-
ria before surgery led to the persistence of irritative symp-
toms more often. Loss of bladder contractility and the pres-
ence of bladder obstruction before surgery were also re-
lated to the persistence of irritative symptoms. Chung et
al reported that the rate of postoperative improvements in
irritative bladder symptoms was higher in the group with
bladder obstruction, and they concluded that the presence
of bladder obstruction is an important factor in symptom
etiology [15].
　In our study, 42% of the patients reported persistence of
postoperative irritative bladder symptoms, and the rate of
persistence was significantly higher among patients re-
porting severe preoperative irritative bladder symptoms
(urgency, urinary frequency, and nocturia). Unlike pre-
vious studies, the rate of persistence was higher in groups
with more severe irritative symptoms; this can be ex-
plained by the fact that this study enrolled only patients
with bladder obstruction, whereas other studies included
patients free of bladder obstruction. This difference sug-
gests a need for a larger study that includes patients both
with and without bladder obstruction.
　Clinically, the presentation of BPH is caused by bladder
obstruction, but there are various morphological variations
of BPH. Wasserman et al classified BPH into 7 morpho-
logical types and compared their ultrasonographic charac-
teristics to their pathology [8]. He reported that the most
clinically common types include hyperplasia of the tran-
sition zone, retrourethral hyperplasia, and concomitant
hyperplasia of the transition zone and retrourethra. Song
et al reported that most BPH patients showed either hyper-
plasia limited to the transition zone or retrourethral hyper-
plasia [16]. They also reported that the postoperative se-
verity of irritative bladder symptoms was different be-
tween the two groups, and that the rate of persistence of
irritative symptoms was especially high in patients with
retrourethral hyperplasia. They suggested that hyper-

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Korean J Urol 2010;51:700-703
Bladder Irritation Symtoms after TURP
703
trophy of the bladder neck as well as an increased chance
of bladder neck injury during surgery was associated with
the persistence of irritative symptoms in patients with ret-
rourethral hyperplasia. Housami and Abrams reported
that desensitization of the bladder neck nerves via injection
of botulinum toxin improved irritative symptoms in their
study population, suggesting that a change in bladder neck
innervation is an important factor in the pathogenesis of
irritative symptoms [17]. Their study also showed a higher
rate of persistent irritative symptoms in patients with ret-
rourethral hyperplasia. This may be due to bladder neck
injury, changes in bladder neck innervation, or injury to the
contractor muscle of the trigone. Further neurologic and
anatomical studies are required for clarification.
　In patients with bladder obstruction due to BPH, TURP
does lead to a significant decrease in symptoms associated
with bladder obstruction in most patients and increases
the patients' quality of life. However, patients whose pre-
operative IPSS comprised mainly irritative bladder symp-
toms and those with retrourethral hyperplasia showed a
significantly higher rate of persistence of irritative symp-
toms postoperatively. Therefore, before undergoing TURP,
patients with severe irritative bladder symptoms or retro-
urethral hyperplasia should be informed about the persis-
tence of bladder irritation after surgery. In addition, ex-
cessive resection of the bladder neck must be avoided in pa-
tients with retrourethral hyperplasia to minimize damage
to the bladder neck in order to prevent potential post-
operative irritative symptoms.
CONCLUSIONS
Many patients show improvements in symptoms after
TURP, but 20% to 30% of patients show persistent irrita-
tive bladder symptoms and a decreased quality of life post-
operatively, eventually requiring medication.
　Irritative bladder symptoms are more likely to persist in
patients with retrourethral hyperplasia and those with a
high proportion of irritative symptoms upon preoperative
IPSS. Such patients may need careful analysis of pre-
operative bladder function through urodynamic studies,
and excessive resection of the bladder neck should be avoid-
ed in these patients.
Conflicts of Interest
The authors have nothing to disclose.
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