Benign prostatic hyperplasia (BPH) is the commonest cause of bladder outlet obstruction (BOO) in aging men. If untreated, patients could suffer from different associated complications such as urinary tract infection, hydronephrosis and renal failure (3, 8, 9). This study attempted to assess the clinical profile, magnitude and pattern of associated complications of BOO among patients with BPH. The mean age of patients was 64.8 years in this series and this was comparable to other studies (10, 11). Mean age of 70 years was reported by Botto et al (12). The lowest age with BOO due to BPH in Ugwumba et al (11), Botto et al (12), and Ibrahim et al (13) studies were 47, 49 and 50 years, respectively. It is observed that many men over the age of 40 will develop histologic benign prostatic hyperplasia, but not all will develop bothersome lower urinary tract obstruction (14). The lowest age in this series was 40 years. The majority of patients in this, Ugwumba et al (11) and Seife et al (15) studies were in age group 60–69 years. Most patients in Ibrahim et al series were between 70–79 years (13). Benign prostatic hyperplasia is primarily obstructive and obstructive symptoms of LUTS are expected to predominate in patients’ presentation. However, men with BPH more commonly present with irritative than obstructive symptoms (3) and this was in agreement to our study where most patients presented mainly with frequency of urination, dysuria and nocturia. Ibrahim et al (13) and Ahmed (16) also showed frequency of urination in 87% and 90.5% of their patients, respectively. About 50.7% of our patients had acute urinary retention and this was observed in 81.3%, 35.6%, 40% and 79% of the patients in Berhanu (10), Ugwumba et al (11), Seife et al (15) and Ahmed (16)) studies, respectively. The majority of patients in the Western world present apparently early with mildly enlarged prostates but in the developing countries most patients present very late with big prostates (11, 13). In this and Ibrahim et al studies (13), the mean duration of symptoms at presentation were 21.8 and 25.8 months, respectively. The duration of symptom presentation ranged 1- 120 months in our series and this ranged 1-168 months in Ibrahim et al study (13). The mean volume of the prostate in this series was 80.7 ml. Mean prostatic volumes of 73.6ml (10), 100.7ml (11), 103.6ml (13) and 70ml (16) were reported in other studies. Deori et al reported mean prostatic volume of 43ml in their series (17).
Berhanu reported recurrent urinary tract infection (UTI) in 60.9% of his patients (10). History of prehospital antibiotic treatment for recurrent UTI was found in the majority of our patients and most of these patients presented to the hospital 2 years after the onset of their symptoms. Patients with BOO 2° to BPH could have recurrent UTI and treatment with antibiotics would provide transient relief of symptoms until another episode of UTI with irritative symptoms occur for patients to revisit health institutions. Prehospital treatment for recurrent UTI and the transient relief of symptoms might be the reasons for some patients’ remarkable late presentation to our hospital. Irritative symptoms of LUTS might mislead clinicians to delay the diagnosis and treatment of the primary cause unless careful history taking and physical examination including digital rectal examination are done and wide ranges of possible causes including BPH are considered in male patients after the age of 40 years (3–7).
Recurrent urinary retention was the predominant complication observed in the developed world (18), whereas features of late presentation such as urinary bladder diverticuli, stones, and impaired renal function were common in the developing countries (19, 20). Acute urinary retention, urinary tract infection and hydronephrosis were the principal associated complications observed in our study and the commonest associated complications observed in Ibrahim’s et al series were urinary tract stones, groin hernia and impaired renal function (13). Our patients with acute urinary retention were managed with transurethral catheterisation and urinary tract infections were treated with antibiotics before surgery. Urinary bladder stones were removed simultaneously at the time of prostatectomy. Preoperatively, continuous transurethral catheter drainage was used to optimise the conditions of patients with bladder outlet obstruction due to BPH complicated by renal function impairment. Patients with frank haematuria were managed by continuous transurethral catheter irrigation and blood transfusion was given for those indicated before surgery.
Comorbid medical conditions are common among elderly males. Hypertension and diabetes mellitus were the main comorbid medical conditions observed in this study and similar findings were noted in other studies (11, 13).
Urinary tract and surgical site infections were the main postoperative complications observed in our patients. Bladder calculi and clot retention were the commonest complications reported by Ugwumba et al (11) and Ibrahim et al observed retrograde ejaculation, clot retention and wound infection as the main postoperative complications in their series (13). Wound infection, transient urinary incontinence and suprapubic leak were the commonest postoperative complications noted by Seife et al (15). Absence of some postoperative complications such as retrograde ejaculation and sexual dysfunction in this study may be due to the cultural barrier of providing such information. The mortality rate observed in this report was comparable to most African studies (11, 13) except to that of Berhanu where he reported no death in his study (10).
There are multiple limitations to this study. It was a hospital based, single centre study and the conclusions made might not represent the society at large. As it was a retrospective study, further clinical symptoms and associated complications of BOO 2° to BPH could not be ascertained. Besides, some variables that could potentially contribute to associated complications such as the severity of bladder outlet obstruction were not directly assessed.
In conclusion, irritative symptoms of LUTS were the predominant symptoms among our patients with BOO secondary to BPH. Transient relief of symptoms by antibiotic treatment might contribute to our patients’ late presentation. Associated complications of BOO 2° to BPH were prevalent in the study and acute urinary retention, urinary tract infection, hydronephrosis, renal function impairment, bladder stones and frank haematuria were the complications observed.
Clinicians should bear in mind the possibility of BPH as a cause and thoroughly examine and further investigate when male patients after the age of 40 years present with predominantly irritative LUTS. This would help to detect BPH early and reduce the occurrence of associated complications which may be associated with increased morbidity and mortality. Further studies are recommended.