Straining while passing urine with painless very high post void residual

68 years male patient presented with history of straining while passing urine amounting to pseudo frequency of stool since 1 year. 

No feeling of incomplete voiding or bladder fullness or pain. No incontinace. 
O/e: Suprapubic fullness. 
Per rectal examination : prostate small,  smooth, firm and non tender  
Uroflowmetery : poor flow. 
Maximum flow 8
Attaching USG for review. 
What is possible diagnosis and treatment? 

Straining while passing urine with painless very  high post void residual


  • Prabir Basu
    Prabir Basu
    13 Feb 2020 10:11:48 PM

    How are the kidneys on ultrasound? Creatinine?

    DRE - anal tone? Comorbidity viz, diabetes?

  • Dr. Anil Takvani
    Dr. Anil Takvani
    14 Feb 2020 07:28:25 AM

    Dr.  Prabir, 
    Thanks for raising relavent issues..
    No hydronehrosis  
    S.  Creatinine : 1.46mG%
    Anal tone good,  no focal neurological issues. 
    No DM
    VPC in ECG but benign in nature 

  • Nitesh Jain
    Nitesh Jain
    15 Feb 2020 06:28:49 AM

    Looks like BPH , needs PSA .... if not on any alpha blocker than a trial can be give and reassessed after couple of weeks (presuming there is no bilateral HUN) .... if still not improved symptomatically than TURP can be planned (belive neurologically he is normal) .... 

    What’s the reason of marginally raised RFT

  • Dr. Anil Takvani
    Dr. Anil Takvani
    15 Feb 2020 08:21:51 AM

    If you see carefully attached USG and report : > 450 cc PVR,  median lobe and thick wall. 

    How the alpha blocker will help in this circumstances? He is almost in retention of urine. 
    P/r: prostrate smooth and firm,  no module or nodules,  it is not hard.  Why PSA?
    Anal tone is good,  neurologically normal. 

  • shriram joshi
    shriram joshi
    16 Feb 2020 08:51:01 PM

    A large intravesical enlargment of the prostate along with lateral lobes which may not be big, will give you these symptoms. I would advise drain the overdistended bladder for at least 2-3 weeks and then proceed for a TUR-P. If yo are using a irrigating resectoscope, you will have to start with the middle lobe resection so as to free the bladder neck. This will allow free flow of irrigating fluid. 

    Alpha blockers have a poor influence on the middle lobe is what I was taught. Any comments  Venu ?

  • Venugopal P
    Venugopal P
    17 Feb 2020 05:53:38 PM

    Dear All,

    This topic raises considerable controversy as regards what causes obstruction in BPO (BPH). Patrick Walsh mentioned concerning Anatomy of Prostate in 1998 that ‘It is humbling to realise that even today basic anatomy may not be known or all understood’. This is true even today 20 years later. We all have been sold by McNeal’s Anatomy of prostate and we no longer accept anything but the views as proposed by McNeal. Unfortunately if only McNeal’s view is considered, then many aspects of the distribution of Prostate lobes cannot be clearly understood.

     McNeal divided the prostatic glands into the peripheral, central, and transition zones and the periurethral gland. The peripheral zone corresponds to our posterior lobe. The central zone corresponds to middle lobe and the transition zone corresponds to a part of lateral lobe. McNeal failed to detect the sub-cervical and anterior lobes, and he also failed to identify BPH in the central zone. Therefore, the origin of the sub-cervical, anterior and middle lobe hypertrophy cannot be fully explained by his theory, because he stated that the origin of BPH was only the transition zone and part of the periurethral gland. In addition to this, his transition zone is located only in the proximal portion of the verumontanum. The lateral lobe, however, extends to the apex of the prostatic gland. Therefore, the apex of lateral lobe hypertrophy extends beyond the verumontanum. Coronal section and oblique coronal section as described by McNeal are useful in distinguishing the middle lobe from the posterior lobe, but these methods are not helpful in locating the Sub-cervical and anterior lobes.

    The human prostate could be classified into two divisions, the outer glands and the inner glands, in all age groups. The inner glands could be subdivided into the lateral, anterior, and sub-cervical lobes and the mucosal glands. The outer glands could be subdivided into the posterior and middle lobes. The sub-cervical lobe was not always identifiable in foetal prostates. The sub-cervical and anterior lobes may disappear in the pre- and post-puberty stages and sometimes reappear in the aged stage.

    Another aspect that needs our attention is concerning why some prostate even when small causes considerable symptoms while some others even when enormously enlarged causes very minimal symptoms.

    The question raised by Shyam needs pondering as why Large Prostates may not have much benefit from administration of α Blockers.

    I am providing few articles that will help you to understand the various issues attached to these controversies. There could be overlap among the materials provided.

    The answer to the first question can be got from the article of KT Foo (2016) ‘Solving the benign prostatic hyperplasia puzzle’.

    This aspect has been amply explained by Jason Gandhi et al (2018) while discussing the section on ‘Pathophysiology and Clinical Manifestations’ in the article provided.

    Urethral resistance ensues due to IPP and impedes the hydraulic energy that normally drives micturition. A fluid structural interaction analysis study demon­strated that IPP predisposed the prostate to deformation caused by intravesical pressure as demonstrated by Junming Zheng, Xing Zhou* et al (2015). The authors found that the compression of the prostatic urethra and increased variation of cross-sectional area around bladder neck would diminish urine flow efficiency. B Raychaudhuri and Declan Cahill* (2008) studying the ‘Anatomy of Pelvic Fasciae’ opined that Bladder neck and urethral constraint may be due to the nature of the fascia ‘capsule’ surrounding the prostate. The prostate is adjoined anteriorly by pubo-prostatic lig­aments, posteriorly by Denonvilliers’ fascia, and laterally by endopelvic fascia. Superior to these connections, there is merging with other fascia that leaves the IPP susceptible to the radial component of intravesical pres­sure, thus leading to prostatic deformation. There are many more factors involved in effect of Prostate enlargement on micturition.

    The question raised by Shyam is true even today. There are many recent articles addressing this aspect and most have concluded that the larger the IPP less is the effect of α Blockers. Hence it is not an old concept but is considered true even today. Yu Mi Seo, Hyung Jee Kim* (2012) studying Alfuzocin, found that  Alfuzosin may be less effective in improving symptom scores, PVR, and Qmax in the treatment of LUTS/BPH in the presence of IPP. L Topazio et al (2018) concluded by stating that ‘IPP has found to be significantly and inversely correlated with treatment success in patients with LUTS and BPE under alpha-blockers therapy. Alpha blockers odd ratio of success is 59 times higher in patients with a low grade IPP in comparison to patients with a high grade’.

    With warm regards,



  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    19 Feb 2020 12:40:07 PM

    Thanks Venu Sir for the interesting articles and wonderful compilation of thoughts.

    I have two questions:
    1. Is it necessary to drain bladder for 2-3 weeks before prostatectomy? 
    2. Will we decide about the drainage based on the Pressure-flow study? If PFS shows good detrusor contractions, then do we still need drainage?
    I feel, in view of significant IPP (appears> 15mm), thick detrusor and high voiding IPSS score, I would get a PFS done and suggest TURP/HoLEP for this patient.

  • Ajay Bhandarkar
    Ajay Bhandarkar
    19 Feb 2020 11:52:27 PM

    No pain or fullness in history and >400 ml residual urine indicates more towards Chronic Retention of Urine. 69 years of age, no neurological signs and IPP/median lobe suggests obstructive BPH. Draining bladder for 2-3 weeks is safer option. If we do, PF study and find high pressure low flow, we can intervene early to relieve him.

    As Prof Venu Sir has nicely elaborated, role of alpha blockers is limited here. Thanks Sir for very informative articles. Your comments reminded me of your favourite question in our classroom teachings..... How do you define Obstruction ? ;-)
     I do believe that small non-adenomatous, fibrous BPH is a separate disease entity than overtly adenomatous large BPH.

  • Abhay Mahajan
    Abhay Mahajan
    20 Feb 2020 04:20:56 PM

    I would suggest -

    1. Catheterisation - for two reasons- A.Will reduce infection by draining the high residual urine. &B. It will decompress the bladder & regain some tone pre-operatively.
    2. Urodynamic study before proceeding for surgery
    3. PSA is must even though the prostate is smooth & firm.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    21 Feb 2020 08:48:29 AM

    Thank you all for very much valuable opinions and raising relavent issues. 

    Patient was a father of dermatologist and father in-law  of cancer physician. 
    1. I put the catheter,  I believe in draining these bladders prior to procedure to decompress the bladder, prostatic fossa and reduce prostatic vascular congestion. Also it brings the s.  creatinine at normal level.  I drained it for only 5 to 7 days.
    2. As on clinical side he was feeling bladder fullnes, no constipation, anal tone good and on USG side,  very big median lobe,  thick bladder wall and his full bladder capacity was 550 cc urine.  I don't think he has in  full blown decompensated bladder or neurogenic bladder. So  I avoided pressure flow study.  But anyone asks for PFS, I think  it is perfectly alright. 
    3. Urethrocystosopy : urethra normal,  large median lobe occupying bladder neck,  projecting till trigone,  boll-valve mechanism of obstruction,  thick trabeculated bladder against smooth very high capacity bladder. With these I do not doubt good outcome of turp. Median lobe was completely respected extending little on both the lateral sides.  Nothing was falling from top,  in view of smaller prostate 10 to 2 o'clock area left without resection to avoid future bladder neck stenosis in such type of cases. 
    3. I have not done PSA,  as there was no suspicious.  Biopsy benign. Will not discuss PSA in this post as we have another thread active on website on that issue. 
    4. He tolerated procedure well and was catheter free on 3rd day.  On his first void his comment was,  he is voiding with full strem and with ease after a long time. 
    Post is still open for diverse opinions...thanks  

  • Lalit Shah
    Lalit Shah
    05 Mar 2020 10:16:42 PM

    In such situations I like to keep catheter and give antibiotics for at least two days before proceeding for TURP.If PVR is more than 700-800 ml or there are ? Neurological issues, would like to get UDS before TURP.

    PSA is mostly a part of routine preop work up .

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