**5.1.1 Mortality**

356 Chronic Kidney Disease

Clinical presentation of BPH/obstructive uropathy varies and reflects the source and duration of obstruction. In BPH, symptoms results from the direct bladder outlet obstruction (BOO) from enlarged tissue (static component) and the increased smooth muscle tone and resistance within the enlarged gland (dynamic component). This physiologic issues reflect in voiding dysfunctions, that significantly affects the health and quality of life of

Most of the patients have characteristic symptoms. Patients' complaints are usually nocturia, urgency (imperious will to hold urine, some with complaints of incontinence), weak urinary stream (with decreased flow rate, low values in Qmax and Qaverage), a sense of incomplete bladder emptying, straining during micturition, increased micturition frequency and dribbling during or after urination (Rule, Lieber et al. 2005). Physical examination consists in a digital rectal examination (evaluating prostate characteristics and volume) and lower

Recurrent or persistent urinary tract infections (UTI) are associated with prolonged urinary stasis of lower urinary tract obstruction, dysuria, frequency, urgency and hematuria are

Chronic urinary retention as consequence of BPH has been defined as a palpable bladder that corresponds to a high PVR (Neal 1990), and most of the patients with chronic urinary retention have an indolent and progressive disease, with worsening of urinary symptoms and the majority of these patients just seek for medical care in bad health conditions with sharp renal insufficiency. It is always necessary to investigate symptoms and signs of chronic renal failure – nausea, vomiting, lethargy, edema and hypertension, that occur at late stage, usually with irreversible renal damage (Sacks, Aparicio et al. 1989), principally in older patients with other comorbidities (mainly diabetes and hypertension). In rare cases patients who resort to the emergency room because of anuria, require interventional procedures like indwelling catheter, nephrostomy (uni or bilateral) and sometimes

Although signs and symptoms of BPH are normally present, there are a significant number of patients that are relatively asymptomatic (Tseng and Stoller 2009) (without significant voiding dysfunction), but can present primarily clinical sequel of renal insufficiency – uremia; with nausea, vomiting and mental status changes – and analytical changes –

Older patients with voiding dysfunctions caused by chronic urinary obstruction, might present hypertension due to hypervolemia in the case of bilateral obstruction or increased renin release (Tseng and Stoller 2009). Hypertension, on other hand can be itself the sole

The development and validation (for different languages) of the standardized, selfadministered symptom index (International Prostate Symptom Score [IPSS]) has been a critical event in the clinical research on LUTS and BPH (Cockett, Barry et al. 1992; Wein 2007). This diagnostic and follow-up tool is extraordinary, and the availability of validated translations in many common languages allows cross-cultural comparisons among man

In addition the enumeration of symptoms by frequency and time of occurrence, the bother associated with the symptoms, interference with activities of daily living, and the impact the

abdominal percussion and palpation to assess for bladder distension.

common complaints among men with UTI.

(depending the level of renal function) hemodialysis.

electrolyte disturbances (hypercaliemia and nonanion gap acidosis).

many older men.

cause of renal failure.

with BPH or LUTS from other causes.

La Vecchia et al, reported that in the early 1980s, overall mortality from BPH ranged between 0,5 and 1,5/100 000 in most western European countries (La Vecchia, Levi et al. 1995). Between the early 1950s and the late 1990s, the overall mortality from BPH in the European Union (EU) fell from 5.9 to 3.5 per million, and the decline since the late 1950s was over 96%. Comparable falls were observed in the USA and Japan, and BPH mortality rates in the late 1990s were lower than in the EU (1.8/10(6) in the USA, 1.4 in Japan). BPH mortality trends were downwards also in the Eastern Europe, although rates in the late 1990s were about fourfold higher than in the EU (Levi, Lucchini et al. 2003).

Recent works have proven decreasing mortality rates related with BPH. The fall in BPH mortality, evident in statistics on underlying cause, was confirmed by statistics on all certified causes of death. In England, underlying-cause mortality reduced from 9.2 deaths per million in 1995 to 4.5 deaths per million in 2006 (Duncan and Goldacre 2011). The fall is remarkable in scale, likely to be attributable to clinical care, and could be regarded as an indicator of improving standards of care (Duncan and Goldacre 2011).

It is important to remember that patients in renal failure have an increased risk for complications following TURP compared with patients with normal renal function (25% versus 17%) (Holtgrewe, Mebust et al. 1989) and the mortality increases up to sixfold (Holtgrewe and Valk 1962; Melchior, Valk et al. 1974).

#### **5.1.2 Bladder stones**

In a large autopsy study the prevalence of bladder stones was eight times higher in men with a histological diagnosis of BPH (3.4%) than in control subjects (0.4%), but no increased incidence of ureteral or kidney stones was found (Grosse 1990). Bladder stones are in line with urinary retention, stasis and urinary infection, factors that propitiate ion aggregation and stone nucleation.

#### **5.1.3 Urinary tract infections**

In previous surgical series, urinary tract infections (UTIs) constitute the main indication for surgical intervention (12% of patients) (Holtgrewe, Mebust et al. 1989). Urinary tract infections are generally due to chronic urinary obstruction caused by increased amounts of residual urine, that predispose to UTIs (Mebust, Holtgrewe et al. 1989).

#### **5.1.4 Urinary incontinence**

Incontinence is one of the most feared complications from surgical intervention for BPH (McConnell, Barry et al. 1994), although it may be the result of BPH secondary to

Benign Prostate Hyperplasia and Chronic Kidney Disease 359

**Incomplete emptying**

you finish urinating?

**Frequency** 

**Intermittency** 

postpone urination?

strain to begin urination?

time you got up in the morning?

**Weak stream** 

urinary stream?

**Straining** 

**Nocturia**

urinated?

**Urgency** 

Over the past month, how often have you had a

sensation of not emptying your bladder completely after

Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

Over the past month, how often have you found you stopped and started again several times when you

Over the last month, how difficult have you found it to

Over the past month, how often have you had a weak

Over the past month, how often have you had to push or

Over the past month, many times did you most typically get up to urinate from the time you went to bed until the

Table 1. International Prostate Symptom Score (IPSS).

**Total IPSS Score**

Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

None 1 time 2 times 3 times 4 times 5 times or more

0 1 2 3 4 5

overdistention of the bladder (overflow incontinence) or to detrusor instability. It is estimated to affect up to one half or more of all obstructed patients (urge incontinence) (McConnell, Barry et al. 1994; McConnell, Bruskewitz et al. 1998; Wein 2007).
