Treatment of Symptomatic Prostate Stones
Transurethral resection (TUR) is the recommended first-line treatment for symptomatic prostate stones, especially when associated with significant lower urinary tract symptoms or complications.
Understanding Prostate Stones
Prostate stones (prostatic calculi) are common findings in middle-aged and elderly men, with prevalence ranging from 7% to 70%. They can be classified as:
- Primary/endogenous stones: Formed within the prostatic ducts due to obstruction from BPH or chronic inflammation
- Secondary/extrinsic stones: Formed around the urethra due to urine reflux
Most prostate stones are asymptomatic and found incidentally during diagnostic procedures for BPH. However, when symptomatic, they can cause:
- Chronic pelvic pain (particularly with chronic prostatitis)
- Voiding difficulties
- Recurrent urinary tract infections
Treatment Algorithm for Symptomatic Prostate Stones
1. Assessment of Symptom Severity
Mild symptoms with small stones:
- Consider conservative management with alpha-blockers (e.g., tamsulosin 0.4 mg daily) 1
- Monitor for symptom improvement using validated tools (International Prostate Symptom Score)
Moderate-to-severe symptoms or complications:
- Proceed to surgical intervention
2. Surgical Management Options
First-line Treatment:
- Transurethral removal using:
- Electroresection loop
- Holmium laser
This approach allows for simultaneous treatment of both the stones and any underlying BPH 2.
For patients with concurrent BPH and bladder stones:
- Transurethral resection of the prostate (TURP) is considered the benchmark surgical therapy 3
- Alternative energy sources may be considered based on surgeon expertise and patient factors
3. Special Considerations
For patients with bleeding disorders or on anticoagulation:
- Ureteroscopy (URS) is recommended as first-line therapy when intervention is necessary 3
For patients with urinary infection:
- Establish appropriate drainage
- Administer antibiotics
- Obtain urine culture
- Delay definitive procedure until infection is cleared 3
Evidence for Conservative Management
Some studies suggest that conservative management may be appropriate for selected patients:
In a study of 34 men with bladder stones and concurrent BPH, 76.5% had no complications with conservative management (alpha-blockers ± dutasteride) during a mean follow-up of 52.6 months 4
Another study of 23 men with bladder stones secondary to BPH showed that 78% had no complications after endoscopic stone removal followed by medical management of BPH 5
However, these studies focused on bladder stones rather than prostatic stones specifically, and the complication-free survival decreased over time (70.5% at 5 years) 4.
Important Caveats and Pitfalls
Prostate volume matters: Larger prostate volume is associated with higher risk of complications when choosing conservative management 4
Watch for recurrence: Stone recurrence rates of 17-18% have been reported with conservative management 4, 5
Infection risk: Always obtain appropriate cultures if purulent material is encountered during procedures 3
Avoid routine stenting: Guidelines recommend against routine stenting following urological procedures unless specific indications exist 3
Consider patient factors: Age, comorbidities, and symptom severity should guide treatment decisions
For symptomatic prostate stones causing significant bother or complications, surgical intervention with transurethral techniques remains the most definitive treatment with the best outcomes for morbidity, mortality, and quality of life.