Which condition should be surgically addressed first in a patient with inguinal hernia and Benign Prostatic Hyperplasia (BPH)?

Management of Inguinal Hernia in a Patient with BPH

In a 70-year-old male with both inguinal hernia and BPH, the prostate surgery should be performed first to reduce the risk of hernia recurrence and postoperative urinary complications.

Rationale for Addressing BPH First

• Treating BPH before hernia repair significantly reduces the risk of urinary tract infections (UTIs) after hernia surgery compared to performing hernia repair first (0% vs. 31% UTI rate) 1
• Unresolved bladder outlet obstruction from BPH can lead to increased intra-abdominal pressure during voiding, which may contribute to hernia recurrence if the hernia is repaired first 2, 3
• Pathologies causing bladder outlet obstruction, such as BPH, are known risk factors for inguinal hernias and can increase the risk of recurrence if not addressed 3

Clinical Considerations for BPH Treatment

• Surgery is recommended for BPH patients with:

  • Refractory urinary retention
  • Recurrent urinary tract infections
  • Bladder stones
  • Renal insufficiency due to BPH
  • Recurrent gross hematuria 4

• Transurethral resection of the prostate (TURP) remains the benchmark therapy for BPH and should be considered the primary surgical approach 4, 5

• Preoperative evaluation should include:

  • Medical history
  • AUA Symptom Index score
  • Urinalysis
  • Post-void residual measurement 5

Approach to Inguinal Hernia Repair

• After successful treatment of BPH, proceed with inguinal hernia repair 1
• Mesh repairs are superior to non-mesh tissue-suture repairs for inguinal hernia 6
• Local anesthesia is a suitable and economic option for open hernia repairs, especially in day-case settings 6

Benefits of Sequential Approach (BPH First, Then Hernia)

• Decreased incidence of UTIs after hernia repair 1
• Lower risk of hernia recurrence due to resolution of increased abdominal pressure from dysuria 2
• No significant risk of hernia incarceration or strangulation while awaiting repair after prostatectomy 1

Special Considerations

• In cases where both conditions require urgent intervention, simultaneous procedures may be considered, though this approach should be reserved for specific situations 2, 7
• Combined procedures have shown good outcomes in selected patients with a morbidity rate of approximately 10.7% 7
• When performing simultaneous procedures, spinal anesthesia is commonly used (96.8% of cases in one study) 2

Potential Complications to Monitor

• After TURP, monitor for:

  • Sexual dysfunction
  • Irritative voiding symptoms
  • Bladder neck contracture
  • Urinary tract infection
  • Hematuria 5

• After hernia repair, monitor for:

  • Wound infection
  • Recurrence
  • Chronic pain 6