What is the recommended hydrotherapy approach for a male patient over 50 years old with prostatic calculi?

Hydrotherapy is Not a Recognized Treatment for Prostatic Calculi

There is no evidence-based role for hydrotherapy in the management of prostatic calculi, and this approach is not mentioned in any current urological guidelines or literature. Prostatic calculi require either conservative management or surgical intervention depending on symptoms, not water-based therapies.

Understanding Prostatic Calculi

Prostatic calculi are common in men over 50, occurring in 7-70% of this population, and are typically discovered incidentally during transrectal ultrasonography for benign prostatic hyperplasia evaluation 1. These stones form through two mechanisms:

• Endogenous stones: Result from obstruction of prostatic ducts by BPH or chronic inflammation 1
• Extrinsic stones: Occur around the urethra due to urine reflux 1
• Composition: More than 80% are calcium phosphate 1

Clinical Management Approach

When Treatment is NOT Required

Most prostatic calculi are asymptomatic and require no treatment whatsoever 1. The majority of cases are found incidentally and should simply be monitored 1, 2.

When Treatment IS Required

Treatment becomes necessary only when patients experience 1, 2:

• Voiding difficulty from large stones causing obstruction
• Chronic pelvic pain associated with chronic prostatitis
• Severe lower urinary tract symptoms (particularly with large type B calculi) 3
• Recurrent urinary tract infections

Definitive Treatment Options

When intervention is warranted, the evidence supports 1, 4:

• Transurethral electroresection loop: For routine stone removal 1
• Holmium laser lithotripsy: Modern minimally invasive option for stone fragmentation and removal 1
• Open prostatolithotomy: Reserved for giant prostatic calculi that replace the entire gland 4
• TURP with stone removal: Historical gold standard when stones coexist with significant BPH requiring surgical management 5

Medical Management of Associated BPH

For men with prostatic calculi and concurrent BPH symptoms, medical therapy can be highly effective 5:

• Alpha-blockers (such as tamsulosin 0.4 mg daily) provide symptom relief within 2-4 weeks by reducing smooth muscle tone 6
• Combination therapy with a 5-alpha reductase inhibitor should be added when prostate volume exceeds 30cc 6
• This approach reduced International Prostate Symptom Score from 18.3 to 9.4 and post-void residual from 354 to 179 mL in men who had bladder stones removed endoscopically 5

Critical Clinical Pitfalls

Do not pursue unproven therapies like hydrotherapy when evidence-based options exist. The key decision points are:

1. Asymptomatic calculi: No treatment needed, routine monitoring only 1, 2
2. Symptomatic calculi with mild-moderate LUTS: Trial of medical management with alpha-blockers ± 5-ARI 6, 5
3. Large obstructing stones or refractory symptoms: Surgical removal via transurethral approach or laser 1, 4
4. Giant calculi replacing the gland: Open surgical approach may be required 4

Refer to urology for patients with recurrent urinary retention, recurrent infections, bladder stones, renal insufficiency from obstruction, or severe symptoms (IPSS >19) despite medical therapy 6.