Postoperative Pain Management After TURP
For patients undergoing TURP, implement a multimodal analgesic regimen consisting of scheduled paracetamol (acetaminophen) combined with NSAIDs (such as diclofenac or ketorolac), with opioids reserved strictly as rescue medication for breakthrough pain. 1, 2
Core Analgesic Strategy
First-Line: Non-Opioid Multimodal Analgesia
Paracetamol (Acetaminophen): Administer 1g IV or oral every 6-8 hours (maximum 4g/24h) starting intraoperatively or immediately postoperatively and continue for at least 24-48 hours 3, 1
NSAIDs: Use diclofenac 75mg IM twice daily or ketorolac 30mg IV as needed, unless contraindicated 3, 1
- A direct comparison study demonstrated that diclofenac provided superior pain control at 6 hours post-TURP compared to paracetamol alone, with pain scores significantly lower (p < 0.05) 1
- Critical safety note: NSAIDs do NOT increase bleeding risk after TURP when used appropriately—no significant differences in hemoglobin levels, bleeding time, or transfusion requirements were observed between NSAID and paracetamol groups 1
Rescue Analgesia
- Opioids: Reserve tramadol, morphine, or oxycodone exclusively for breakthrough pain not controlled by the baseline regimen 3
Evidence-Based Rationale
The multimodal approach is superior to single-agent therapy because it targets pain through different cellular pathways, providing additive or synergistic effects while reducing individual drug doses and side effects 4, 2, 5. While the evidence base specifically for TURP is limited, the principles derive from robust prostatectomy guidelines that are directly applicable 3.
Why This Differs from Radical Prostatectomy Protocols
TURP is significantly less invasive than open or robotic radical prostatectomy, resulting in lower baseline pain intensity 3. Therefore:
- Regional anesthesia techniques (TAP blocks, wound infiltration, epidural) recommended for radical prostatectomy are NOT indicated for TURP 3
- Intravenous lidocaine infusions recommended for open prostatectomy are unnecessary for TURP 3
- The simpler oral/IV multimodal regimen is sufficient and appropriate 1
Common Pitfalls to Avoid
Bleeding Concerns with NSAIDs
This is a myth that must be dispelled: A prospective randomized study of 50 TURP patients demonstrated no significant difference in postoperative hemoglobin levels, bleeding time, prothrombin time, or INR between diclofenac and paracetamol groups 1. No patients in either group required blood transfusion 1. NSAIDs should be used for postoperative TURP pain control when indicated 1.
Catheter-Related Discomfort
- Bladder spasms and catheter discomfort are distinct from incisional pain and may require anticholinergic medications (e.g., oxybutynin) rather than escalating analgesics 3
- Early catheter removal (day 1-3) when appropriate reduces discomfort without increasing complications 3
Over-Reliance on Opioids
- Opioids should NOT be the primary analgesic strategy—they increase urinary retention risk, nausea, and sedation without superior pain control compared to multimodal non-opioid regimens 4, 2, 5
Practical Implementation Algorithm
Hour 0 (End of Surgery):
- Paracetamol 1g IV + Diclofenac 75mg IM 1
Hours 1-24:
- Paracetamol 1g every 6-8 hours (oral or IV) 3, 1
- Diclofenac 75mg IM every 12 hours OR Ketorolac 30mg IV every 6-8 hours 3, 1
- Assess pain with VAS at 30 minutes, 1,2,4, and 6 hours 1
Breakthrough Pain (VAS >4):
- Tramadol 50-100mg oral/IV OR Morphine 2.5-5mg IV 3
Beyond 24 Hours:
- Transition to oral paracetamol + oral NSAID (ibuprofen 400-600mg every 6-8 hours) as needed 3
- Discontinue scheduled analgesics when pain is mild (VAS <3) 1
Special Populations
Patients on anticoagulation: NSAIDs can be used safely once hemostasis is confirmed and anticoagulation is appropriately managed perioperatively 6. The evidence shows no increased bleeding with NSAIDs in standard TURP patients 1.
Elderly patients: No dose adjustment of paracetamol or NSAIDs is required, but monitor renal function if using NSAIDs beyond 48 hours 1, 2