After a HoLEP, most of the questions I get are about the days that follow rather than the operation itself: how long will the catheter stay in, why am I still seeing blood, when can I get back to normal, and what is normal and what is not.
This guide answers those questions. It does not replace the specific instructions you are given when you leave hospital (every patient and every prostate is different), but it will help you know what to expect and when something needs checking.
First, what exactly has been done
In HoLEP (holmium laser enucleation of the prostate), the prostate is not removed. The inner part, which has grown and is pressing on the channel that urine passes through, is separated and taken out, and the outer capsule is left intact. It is the modern equivalent of open surgery, but done endoscopically, with no cuts in the abdomen.
That explains two things about the recovery. First, the improvement in passing urine is usually noticeable early on. Second, the operation leaves a raw surface inside that has to heal, and that surface is behind almost everything you will notice in the first few weeks.
The first few days
The catheter. You come back from theatre with a urinary catheter and a continuous washout that keeps the bladder clear of clots. The catheter usually comes out after 24 to 48 hours, once the urine is clear enough. It is not painful, but it is uncomfortable: it is common to feel the urge to pass urine even with the catheter in place.
Your hospital stay. Usually one or two nights. You go home once you are passing urine on your own and it looks acceptable.
Passing urine again. Once the catheter is out, it is common to have some stinging and urgency and to need the toilet often, including at night. This does not mean the operation has gone wrong: your bladder has spent years working against a blockage and needs time to adjust.
Blood in the urine: the most alarming part, and the most normal
This is what prompts the most phone calls, so it is worth explaining properly.
Pink or bloodstained urine in the first few weeks is to be expected. It can come and go: the urine is clear for a few days and then one day it turns pink again, often after some physical effort or simply because a scab inside has come away as the surface heals. It is common for the bleeding to pick up again around the second or third week, just when you were feeling well and least expecting it.
What helps: drinking plenty of water (one and a half to two litres a day, unless you have been told to limit your fluids), avoiding strenuous effort and avoiding constipation.
When you do need to seek help is explained below, under warning signs.
Bladder control in the first few weeks
After the catheter is removed, many patients notice some leakage of urine, especially when they feel a sudden urge or exert themselves. This happens because an outlet that had been narrow for years has suddenly been opened up.
In most cases it improves gradually over the first few weeks. Pelvic floor (Kegel) exercises are the main way to speed up that recovery. You start them once the catheter is out, never while it is still in.
I explain them step by step in a separate article, because it is very common to do them wrongly, and done wrongly they are no use at all.
Ejaculation
It is better to know this beforehand than to find out afterwards: after a HoLEP, the most common result is retrograde ejaculation. Instead of coming out, the semen goes back into the bladder and is passed later with the urine.
It is neither dangerous nor painful and does not change the sensation of orgasm, but it does affect fertility. It is a common effect of this type of surgery and is generally permanent. Erections are a separate matter, and this operation does not usually affect them.
If fertility matters in your case, please tell me before the operation, because it changes the conversation about which technique is right for you.
Getting back to normal
These times are only a guide and depend on your case and on the work you do:
- Walking: from the first day. I actively recommend it.
- Driving: once the catheter is out and you feel comfortable, usually within the first week.
- Office work: after about two weeks.
- Physical work, sport, heavy lifting: best to wait three to four weeks, then build up gradually.
- Cycling: one of the last things to go back to, because of the direct pressure on the area.
- Sex: usually from three or four weeks.
Two pieces of advice apply throughout the recovery: avoid constipation (straining on the toilet is one of the most common triggers of bleeding) and do not stop any of your usual medication unless you have been told to, especially if you take anticoagulants or antiplatelet drugs (blood thinners). That is planned individually for each patient.
Warning signs: when to get help straight away
Go to A&E (Urgencias) or contact me if any of the following happens:
- You cannot pass urine and your bladder feels full and painful. This is the most important one.
- Your urine comes out very red, thick or with clots that make it difficult to pass.
- A temperature of 38 °C or above, with or without shivering.
- Severe pain that does not settle with the painkillers you have been prescribed.
- Severe stinging when you pass urine, getting worse rather than better as the days go by.
Everything else (urine that turns pink on and off, urgency, the odd leak, discomfort when passing urine) is to be expected during the first few weeks.
Follow-up appointments
The first follow-up appointment is usually a few weeks after the operation. At that visit I look at how you are passing urine and go over any symptoms you still have; depending on the case, a urine flow test and an ultrasound scan are done to check that your bladder is emptying properly.
That is the time to raise anything you noticed at home. No worry is too small to mention: most questions after surgery can be cleared up with an explanation.
Key points
- The improvement in passing urine is usually noticeable early; full recovery takes weeks.
- Blood in the urine on and off in the first few weeks is normal, even if it picks up again for a while.
- Early leakage usually improves, and pelvic floor exercises help.
- Retrograde ejaculation is common and worth knowing about in advance.
- Being unable to pass urine, a high temperature or clots mean you should seek help straight away.
If you are waiting for prostate surgery, or have already had it and something is not going as you expected, you can book an appointment. I see patients in Palma (Quirónsalud Palmaplanas) and in Manacor (Més Consultes Mèdiques).
Appointments: +34 971 918 000 (Palma) · +34 971 559 000 (Manacor). You can call in English.
Find out what HoLEP laser prostate surgery involves
Dr José Luis Bauzá Quetglas
Urologist. Registered with the Balearic Medical Association (COMIB), no. 070709805.
Palma — +34 971 918 000 · Manacor — +34 971 559 000
info@urologodrbauza.com
This article is general information and does not replace a medical consultation. Every case needs to be assessed individually.
