Experts indicate a conservative approach as the first-line treatment option of BPH in patients suffering from neurogenic lower urinary tract dysfunction [18]. The use of α-blockers (α-adrenoreceptor antagonists ) in mild/moderate obstruction has shown significant voiding improvement [19, 20] but clinicians should expect poor results in those with more severe neurological impairments [21, 22]. Combining this with a 5-α reductase inhibitor in order to reduce the size of the prostate, decrease symptoms, and allow for continued catheterization (if performed), may be taken into account [10, 23–25].

It is important to emphasize that it is sometimes impossible to discriminate between lower urinary tract symptoms resulting from BPH and those secondary to neurological disease. Symptoms secondary to BPH such as poor urine flow, frequency, urgency, and nocturia may also be induced by neurogenic bladder dysfunction. Urodynamic study may also present ambiguous findings. In these settings, conservative treatment is preferable to irreversible surgical intervention [1].

Surgical treatment of BPH in patients suffering from retention with concomitant neurological disorder remains a matter of dispute. The main concern includes post-surgical appearance or exacerbation of urinary incontinence instead of retention . Unfortunately, there is a paucity of long-term and randomized studies performed on large cohorts. Existing data are limited to single studies or case reports and do not allow one to make reliable conclusions and recommendations.

It has been proposed that patients who do not suffer from sacral/infrasacral lesions and peripheral denervation involving the pudendal nerve responsible for the activity of the external sphincter (these lesions typically leads to neurogenic detrusor underactivity and/or neurogenic sphincter deficiency—see Chap. 3) should have no negative consequences (especially stress urinary incontinence) from prostatic surgery and might benefit from removal of bladder outflow obstruction [18].

Some data are available for patients suffering from Parkinson disease. Because Parkinson disease and BPH are common in late middle-aged males, their concurrence is probable and often seen. A retrospective study of 23 men suffering from Parkinson disease who underwent transurethral resection of the prostate (TURP) due to bladder outlet obstruction secondary to BPH and were followed for 3 years after surgery demonstrated interesting findings [26]. According to the preoperative Abrams–Griffiths nomograms 52% of patients were obstructed, 22% equivocal, and 26% unclassified, as they could not void but did demonstrate increase in detrusor pressure. Of the 14 patients with a preoperative indwelling urinary catheter, TURP restored voiding in 9 (64%), and only 5 (36%) required catheterization postoperatively. Of the 10 patients with preoperative urge urinary incontinence, continence was restored in 5 and improved in 3 following TURP. There were no cases of de novo urinary incontinence after transurethral prostate resection. To summarize, at a median postoperative follow-up of 3 years TURP was successful in 16 of the 23 patients (70%). Authors concluded that TURP for BPH in patients with Parkinson disease may substantially improve lower urinary tract function and the risk of de novo urinary incontinence is minimal. They added that Parkinson disease should no longer be considered a contraindication for TURP, provided that preoperative investigations including urodynamic assessment indicate prostatic bladder outflow obstruction. In view of these findings, multiple experts propose that patients with Parkinson disease and BPH can be considered for appropriate surgery and that preoperative investigations, including urodynamic assessment, should be used to confirm the diagnosis of BPH in such patients [18, 27, 28]. On the other hand, a retrospective study on post-TURP continence in 50 parkinsonian patients revealed a high incidence of incontinence following the procedure [29]. However, authors emphasized the fact that some of these patients were likely to have had multiple system atrophy, a disease with frequent denervation of the external urinary sphincter resulting in neurogenic sphincter deficiency [30]. Therefore, accurate differentiation between Parkinson disease and multiple system atrophy (more severe, rapidly progressive, multisystemic and fatal disease classified as a form of atypical parkinsonism—see Chap. 3) is critical before surgical intervention for BPH [1]. In patients with a diagnosis of Parkinson disease but who have clinical symptoms that are more aggressive and extensive, including pyramidal or cerebellar signs, erectile dysfunction, severe postural hypotension, and marked urinary incontinence, a diagnosis of multiple system atrophy should be suspected and investigated before proceeding to surgery [31].

A series of 39 patients with a history of one or more cerebrovascular accidents and who underwent TURP for BPH showed less encouraging results [32]. Only 50% had a satisfactory result from the operation and 11.7% died within 3 months of surgery. Better results were achieved in those under the age of 70 and who had their operation more than 1 year after the stroke. Authors also indicated that the degree of neurological deficit at the time of operation has a significant influence on final outcomes.