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Rezum Post-Procedure: Symptoms, Recovery, & Medications

Author Zachary Schmitz covers Rezum Post-Procedure: Symptoms, Recovery, & Medications on BackTable Urology

Zachary Schmitz • Aug 23, 2023 • 1.8k hits

Rezum is a minimally invasive procedure to reduce symptoms of benign prostatic hyperplasia (BPH) by injecting sterile water vapor into the prostate gland. Rezum post-procedure practices consist of catheterization, antibiotics such as Bactrim and Celebrex, anti-inflammatory drugs including steroids, patient counseling, and periodic follow-up evaluations. Urologist Dr. Seth Bechis describes his Rezum post-procedure practices, recovery timeline, and typical patient outcomes, as well as possible irritative and storage symptoms that can occur post-procedure.

This article features transcripts for the BackTable Urology Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.

The BackTable Urology Brief

• Patients undergoing the Rezum procedure should expect to have a catheter postoperatively. The duration of a catheter after Rezum procedure can vary between 3 to 7 days, depending on the size of the prostate. Symptom improvement may not be immediate; patients might start seeing improvements as early as three weeks, but maximum improvements are typically seen between 3 to 6 months.

• Approximately one in four patients may experience Rezum side effects, or a worsening of irritative symptoms post-procedure, including a less commonly discussed symptom: urethral pain at the tip of the penis, especially towards the end of voiding.

• Bactrim can help prevent urinary tract infections related to catheter removal and may reduce inflammation, potentially accelerating Rezum recovery. For patients complaining about postoperative urethral burning or irritative symptoms, a four-week course of Celebrex has been found to be highly effective.

• There is potential benefit in the proactive use of Celebrex, particularly if during the procedure, a significant amount of bubbles escape, indicating a potential risk for short-term urethral inflammation. Some practitioners use a short course of steroids in the first postoperative week to reduce inflammation.

• Follow-up for patients after a Rezum procedure typically involves visits at three days, six weeks, and three months. Some patients may exhibit storage symptoms despite successful prostate enlargement reduction. In such cases, it's critical to manage patient expectations and ensure comprehensive counseling.

Rezum Post-Procedure: Symptoms, Recovery, & Medications

Table of Contents

(1) Setting Patient Expectations for Rezum Side Effects & Symptom Improvement

(2) Rezum Post-Operative Medications: Antibiotics, Anti-inflammatories & Steroids

(3) Rezum Post-Procedure Care: Follow-Up Evaluations & Patient Counseling

Setting Patient Expectations for Rezum Side Effects & Symptom Improvement

Dr. Bechis elaborates on his approach to setting patient expectations for the Rezum procedure, particularly addressing potential misconceptions drawn from online research. Key points include informing patients about the need for temporary catheterization, the recovery timeline of expected symptom improvement, and the possibility of side effects and initial worsening of irritative symptoms. Dr. Bechis underlines the importance of explaining to patients that the catheter is a necessary inconvenience for a few days post-procedure, with the duration varying depending on prostate size. He also emphasizes the necessity of patience, as symptom improvement may not be immediate but can take up to three months to fully manifest. Finally, he touches on the less commonly discussed symptom of urethral pain, which some patients may experience towards the end of voiding.

[Dr. Silva]
What do you tell the patient preoperatively what to expect after the Rezum?

[Dr. Bechis]
This is where I think I've evolved a little bit in my practice. I think like any procedure, patients go on the internet and they read Dr. Google, and so they often come in with expectations or ideas that may not quite be accurate. I usually counsel them.

First and foremost, they do get a catheter. For my practice, I typically leave it in three days. I used to do two days. I probably can go back to that someday, but I just found at two days, every once in a while, I would get someone who went back into retention. I moved to three days and I haven't really had any trouble with failing void trials.

If the prostate is larger like over 70 grams and certainly over 80 grams, then I typically will leave it in five to seven days. I explain to them, "The reason for this is just physics. You have a larger volume of tissue, we blast it with steam, the entire area gets swollen and you're not able to urinate. It takes time for all that swelling and tissue changes to start to occur."

That's, I think, the big one. A lot of men are like, "Oh, it's a minimally invasive procedure, but wait, I need a catheter?" I'm like, "Yes. It's worth it. If you can put up with the catheter for three days, seven days, and get through it to preserve ejaculation and have a pretty minimal recovery is great.”

Then I usually tell them, "You're not going to see a change right away. You might see it as early as three weeks. You might start to see improvement in your symptoms but it may take up to three months. Certainly, by three to six months is when the studies would show that that's when you see your maximum improvement. Even if you're not feeling there's a difference at three weeks, be patient, it's going to take time."

Then I also tell them, "There's a chance in my practice. It's probably about one in four men may have a worsening of irritative symptoms." For, me actually, the symptom that people pick up if they're going to get something is urethral pain. It's pain at the tip of the penis. I find it's right at the end of voiding, sort of a terminal voiding pain. If you ask them where it is, they always point to the tip of the penis. I think it's related to prostate inflammation because of the nerves for the prostate and the penal urethra are similar. I think it's just inflammation in that area.

Listen to the Full Podcast

Treating BPH with Rezum with Dr. Seth Bechis on the BackTable Urology Podcast)
Ep 101 Treating BPH with Rezum with Dr. Seth Bechis
00:00 / 01:04

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Rezum Post-Operative Medications: Antibiotics, Anti-inflammatories & Steroids

Dr. Seth Bechis shares his protocol for postoperative medication following a Rezum procedure. Typically, his patients continue with tamsulosin, which is commonly used preoperatively, and they are given intraoperative IV antibiotics. Patients are also sent home with Bactrim until the removal of their catheter, a strategy that Dr. Bechis finds beneficial for both preventing urinary tract infections and managing inflammation. He finds Celebrex particularly effective for addressing urethral burning or irritative symptoms post-procedure and is considering its proactive use. The conversation also touches upon the use of short-course steroids to combat inflammation, which while not a common practice for either physician, is acknowledged as another potential strategy to improve postoperative outcomes.

[Dr. Silva]
You mentioned two or three days with the catheter. After the procedure, what medication do you use for the patient?

[Dr. Bechis]
Typically, most of them are already on tamsulosin, usually. I may even try them on it and say, "Hey, are you okay?" Just continuing it through the surgery just to help improve your chance of passing your void trial. If they can tolerate it, I'll have them on that already. Then, typically, I give everyone intraoperative dose of IV antibiotics. We use a hospital nomogram to determine that, and then I usually send everyone home on Bactrim until the catheter's removed.

I've found that that has two benefits. One is I was actually surprised that there were a few people who were getting urinary tract infections from the catheter removal procedure. I found that giving them Bactrim until then really reduces that. I do think that there is an anti-inflammatory component to Bactrim, which also helps shrink the prostate, I think, early on, and gets that inflammation down sooner so that they'll be voiding sooner and recovering faster. That's typically all I give them. If they're on Flomax, we’ll continue it until the first follow-up visit, which I usually have around six weeks, and that's it.

If a patient is complaining later about having that urethral burning or urethral irritative symptoms, then I'll typically give them Celebrex for four weeks, and I've been blown away by how effective it is. It works really well. All of their irritative symptoms go away very quickly.

I've debated whether or not to just start it proactively in everybody, or possibly to your point, if you see during the procedure that maybe there's a lot of bubbles escaping, and maybe that might increase their risk of having short-term urethral inflammation, that might be an opportunity to just put them on a course of Celebrex proactively. I typically tell the patient, "If you're having trouble after a week or two, just give my office a call and we'll start you on something."

[Dr. Silva]
I use meloxicam because this is what I was using for GreenLight. I started using Celebrex for testicular pain, and it's been amazing. Probably I’m going to start using it for Rezum also.

[Dr. Bechis]
Yes, I have to give credit to my men's health colleagues because they use it a lot in the groin pain arena. Then I found it works really well for inflammatory-related stuff.

[Dr. Silva]
I'm going to take that also and start using it for the prostate, because I use it just for the groin but not for the prostate. I want to start changing my post-op orders.

[Dr. Bechis]
Some people I know will give a short course of steroids in that first week, which I think probably just helps reduce the inflammation from the swelling. I haven't routinely done it. I think the Bactrim serves that same purpose for me. Just something that I think is a nice additional option, that if you have someone who maybe fails their void trial or they're struggling with a weak stream, a short course of steroids might be helpful.

[Dr. Silva]
Hey you use a Z-Pak or what do they use?

[Dr. Bechis]
I think a Z-Pak probably the easiest. It’s the short taper.

[Dr. Silva]
For some reason, I don't use steroid. I don't know. During residency, they got them by rep or something, but I don't use steroids in our practice. Don't know why.

[Dr. Bechis]
Me too. We were taught that if you're already giving antibiotics to reduce your risk of infection, I always worry with steroids because that potentially worsen your chances of preventing an infection. Who knows? It's probably just how we were trained.

Rezum Post-Procedure Care: Follow-Up Evaluations & Patient Counseling

Dr. Bechis and Dr. Silva delineate the typical follow-up process after a patient has undergone the Rezum procedure for benign prostatic hyperplasia (BPH). They emphasize the importance of periodic evaluation at approximately three days, six weeks, and three months post-operation. Particular attention is given to the potential impact of the patient's post-operative International Prostate Symptom Score (IPSS). Moreover, the doctors share insights into handling complicated cases, such as patients with persisting storage symptoms after the procedure and those exhibiting high Prostate-Specific Antigen (PSA) levels. They close the conversation by looking towards future indications of the Rezum procedure and its potential expansion to accommodate larger prostates.

[Dr. Silva]
Seth, you mentioned the patient, you see it three days after we do the voiding trial, then six weeks after. Then what? If the patient is doing good, symptoms are better, three months afterwards, or when do you see them again?

[Dr. Bechis]
They'll have a nurse visit at three days to take out the catheter, and then I'll usually see them around six weeks. Partly research-driven, we'll typically do a PVR and a uroflow partly for academic kind of collecting our data on it. Then if they're doing well, I'll usually see them back at three months, and then we'll definitely do an IPSS and a uroflow and a PVR and compare it to the pre-op.

I think some early data we're finding is maybe the IPSS score early on is an indicator of whether they're going to have some irritative symptoms during the Rezum recovery. I think at that six-week mark, usually, if they had some short-term irritative symptoms, they would be gone by then.

I usually joke to the patient before surgery. I say, "I'm going to wait till six weeks to see you because then you'll be really on the road to improvement." If they are having trouble at six weeks, if I haven't considered Celebrex for example, I'll try that, or rarely would I add a beta3 agonist. Although it's pretty unusual, to be honest. Usually, at six weeks they're doing really well.

Then I'll do a three-month follow-up and then usually after that, I joke. We had a MA who would make a certificate of graduation and so we would give it to them at the three-month visit or even the six-month and then send them on their way.

[Dr. Silva]
That's an excuse to just get one patient out of the office and try to get new patients in.

[Dr. Bechis]
Giving them a certificate is great because otherwise they always want to keep coming back every three to six months. They're so used to that from having medicines titrated and you're like, “You don't need that anymore. Once a year or just see your PCP and give me a call.” I would say obviously following their PSA annually, even after this procedure, but I usually defer that to the primary care if possible just to free up space to see new patients.

[Dr. Silva]
In terms of PSA, I have seen patients that the PSA after Rezum procedure goes up. I had a patient, I saw him last week, and I did a Rezum two or three month ago. The PSA was high, baseline it was very low. I told him, "Hey, don't worry. Let's just wait a couple of months." Sometimes it takes a while for that PSA to go down.

[Dr. Bechis]
I usually try to avoid it for six months just because I've run into that. You get a super anxious patient who for whatever reason is able to check his PSA every three to six months because he is just nervous. Then someone writes him an order and he checks it after the Rezum, and then it leads you down a rabbit hole just following them until they come down again.

[Dr. Silva]
Most of the time just the patient has the annual exam with the primary and they include just part of it, and it's high. Then the patient calls, they're concerned, “Let's wait, let's wait. You had a great one last year. Let's not jump into the conclusions.”

I was going to mention. I had a patient, I think for now hopefully it's the only Rezum fail that I had. I took the patient to the OR and when I was there, it was actually open. When I did his cystoscopy in the office, it looked closed, but in the OR it was open. I was already there. I did a laser afterwards. I showed the wife, "Hey, most likely it's not the prostate," it was a patient that continued with some frequency, urgency, uncontrolled diabetes, so probably just that.

[Dr. Bechis]
Was there a lot of tissue to laser? Did you incise the bladder neck, or what did you see? That's typically what I would do just because that's all there's left.

[Dr. Silva]
I didn't want to add any… but it was open. He was open. He was good. Usually, when I do a GreenLight, do a… so I open up the lateral lobes more, but it was nothing. He was open.

[Dr. Bechis]
I think that's probably the one area that I think in general, I know we touched on it earlier, is that the days of seeing just a purely obstructive picture seem to be less frequent. Patients have more and more of these mixed pictures. I don't know if that's just because there's more prevalence of diabetes and metabolic syndrome and obesity, or maybe people are just having more bladder changes from obstruction and they're getting this urgency-frequency stuff.

I think it's tricky. You just have to really counsel them because there are times where you do a great procedure and you feel like it's going to be perfect, and then they come out and their flow is stronger, but then they're like, "I'm still having all these other storage symptoms." I think that's the one population where sometimes it's tricky because sometimes you still need to treat the outlet just to rule that out and to say you've done it, because if you just treat the overactive symptoms, you're like, "I don't know."

[Dr. Silva]
Exactly. You do the urodynamics after and it gives you mixed results, some other activity, but there might be some outlets still. It force you to go to take the patient to the OR again.

[Dr. Bechis]
The equivocal for obstruction is the worst. It's like moderate detrusorize with low flow, equivocal for obstruction, and you're like, "Great. Now what do I do?"

[Dr. Silva]
You need to tell the patient, "We need to do it again," or do something. I take pictures and, "Hey, you look open. Let's see." I open it a little bit more, but it was open.

[Dr. Bechis]
I would say that's another point I forgot to mention earlier, when you're counseling them upfront about their options. Sometimes if a patient is, I don't know, mid 60s, sometimes they think that maintaining antegrade ejaculation is really important for now.

That's another point that I forgot to say that I'll mention, is I'll say to them, "The nice thing about this procedure, too, is let's say you get it, and let's say you're one of the unlucky 4% who needs another retreatment, in five years, maybe by then we could either do it again. By then if your priorities change and maybe preserving ejaculation is less important, you could always do a different procedure then if you need it." I think the nice thing is it gives you that flexibility. You don't really take anything off the table early on.

I used to joke with patients that I think every man when they hit 55 or 60 should just get a prophylactic Rezum, keep things open. [chuckles]

[Dr. Silva]
That's the thing. I think I see every day patients, "I have a big prostate." "Your symptom score is zero." "No, but I have a big prostate." "We don't do anything about that. We treat the symptoms, sir." At some point, I think we're going to start doing something like that because the patients want it. If eventually in a couple of years, they're going to have problems-- That's the thing, we don't know who's going to have problems or not. Maybe there's going to be data in the future that probably likely we're going to be doing Rezums.

[Dr. Bechis]
Yes, that's the holy grail. When you pull that trigger?

[Dr. Silva]
Exactly. Seth, anything else you want to add?

[Dr. Bechis]
No, I think this has been great. I think one of the exciting things in this arena that we talked about is just how prevalent BPH is. So many men have it. It's such an expensive, costly disease to the health care system. Obviously, you're balancing functional outcomes, but also quality of life and symptom score and patient satisfaction. There's so many options out there, but I think really customizing your treatment plan with the patient's goals is important.

I think that's probably partly why setting expectations upfront and talking through. I think at least the approach I take is really trying to make sure every step of the way they understand the next step and what are the outcome, because I think there's often many ways to treat the same problem, right? Having the patient buying into their treatment plan is ultimately really important.

[Dr. Silva]
Exactly. That's beautifully said. Looking forward also for the next indications of Rezum. [chuckles] I heard that they're expanding the indications for bigger process. Hopefully, they'll come out with the data soon and we can offer it to more patients.

Podcast Contributors

Dr. Seth Bechis discusses Treating BPH with Rezum on the BackTable 101 Podcast

Dr. Seth Bechis

Dr. Seth Bechis is a practicing urologist and associate professor with UC San Diego in California.

Dr. Jose Silva discusses Treating BPH with Rezum on the BackTable 101 Podcast

Dr. Jose Silva

Dr. Jose Silva is a board certified urologist practicing in Central Florida.

Cite This Podcast

BackTable, LLC (Producer). (2023, June 7). Ep. 101 – Treating BPH with Rezum [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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