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Topic: Urology

Expert: Arthur Goldstein, M.D.
Date: 9/20/2008
Subject: burning and sever discomfort in the urinary tract.. PLEASE help!

Question
QUESTION: I am not sure if you can help, but I am at the end of my rope, and my
research has brought me to you.

Around 5 weeks ago I began experiencing irritation and sever burning in my
urinary tract. I went to the doctor, and they of course thought it might be an
std. They gave me a 'cocktail' of antibiotics, as well as running urinalysis and
blood test. A few days later it got very extreme, painful and burning. I went
back to see the Dr and he had the test back... normal. They also prescribed
Ciprofloxacin, which I took for 10 days, with no change. They sent me for
more blood work and urine test, including PSA, which all came back normal.

I then went to see a Urologist who also thought I must have an std and
prescribed me Doxycycline for 14 days. As well as swabs from inside the
penis.

The Doxycycline didn't seem to be working at all, so I went to see another
urologist two weeks ago, referred from my GP. He said all test, blood, swabs,
urine were normal, but when he checked my prostate it was a little sore and
swollen (hard to define, as he hadn't checked it before). He thought there
maybe something causing this, perhaps an infection deep in the prostate,
which is difficult to check for. He then put a scope up to my bladder, and he
said all was normal, though a slightly inflamed.

He put me on a long-term antibiotic (cipro 1000mg) for 30 days, in case it is
the prostate that is infected. He said it takes much longer with the prostate
for antibiotic reach it and take affect. Or, it could be prostatitis, in which case
not much can be done.

I have been off work for a while with this, and getting very depressed and
anxious. The only thing that gives any relief is Phenazo, and that has stopped
being affective. If you feel this is an area you could help with, any
suggestions or help would be sincerely appreciated! I am extremely
uncomfortable. Burning and discomfort in the perineum, within the urinary
tract, through to the tip of my penis. There is no discharge, blood, cloudy
urine, etc. Everything seems normal, other then the burning in the tract,
which is worse after urinating... not during urination. When it isn't burning,
there is a gnawing sensation.

Please give me any advice or point me in a direction that perhaps hasn’t been
looked at.

Thank you.

ANSWER: Losing Hope, by the most common cause of these complaints is an inflammation of the prostate gland, so called prostatitis. I would continue taking the Cipro as it takes a minimum of 4 weeks of continuous antibiotic therapy to clear bacterial prostatitis. The Phenazo coats the lining of the urinary tract with a substance so that the normally acid urine does not burn as much during passage. However, this only provides symptomatic relief of burning but does nothing to cure the underlying problem. There are several types of prostatitis and you might have one of the abacterial varieties. Treating this condition requires more than just medication. Diet, life style, sexual activity, stress, etc. are just some of the factors that can be involved. I don't know if you have previously read my "macro" on prostatitis so I will attach it as follows:

Symptoms that might occur with prostatitis include frequency of urination, slowing of the urinary stream, burning with voiding or ejaculation, burning in the penile tip unrelated to voiding, urethral discharge, sexual dysfunction (such as difficulty with erection), aching in the penis, testicles, and discomfort in the lower abdomen, low back, groin, rectum or perineum (the area between the scrotum and rectum – between the “wind and the rain”) and constipation. The passage of blood at the initiation or termination of urination or in the semen can also be noted. semen. During sexual arousal the prostate gland & seminal vesicles manufactures fluid that account for the majority of the semen. The seminal vesicles are paired structures located behind the prostate gland that are also sensitive to sexual excitement. Sperm from the testicles (which account for only 1-2 % of the semen) travel up a series of tubes (epididymis and vas deferens) on each side to join the seminal vesicles forming the paired ejaculatory ducts. These structures empty into the prostatic portion of the urethra. At the time of ejaculation, fluid is discharged from the prostate gland and ejaculatory ducts into the urethra (urinary canal) forming the semen. The average semen volume is 2-6 cc. With the inception of ejaculation, the bladder neck closes and the semen is forced forward out the urethra by contraction of the pelvic muscles. It is not uncommon for inflammation and/or infection to spread in a retrograde manner into the vas and epididymis. Even without such spread, prostatic discomfort is often referred into the testicle. Too frequent or too infrequent ejaculation, sexual arousal without ejaculation, withdraw at the time of ejaculation, aggressive bike or horse back riding, and excessive spicy foods, alcohol, and caffeine in the diet can predispose you to this. Sitting for long periods of time, especially in an automotive vehicle, can put undo pressure on the prostate and aggravate the condition. For the latter, it is best not to sit more than 2-3 hours at a time. Stop the vehicle periodically, take a short walk and go to the bathroom to urinate. A thick pad or piece of sponge rubber on your seat will also help to cushion the prostate. One should avoid any of the above that apply. Eliminating all of these factors that apply to you are just as important, if not more so, than taking medication! Ejaculation beyond the tolerance of the prostate to fill and empty may also cause discomfort. Likewise if one does so infrequently, fluid still builds up from thoughts, dreams, fantasies, etc. and has to be released periodically to decompress the gland and relieve the symptoms. For most men, ejaculation in moderation, perhaps 1-2 times a week, is reasonable. A daily warm bath for 10-15 minutes 1-2 times daily also lessens the discomfort. Attention to sexual activity and warm bathes should be utilized regardless of the type of prostatitis and whether or not medications are prescribed.

There are several types of prostatitis. Sometimes prostatitis can be due to an infection of the gland with bacteria. Typically, pus cells and bacteria are found in the prostatic fluid. The infection usually requires an initial 4 week course of an appropriate antibiotic (the commonest prescribed are the fluoroquinolones, but tetracyclines, sulfas and other agents can also work).

Abacterial prostatitis has several varieties. In one, the prostatic fluid demonstrates pus cells but no bacteria. In the other, there are neither pus cells nor bacteria in the fluid, just the symptoms. In all types of prostatitis, the urinalysis generally is normal unless the infection spreads into the bladder. Abacterial prostatitis is an elusive entity that has been called by a variety of names including nonbacterial prostatitis, prostadynia, pelvic congestion syndrome and most recently pelvic myoneuropathy. The latter name was coined by Dr. David Wise of Stanford. He believes that this may represent up to 95% of all cases of prostatitis. This variant may be an expression of interstitial cystitis and possibly is due to autoimmune or neurogenic factors. Dr. Wise suggests that the primary cause of the symptoms involves pelvic muscle spasm, nerve trigger points and some degree of anxiety (either the cause or result of the symptoms). His therapy involves the use of anti-depressents (we have used Elavil for years in refractory patients), relaxation techniques, trigger point physiotherapy, and biofeedback. Some others recommend Yoga & meditation as being useful. Although he may well prove to be correct, I generally recommend an initial course of antibacterial therapy for patients who clinically have symptomatic prostatitis of any variety. The majority of patients (even those with nonbacterial prostatitis) seem to respond favorably. It has been know for decades that many patients with the abacterial variety of prostatitis do well with antibiotics but the reason has been vague. Some theorized that they may harbor bacteria in the tissues of the prostate that are not being picked up in cultures (possibly walled off loci of infection). For more information on Dr. Wise's studies check out:
http://www.pelvicpainhelp.com/
In my experience, symptoms usually responds to the general measures mentioned in the initial paragraph. Medications that sometimes help include the over-the-counter natural supplement saw palmetto 320 mgm daily and alpha-blockers (such as Flomax, Hytrin, Cardura & Uroxatral). The latter require a prescription from you physician if he thinks it is indicated.

Prostatitis may also be classified as acute (severe), subacute (mild), or asymptomatic. It may also occur as a single episode, be recurrent or chronic. In chronic bacterial prostatitis, long term low dose antibacterial therapy often works well in suppressing symptoms. In refractory cases, culture of the prostatic fluid or semen often will disclose the offending bacteria. If found, sensitivity studies can identify which antibiotics are most likely to eliminate that particular germ.

In other cases refractory to treatment, there is another condition that can produce similar symptoms. This disorder is ejaculatory duct obstruction. Usually the doctor will find the seminal vesicles to be very swollen on rectal examination. The patient will notice either absence or a markedly diminished semen volume. The diagnosis is made by doing a transrectal ultrasound of the prostate and seminal vesicles.

Therefore, if symptoms persist, consultation with a urologist should be scheduled. In cases with recurrent prostatitis or hematuria, it often is necessary to study the urinary tract more completely. Predisposing factors to prostatitis such as a urethral stricture (narrowing) and other disorders can then be evaluated. A man should learn to listen to his body. Good luck. 

---------- FOLLOW-UP ----------

QUESTION: Dr. Goldstein,

Thank you for the reply and all of the valuable information. I sincerely
appreciate it.

Based on my symptoms listed, could it be anything other then prostatitis? I
ask because I don't have any of the other symptoms usually listed with
prostatitis, other then the burning post urination, and the extreme discomfort
in the base of the urinary tract. Further, I am on my third antibiotic now,
granted this time its for 30 days of cypro.

If you can think of anything else I should investigate, any urological or other,
I would be very grateful.

Thank you once again,
S

Answer
Losing Hope, the possible symptoms one may experience with prostatitis are listed for the sake of completeness. With any disorder, it is rare for a person to have all possible symptoms. In fact, it is quite common with prostatitis to have only a few symptoms. Although one of the types of prostatitis is most likely your problem, any condition that inflames the lower urinary tract might cause this. Included in this list would be bladder infections (cystitis), urethral infection (urethritis), bladder stones, and occasionally kidney stones that become lodged in the lower ureter. With the latter, there generally is associated frequency of urination and severe unilateral flank pain - although not always. I suggest you follow all of the recommendations in my prior note and if no better, urologic investigation is warranted. Good luck.

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