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Question
Complex question so I'll try to be brief as possible. I am a male aged 66 and the following has been a steadily escalating problem for the past 18 years. Initially it began with all the usual symptoms & issues of an enlarged prostate but then developed fairly rapidly into a scenario whereby I am constantly awoken at night by the need to urinate accompanied by overall bladder discomfort and a very hard erection -(the latter being the main problem) - I then have to wait for everything to calm down physically before I can have a pee - (which varies in amount) - after which I can then attempt to go back to sleep again -(with varying degrees of success) - to be followed a short while later by all the same symptoms all over again - (a good night would be a 3 hour interval between waking - its very often shorter) - and so it goes - There is no pattern, it only bothers me at night, only when I sleep, nothing to speak of during the day - I have experimented with all the usual & conventional things such as no coffee, no alcohol, cutting fluid consumption prior to bed, etc, etc - I have over the years, at the suggestion of urologists, taken every drug known to the medical profession from flomax to anti-depressants,to Chinese herbs, etc, etc - again to no avail - I have had cystoscopys where nothing untoward was found other than than the usual narrowing problems associated with an enlarged prostate - I contemplated at one point conventional prostate surgery but in the end decided against as my surgeon could offer no guarantee that the surgery would solve the uncomfortable night time erections, etc - I finally in 2003 opted for laser surgery - (again with a warning from the surgeon that the procedure might not solve the erection issue) - And it didn't - and after surgery all my symptoms remained exactly the same as before - And from that point onward I have more of less lived with the problem as I have been unable to find anyone, urologist or otherwise, who can come up with any answer or solution - And to bring things right up to date, I recently, with advice from yet another urologist, had a further cystoscopy and prostate biopsy just to make sure there was no cancer, etc - and all results returned completely clear - (plus no scarring issues from the laser surgery) - so - back to the drawing board - I am at present, again at my urologist suggestion, looking into sleep apnea, and am spending a night at a sleep clinic in December to see if anything untoward might show up - I don't have much confidence in it, but am prepared to explore any avenue - So, to sum up - As the problem only happens at night, and only when I sleep, if all I had to do was wake up, have a pee, and then go back to sleep, I probably wouldn't be making a fuss - but to never get proper sleep, to be constantly woken in severe discomfort as described, is totally debilitating - so - any ideas?? - I'd be very grateful for your input - Many thanks -

Answer
Stuart:

There are two parts of the problem.  First, you have the erections which complicate voiding,  Next, there is the nocturia.  The first thing I would do is check the testosterone level.  Next, it may be possible to look into a treatment for the erections such as Lupron.

The nocturia can be evaluated with a voiding diary to see when and how much you void over 24 hours.  If there is more urine produced overnight than during the day on an hourly basis, this can be treated with DDAVP that temporarily reduces urine production.

Bladder pressure testing can also be considered to see if the bladder muscle tone is normal.  If not, bladder relaxing medications can be tried.

Sleep apnea is a good idea as it can affect nocturia as well.

You may want to consider an opinion from a University center where they deal with more complex issues than most urologists do in community practice.

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Stephen W. Leslie, MD

Expertise

Questions concerning erectile dysfunction, kidney stones and prostate disorders including prostate cancer. I have a special interest in kidney stone disease prevention.

Experience

Full time practicing urologist with 30 years experience. Associate Professor of Surgery and Chief of Urology at Creighton University Medical Center. Editor in Chief of eMedicine Urology internet textbook. Author of only NIH approved book written for patients by a urologist on the subject of kidney stones "The Kidney Stones Handbook". Inventor of the "Parachute" and "Escape" kidney stone baskets and the "Calculus" stone prevention analysis computer program.

Organizations
American Urological Association, Ohio State Medical Association, Sexual Medicine Society

Publications
Men's Health, Journal of Urology, Urology, Healthwatch Magazine, Emergency Medicine Monthly, eMedicine, "The Kidney Stones Handbook", and numerous articles in various newspapers. He is also the editor of the Urology Board Review by McGraw-Hill used by urologists to study for their Board Certification Examinations.

Education/Credentials
Graduate of New York Medical College with residencies completed at Metropolitan Hospital New York, Albany Medical Center and University of Wisconsin-Madison.

Awards and Honors
Thirlby Award of the American Urological Association. Rated as one the country's Best Urologists by the Independent Consumer's Research Institute

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