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Urology/Urine Retainage

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QUESTION: 8 months ago I went to the urologist because of severe bleeding from the urethra. It turned out to be from the bladder. I had retained 1 liter of bloody urine which caused thickening of the bladder walls and severely stretched the bladder. I had 100% prostate blockage. 6 months ago I had the urodynamics test done and the resident doctor said my bladder was working fine. 3 months ago had the HOLEP procedure done. During these 8 months I have self catheterized.

After the HOLEP was done I was able to urinate on my own but only after about 22 ounces were retained. That gradually decreased to about 14 ounces. Within the last month or so the retainage has gone back up to 16 ounces. I do get a sensation to urinate but it is not until these retainage levels have been met. It seems I am stuck here and not improving.

The doctor ways self catheter after I go naturally... Well I put out about 2 ounces then self catheter. Sometimes I wait and go naturally a few times before I self catheter.

I currently take the tamsulosin medicine but I have no idea if it is working.

Can you answer the following:
1.Is this never going to get better?
2. Can I just leave the 16 ounces in for good and stop self catheter?
3.Should I continue taking tamsulosin?
4. Is there any other medical procedure that will get this retainage out?  I only have a sensation to relieve myself after the retainage level is reached.
5. What  is causing the 16 ounces to be retained?
6. Is this problem with the bladder, the mind, or both. Is it a physical problem with the bladder from the stretching and thickening that is the problem?
7. Is the lower part of the bladder permanently damaged so it cannot push the urine out?
8. Can part of the badder be damaged and another part be not so damaged that I could pass the urodynamics test?

I have asked these questions to my surgeon but he nevers answers. He just stares at me looking dumbfounded. He says maybe with time the brain and body will coordinate. That does not appear to be happening.Maybe you have some answers and can suggest if there is anything else I can do to get better.

This has really become frustrating. I have been through so many operations including a false bladder cancer diagnosis. Now the surgeon after the HOLEP operation basically is saying I did my job...good luck and has now dismissed me.

ANSWER: Larry:

I'll try to answer your questions.

This may or may not get better.  It depends on the health of the bladder muscle.  we can easily remove blockage one way or another, but if the bladder muscle is severely damaged, then you will probably have to use a tube in some way or another to empty the bladder.  This can be checked by doing a bladder pressure test or CMG.

Not draining the 16 oz left in the bladder will cause additional bladder damage and deterioration, increase the risk for infections, lead to bladder stones and kidney failure, etc. so it is not recommended.

We would expect that if the HOLEP was successful, there should not be any need for the tamsulosin. However, check with your physician about this.  To be sure, a cystoscopy (look into the bladder with a telscope) would help identify if there is any remaining obstruction or tissue that might need removal.  Without more information about any existing blockages and bladder muscle function, it's impossible to determine if some other procedure might help.

Generally, the bladder is either damaged or not; it's not usually damaged in just a portion.

When sensation is not a reliable indicator of when the bladder is full, we have to go to an alternative method such as voiding every 3 or 4 hours.

At this point, you might want to get a second opinion.



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

QUESTION: Thanks for responding. To follow up...

Issue One:
Is the bladder pressure test the same as the urodynamics test?  As I said the resident doctor who did the urodynamics test said my bladder was working fine. Lots of pressure.

Issue Two:
I still do not understand why 16 ounces is being retained if I passed the urodynamics test. Could it be a nerve issue? Has my mind forgotten to relieve this since it retained so much urine for so long? I still do not understand why I have no urge to urinate until after 16 ounces have been retained. This is so confusing to me...how can my bladder work and not work at the same time? As you say the bladder is either all good or all bad. No in between.

On any given day I can urinate 32 ounces on my own if I delay the catheter to once a day. I just cannot get out those  16 ounces. What possible reasons is causing this because the bladder is working?

Issue Three:
I occasionally have high blood pressure. Is lisinopril OK to use with tamsulosin?

Issue Four:
You did not answer if my condition could get worse as I get older?

Issue Five:
If I catheter every 4-6 hours I will never go on my own. Should I try to keep going on my own so my bladder does some work?

Answer
Larry:

Urodynamics is another name for the bladder pressure test.  If that test shows good bladder pressure, then there is likely to be some remaining obstruction.

A nerve issue is possible but unlikely.

Your mind does not forget how to empty the bladder.

I didn't say the bladder either all good or all bad; just that it pretty much all works together.  It can be partially damaged but this affects the entire bladder and not just a part of it.

The reason for your incomplete emptying is still unclear, but the evidence suggests that some blockage still remains.

Lisinopril can be taken with tamsulosin.

If you have an abnormally functioning bladder and nothing is done to fix or repair it, then it is likely to deteriorate over time.

If you do straight catheterization, it is always done after you try to void first.  At some point, your residuals might decrease to the point where the catheterizations are no longer needed.

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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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