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Urology/Urinary retention and pelvic pain

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Question
Hi Doctor,

I'm a 27 year old guy, weigh 70 and 6 foot tall.

I have had urinary problems since a long time(6 years). It started with mild dribbling at the end of voiding, slowly progressed to weak stream at times and pain in perineum (3 years ago) which is when I visited a urologist.

The urologist performed a retrograde urethrogram and found the contrast did not go past the external spinchter, also post voidal residue was about 20 cc. He said I have bladder neck obstruction and chronic prostatitis and put me on alfuzosin. My urinary symptoms improved initially but after sometime alfuzosin did not seem to work and I stopped taking it.

Its been more than a year since I am not taking any medicines and my symptoms currently are

-I feel I'm not voiding completely,(stream is ok but mild dribbling in the end, I manage by milking the urethra)
-Mild pain in perineum
-Some days I feel no urge to urinate

The above symptoms are not present all the time, some days I feel fine and some days the symptoms are bad.

I noticed I tend to clench my pelvic muscles during any physical activity like when I'm brushing my teeth or taking bath. When I lie down on my back and relax for sometime, I feel a muscle suddenly relax in my pelvic area as if it was in a spasm. I think this  clenching  habit is the cause of all my problems. I have noticed my symptoms improve after cardio exercises and stretching the pelvic muscles, which I am unable to do consistently due to busy schedules.

Based on my symptoms can you suggest what could be causing it and any possible treatment for the same?
Do you think my urinary symptoms are due to the involuntary  clenching habit?
Please can you advise if I should ask for more tests(kindly suggest which ones) to diagnose this further or is it ok to manage this with physical exercises?

Thanks a lot in advance for any help you could provide and for your kindness.

John

Answer
John, by far the most common cause of your symptoms would be an inflammation of the prostate gland, so called prostatitis.  The results from your retrograde urethrogram are not impressive or totally diagnostic.  A residual urine of only 20 cc is normal and non-passage of the contrast beyond the external sphincter is common in men.  I doubt that your problem is related to muscle spasms.  

Post voiding dribbling is a very common problem.  It is due to trapping of some urine in the urethra which then leaks out after one has finished urinating.  Minor leakage is common in most men.   It is usually due to an obstruction such as from a swollen prostate, a narrowing of the urethra (stricture) or a narrowing at the penile opening (meatus).  The most common causes are from a swollen prostate (either an inflammation, so called prostatitis or a benign enlargement of the prostate - BPH).  In my experience, another frequent cause is in those men who remove their penis through the unzippered fly, void and then put the penis back.  Often, the space is not adequate for total free flow as the lower (bottom) edge of the fly can actually push on the urethra causing urine to be trapped.  This phenomenon can be totally avoided by dropping your trousers and then urinating in the standing or sitting position.  Try the latter and if this [particular symptoms disappears.

Prostatitis is a disorder that I have commented on extensively on this web site.   In case you have not read it before, to follow is a "macro" I have written on this problem that will explain the various types of prostatitis and their treatment to you.

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. During sexual arousal the prostate gland & seminal vesicles manufacture 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 - which is alfuzocin).  The latter require a prescription from you physician if he thinks it is indicated.  More recently, a naturally occurring flavinoid with anti-oxidant and anti-inflammatory properties (such as quercetin) has been used in prostatitis.  It's success is yet to be confirmed.  

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.  One should be off of all antibiotics for 7-10 days before the culture is taken.  Otherwise, if there is residual antibiotics in your system, this may prevent bacteria from growing in culture.  

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, re-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.  

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Arthur Goldstein, M.D.

Expertise

Problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, etc. I no longer answer questions related to erection problems or male sexual dysfunction.

Experience

I am retired from the active practice of urology. My 34 years was totally in the clinical field and involved the entire gamut of genitourinary problems, with special interest in endourology.

Organizations
American Medical Association, American Urological Association, American College of Surgeons

Education/Credentials
College degree - BS Medical degree - MD Master of Science - MS

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