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Urology/weak stream


Dr. Goldstein,

Hello and thanks for all the time you spend answering questions on this website as 1 of the top rated experts.

I read your past responses on prostatitis but would like to get your opinion of my specific case as best as possible over email.  I'm otherwise healthy white guy in my mid 40's.  Here's a summary of my symptoms:

- started noticing a little burning during urination about 5 years ago.
- also have some semen discharge during bowel movements when I have to strain alot - have had this symptom past 5 years.
- then 3 years ago lost a lot of weight due to stomach problems - BMI was down to 15, took about a year to get back to 21.  For many months during this time at low weight I don't recall having any erections.  During this time started having burning between urination, so went to urologist who did camera inside the bladder and urodynamics - all was normal.  As I gained weight and got better and started having erections again this burning in between got better, but still had burning during urination.
- since then and esp. in last few months have noticed more burning during urination, and stream has definitely slowed, to the point where sometimes it doesn't feel like my bladder is empty and have to go again not long after.  As far as night, I wake up at 3am to go, and then go again when i get up at 7am.
- a couple months ago had CT scan due to ongoing pain that other dr. thought was gas (i do have constipation often).  This scan showed diffuse thickening of the bladder wall, and because of this I went back to urologist, who gave me script for rapaflo which seemed to help only a little after 3 weeks
- urologist did urine culture which was normal; also my PSA has always been low 0.4   rectal exam of prostate also showed it was normal size/shape.  kidney function normal
- last few months have also had aching pain in both testicles, esp. the left.  The rapaflo does seem to have reduced this pain to almost nothing
- i do notice my stream does seem stronger after sex
- i have an office job where I sit a lot
- also I tried saw palmetto but after 1 pill my testicles really hurt all day, so didn't take any more

To summarize, the most worrying symptom to me is the weak stream.  My urologist said to continue the rapaflo and come back in 3 months.  I hope to get your opinion of my case, and suggestions what to do from here in terms of treatment and/or tests.  Another important question I have is whether I'm doing any damage to bladder or anything else by having this low flow



Fred, there is little doubt that you problems are due to your prostate gland.  I suspect you have a combination of congestive prostatitis along with periodic flareups of prostatitis.  In both of these disorders, the prostate may well be normal on rectal examination.Some of the following information you may have read before from me but I will try to tailor it to your specific problem.  During sexual arousal the prostate gland & seminal vesicles manufacture fluid that accounts 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.  

Arousal without ejaculation causes the prostate to swell with fluid producing tension on the prostate’s capsule.  This may occur with prolonged foreplay, with coitus interruptus, or by holding back ejaculation during intercourse or masturbation.  It may also occur if a man rarely ejaculates.  In this case, the prostate is still stimulated to  secrete fluid in response to sexual. dreams, fantasies and thoughts.

There are a variety of symptoms that may occur with this condition. Often the urinary stream may be split, spraying or manifest a decreased caliber or force.  Stool passing through the rectum may push on the distended prostate producing a penile discharge.  Prolonged sitting (you sit on the prostate) can cause the discharge to be noted before voiding.  At the end of urination, as the bladder is emptying out the last few drops of urine, it actually squeezes the prostate.  If the prostate is congested, one may note  fluid at the end of urination.  A man may notice this more with sitting to void as there is more pressure exerted on the prostate in this position.   With congestive prostatitis one may experience discomfort which is often referred  to the penis, testicle(s), groin, low back or rectal area.  This pain in the testicles is denoted by the slang terms: “blue balls” or “lover’s nuts”.  Irritating urinary symptoms such as frequency or urgency may also occur.  Symptoms are typically immediately relieved by ejaculation and prevented by avoiding sexual arousal without ejaculation.  The fact that your stream improves after ejaculation is characteristic of this disorder.Sitting in a warm bathtub for 10-15 minutes daily will also provide some relief.  Congestion of the prostate can also predispose to infection of this gland.  This often requires a course of antibiotic therapy.   

For the sake of completeness, I will attach my "macro" on prostatitis so you do not have to look it up again.
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.

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:  /

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.  I do not believe the saw palmetto caused you any adverse side effects and I suggest you give it another try for a longer period of time.  The Rapaflo you are taking is a new type of alpha one blocker and it is reasonable to continue this if your symptoms are improved on it.  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.

As many symptoms of prostatitis and prostatic congestion are preventable, avoid those factors that can predispose you.    A man should learn to listen to his body.  Good luck.  


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Arthur Goldstein, M.D.


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.


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.

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

College degree - BS Medical degree - MD Master of Science - MS

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