Urology/High-pressure chronic retention
Greetings Dr. Goldstein
Three years ago when I was 58 doctor told me I have an enlarged prostate and said it’s normal for my age and told me I am a healthy adult (due exercise) and gave me Uroxatral to try for frequent voiding during the night (3-4 times). I stopped taking it after a year because it gradually stopped having any effect. On 5/29/14 I went to hospital ER, the ultra sound technician told me use this bucket and go void as much as you can in it. I did about 400cc on my own but she noticed that a large amount is still in there. They put a foley catheter and drained 1.8 Liter extra from my bladder and sent me home with a foley catheter and a bag attached to my leg. A CT-scan on 6/6/14 showed my bladder wall was 4-cm thick. I saw a urologist on 6/13 and all he gave me was FlowMax (once a day). An ultra-sound on 6/19 showed my bladder wall became 2-cm thick. On 7/9/14 they took out the foley catheter and showed me how to self catheter and I am doing that 4-5 times a day since then. But I am NOT able to void on my own. Sometimes I apply heat-pad to my lower bladder area and occasionally I get lucky and get about 30-40cc out on my own. So, I try that for 30-45 minutes and I may void 2-3 times each about 30-40cc. Then I get tired and use self catheter and 400cc to 750cc comes out depending on time of day or night. When I self-catheter early morning about 3:00am to 4:00am I drain close to 700cc to 800cc. How can I regain my urinary control? What can I do to help the process? How soon may I expect any reasonable improvement? What other medication may help? Is there a physical therapy to do? I have family and 2 young kids below age of 10. Any advice is greatly appreciated.
Ivan, benign enlargement of the prostate gland (benign prostatic hyperplasia or BPH) occurs to varying degrees in all men as they age. The prostate surrounds the urinary canal (urethra) just after its connection to the urinary bladder. Inward growth of the prostate either into the bladder neck (opening) or into the urethra itself can cause difficulty with urinating. The prostate is checked by digital examination through the rectum. This gives the doctor an idea as to the size and benignity of the gland. However, it does not always correlate to symptoms as a small gland may have significant inward growth and a large glands enlargement may be entirely peripheral.
The ability to urinate involves the urinary bladder muscle actually becoming stronger as it works against increasing resistance from the prostate. This shows up as thickening of the bladder wall (called trabeculation) as was noted in your case. This delicate balance, however, can be upset by any factor that decreases the bladder muscles ability to contract with sufficient force to open the prostate (such as medications, anesthesia, too much alcohol, ignoring the desire to urinate, etc.) or those factors that might cause the prostate to swell (i.e. progressive growth of the prostate, acute prostatitis, sitting for extended periods of time, biking, horseback riding, etc.). The typical symptoms that occur include diurnal frequency (daytime), nocturia (night-time frequency), urgency, hesitancy, slow stream and dribbling after voiding. This complex of symptoms is termed “prostatism”. If the obstruction to flow progressively worsens, the bladder eventually may not be able to empty completely. This leads to the accumulation of “residual urine” which may predispose to urinary infections and kidney damage from back pressure. Because you are unable to empty, you are doing self catheterization in order to keep the bladder empty and avoid these complications.
However, relatively asymptomatic men with BPH do NOT necessarily require therapy. Treatment is indicated to relieve symptoms and prevent complications. In many cases medications can be used. Alpha - blockers (ie Hytrin, Cardura, Flomax, Uroxatral etc.) work by relaxing the bladder neck and urethra so the pressure generated by a bladder contraction has less resistance to work against. Natural herbal products such a saw palmetto and pygeum often provide symptomatic relief but the exact mechanism of action has not yet been defined. The prescription drugs Proscar and Avodart actually shrink the prostate. They work best in the larger glands and improvement may not be noted for up to 6 months.
In cases refractory to medication, interventional measures are indicated. In your particular case, I would suggest that you be cystoscoped to examine the interior of the urethra, prostate and bladder to determine the local anatomy and degree of prostatic obstruction. I suspect it will be significant. I would then have a test called a cystometrogram done to devaluate the muscle tone of the bladder. After this, I would suggest you have the prostate resected to open up the bladder outlet and remove the obstructing portion of the prostate. Depending on the bladder muscle tone, you may or may not void after this. However, most men with a trabeculated bladder will do so. If not, you need to do self catheterization until the tone comes back over time. There is no god way to predict this but with a thickened bladder wall this is much more likely to occur than if you bladder was thin and from being over stretched. The “gold standard” for treatment is the time honored transurethral resection (TUR) of the prostate. For huge glands, open surgery may be necessary. In the past decade a number of other less invasive interventional therapies have been developed to reduce the obstructing prostate tissue utilizing various forms of energy. These include laser prostatectomy, microwave (TUMP or transurethral microwave of the prostate), and radiofrequency (TUNA or transurethral needle ablation of the prostate). TUMP is actually a minimally invasive, out-patient treatment that can be tried initially if the patient's gland size is appropriate.
Here is an explanation of a TUR of the prostate gland. The prostate gland can be thought of as being composed basically of three parts which from inside to out are: the prostatic portion of the urethra (urinary canal), the prostatic glandular tissue causing the obstruction (adenoma) and the compressed capsule of the prostate. In a TUR, the prostatic urethra and adenoma are removed leaving only the capsule. This surgery can be likened to coring out an apple from the inside leaving only the skin. The prostate is resected into many tissue slivers which wash into the bladder and then are removed at the end of the operation by suction. This leaves a raw bed, which, over a period of 6-8 weeks, regenerates a new urethra! At the termination of the procedure, one can look from the far end of the prostate into the bladder without residual obstruction. A catheter is left in for a few days to drain the bladder and to initiate the healing process. Good luck!