Urology/Recurrent UTI and Pain and sometimes Milky /mucous in urine
QUESTION: I am a 39yrs male, married . For the past 9 months i experience unusual problems while urinating. I have the following symptoms...
1. Started as a Split stream , dribbling and weak flow, pain in groin area, back.......was detected UTI in month 1 and kidney stones (5mm and 4mm in the right kidney ) .... took antibiotics for a week ....followed by 2 month of Cystone (Himalayan drug for stones)
2. Post first UTI ...4-5 months were fine .... i again developed same symptoms in 5th month ....took again a week course of antibiotics ....but post have not recovered fully as have had another UTI in month 8 .
3. Visited urologist who did Uriflow, Utrasound
Ultrasound should 2 stones sizes 4 and 3mm respectively .... Uriflow showed weak flow with peak flow rate being 14ml/sec and avg 12ml/sec . Was prescribed tamusolin ...but had to leave medicine in week due to side effects .
Urlogist says its early symptoms of Postrate but medicine is having side effects with you.
4 . My GP is not in sync with the urologist and feels it is due to stones the recurrent UTI's .
5. After last UTI 20 days ago i took course of antibiotics alongwith Potassium/Mg citrate and 2 Cranpac D tablets a day as suggested by my GP .
After week of antibiotics have been on 2 tabs Cranpac D and Potassium/Mg citrate for last 15 days .
4. Day before yesterday after intercourse had pain/discomfort in right groin area . Today afternoon when i felt urge to urinate , it was difficult to start as if something had blocked the way ....after 5-7 secs find a milky(greyish) liquid comes alongwith urine .Post that the right groin area pained a lot for 1 hr and subsided .
Otherwise i have had some relief with cranpac d and citrate soln in last 2 weeks of .
Tense as to what this is ........my GP says it is only because of stones ....that i develop UTI due to them ....nothing to worry ..... should continue Cranpac D to avoid further UTI's due to stones .Should not be worried about this milky stuff and have lot of water and fluids
Consuming 3 litres water daily for last 15-20 days and flow seems improved apart this milky soln and mucous i find having passed 2-3 times in last 15 days .
Pls could you advise what this could be and is there anything to worry ?
Is there a way/test to figure out the correct reason of pain/UTI's
ANSWER: Manish, your symptoms are rather typical of an inflammation of the prostate gland, so called prostatitis. I do not think that your 2 kidney stones are causing any symptoms at present. I do not think the medication that has been prescribed for you to treat the kidneys stones will work. It is very rare that these can be dissolved. In addition, there are many chemically types of kidney stones but only the uric acid variety is potentially dissolvable with oral medication. The best treatment would be ESWL therapy (the so called stone bath). The milky (grayish) material in the urine is either prostatic fluid or pus coming from the prostate gland.
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). This is the most likely type of prostatitis that you have. However, you have not been treated for a long enough period of time.
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. 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. The Tamulosin is Flomax so this option is not available for you as you had a side effect from the medication.
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, 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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QUESTION: Thanks a ton Doctor for the detailed reply .
Very next day of your reply I visited my urologist . He read your revert too .
He did a physical rectal examination of postrate and physical of testes , and ruled out acute prostatitis .
He also basis his analysis ruled out blockage in urethra .
He got a uriflow done again where a weak steam is what he diagnosed as root cause of getting infection again .
The peak flow was 16ml/sec and avg flow was 8ml/ sec . But the graph was what showed a extended triangle than a parabola . PRV Was 20ml .
He advised me to start with Flotral 5mg again and conveyed that we would have to try and get the right medicine which suits .
The very next day I got my urine tested which was positive for pus cells , 16-18.
I called him where he said the infection had not gone and we need to treat long term else it may become chronic prostatitis .
Put me on 750mg levofloxacin for 2 weeks and said after a culture would bring medicine down a bit but give for another couple of weeks .
Today is 8 day of antibiotic 750mg levofloxacin and flotral 5mg .
Partial improvement in symptoms .
Pain is only in right side ( mainly right testicle ) , groin area and also goes to my right hand side back . Wanted to know why is it one sided only as incidently stones are also in right kidney .
Just want your guidance if the treatment is correct .
Also would request you to suggest me all tests that may need to be done to rule out any other possibity or minimise chances of reoccurance .
Last 9 months have been bad and want to ensure that this time treatment is complete and we rule out all other possibilities ie ureter blockage , kidney infection , testes infection or anything else that could also be the cause .
The flow post 4-5 days of infection is better as earliar used to stop in between suddenly while having Uti .
Haunted by fact that once anitibiotic course is over , I may again develop an UTI .
Also one last thing , read somewhere that should ejaculate /mastrubate 1-2 times a week to empty the prostrate gland ?
ANSWER: Manish, Flotral is Uroxatral one of the alpha blockers mentioned in my note to you. This is quite appropriate to use. The course of levofloxacin is also proper. If you have recurrent episodes of prostatitis after the course of antibiotics is completed, I would suggest a culture of your prostatic fluid and then re-treatment for 6 weeks followed by a continuous course of low dose prophylactic antibacterial therapy. If you continue to have break through infections in spite of this, an ultrasound of the prostate and seminal vesicles is indicated. It is not unusual for the discomfort of prostatitis to be on one side although it is often bilateral. The kidney stones probably are not causing your pain as you describe it but if there is a question of this, you need your doctor to order an imaging study of your upper urinary tract to see if the stones are blocking the outflow of urine from your kidney. If so, this needs prompt attention. As far as sex is concerned, it is important to ejaculate in moderation to keep the prostate from becoming congested. I would suggest 1-3 times a weeks. Avoid sexual arousal without ejaculation as this may further irritate the gland. Good luck.
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QUESTION: Dr Goldstein ,
I had 2 weeks of 750 mg levofloxacin and then 3 weeks of lesser dose of 250mg alongwith 5mg flotral for 4 weeks .
Had to leave flotral due to side effects . Post a week had discomfort symtoms increased .
Had urine with Pus cells of 8-10 , but culture showed sterile .
My urologist did a urodynamics study 2 days back and diagnosed BLADDER Neck obstruction .
He has suggested alpha blockers /BNI .
As alpha blockers not working with me , surgery looks the only option .
Although I am not very keen for this , but looks as only option .just wanted your inputs and advise .
Also unable to correlate my back ache with this diagnosis .
Attaching my reports for your perusal and will all symtoms go after the surgery . Does surgery have any other effects later on ?
I am trying saw palmetto since yesterday , if it works can it avoid surgery ?
Manish, I would leave surgery as the absolute last resort & not rush into it yet. First I would suggest you be rechecked for residual urine (RU) (the amount left in your bladder after a NORMAL urination). You should void normally first and then either have an ultrasound (US) of the bladder for RU or be catheterized to measure the amount. If less than 2 ounces (60 cc), I would not be concerned about this. The uroflow is inaccurate if you were able to void only 3 cc.
I still believe you have an inflamed prostate gland, I would recommend an US of the prostate and seminal vesicles to look for a prostatic abscess or blocked ejaculatory duct. Also, you need a culture of the prostatic fluid once off antibiotics for 7-10 days. If infection is found, appropriate antibacterials are indicated according to sensitivity studies. In the meantime, it certainly is worth a trial of saw palmetto because it is rare to give side effects. However, you need to take it for several months to see beneficial effects. It it works, stay on the medication. If all else fails and you are carrying large amounts of residual urine, a TUI of the prostate may be indicated. However, narrowing of the bladder neck is a difficult diagnosis to make with certainty. If a TUI is done, there is the risk of retrograde ejaculation occurring post-operatively. Again, surgery is the last resort. It does not always alleviate the problem and occasionally makes the symptoms worse.
As you have WBCs in the urine & persistent symptoms, you should be cystoscoped to look for a bladder source of this. It will also allow a good inspection of the interior of the prostate gland and bladder neck. Your back pain is probably unrelated to your prostate condition. Good luck.