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Urology/Dy and painduring and after urinationsuria

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Question
Dear Dr.
I am seeking your  valuable advice on my Urinary Tract problem which I am having since Jan 2013. I felt little intermittent  burning sensation and pain initially during urination which went on increasing and became constant during urination and thereafter intwo months.I consulted a Urologist who advised blood , urine and scans.All the test reports were normal except that the Prostate size was 32cc for wich he prescribed certain medicines .After three months the prostrate size reduced to 17cc. But the dusuria and reduced urine  flow continued.He then advised CYSTOSCOPY AND IF REQUIED TURP which was done in Aug 2013.But nothing serious could be found out. He advised that the problem will be over inabout 12weeks but the  problem still continued.Last year in June 2013 I consulted another urologist in a famous Hospital in KOCHI who initially prescribed certain medicines for three months .But no relief.He then did URETHRA CALIBRATION AND RETROGRADE  URETHROGRAM and  IDENTIFIED A STRICTURE IN THE URINARY CANAL AT THE PROSTRATE REGION. Again another CYSTOSCOPY AND TURP was done inFEB 2015 and the stricture was corrected.Now  the flow has become normal but the problem of DYSURIA AND BURNING SENSATION  STILL CONTINUES. I am totally upset since the surgery and medicines could not relieve me  from  the symptoms. I seek your valuable medical advise.
P.S.Nambiar,
Prathibha, naduvattam,
Beypore north, Calicut-15, Kerala India,
10 May 2015
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Answer
Sivadasan, sorry you are having so much trouble.  I suspect that your problem is indeed arising from the prostate gland.  More than likely, you had a combination of BPH and inflammation of the prostate gland, so called prostatitis.  The BPH  can cause a decreased flow but will not cause the burning or discomfort.  The TUR generally takes care of the flow problem but not always the inflammation.  In fact, sometimes the surgery (TUR) makes the prostate more inflamed for a while.  It is unlikely that you will require another TUR but sometimes the strictures can recur.  If, once better, you notice the stream narrowing or slowing down, a dilation of the stricture generally solves the problem.   To follow is information I have written on prostatitis which will explain the genesis and treatment of the condition.

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).  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, 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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