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Urology/Urine Drops in Urethra issue

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QUESTION: Dear Mr Arthur Goldstein,

From the past 6 months I have this problem and I will be really grateful if you can help me out.

Whenever I pass urine or even when I don't feel like passing urine, I always feel and sometime see a drop or may be just a mark on urethral opening of my penis.

I don't have any symptoms of leakage or passing urine when sleeping or passing urine in my trousers, in fact it never happen to me in my life. It just that I always feel that there is some urine left in urethra which remain there always. I am not even too sure if it is urine left or some sort of semens left in urethra but there is definitely something in urethra 24 hours which irritate me a lot.

I really hope you will help me with recognising what is causing this and how can  I avoid this or may be there is some home remedy or medicine I need to take?

Thanking you in advance for your help

Regards
Nas

ANSWER: Nas, based on your rather vague symptoms, the most likely cause of your problem is an inflammation of the prostate gland, so called prostatitis.  I suggest that you see a urologist in consultation for a proper history, physical examination and at the very least, a urinalysis.

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).  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.

Consultation with a urologist is recommended.   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.

---------- FOLLOW-UP ----------

QUESTION: Hi Mr Goldstein,

Thank you so much for your detailed explanation of my symptoms. Its so nice to see there are still people who help others. Much appreciated.

After reading your suggestion, I went online and researched about prostatitis but it look like I may not have that because it says that the symptoms of prostatitis are:

* make it difficult for you to start urinating
* weaken the flow of urine or cause 'stopping and starting'
* cause you to strain to pass urine
* cause you to pee more frequently
* wake you up frequently during the night to pee

and some other symptoms which does not apply to me.

The only problem I have is that I always feel there is a drop of urine or I would not even call it urine, It is more of a some form of semen (thick fluid) remain in urethra.

Other than this everything look normal to me ie I dont have any pain anywhere, I go to the rest room normally, I pass urine normally I ejaculate normally, my sex life is very normal etc...

I want to mention that I do drink GREEN TEA quite often... may be 3,4 cups a day.


Thank you again in advance for looking in to this

regards
Nas

Answer
Nas, the green tea will give you perhaps some urinary frequency but not the symptom you complain of.  I stand by my original diagnosis.  When one has any medical condition, they may have none, one or all of the possible symptoms that disorder may cause.  Symptoms related to irritation of the prostate gland are typically referred to the end of the penis.  Whether this is urine or some semen (or more likely prostatic fluid) is irrelevant.  Often men get this from what is called congestive prostatitis.  I have written a "macro" on this and will attach it now.  Some of this information is redundant from the message I sent to you on prostatitis previously.  Regardless, if you problem persist, I suggest urologic consultation.

I suspect that your symptoms are due to a very common condition with the medical name congestive prostatitis. 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.  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 requires a course of antibiotic therapy.   Therefore, if the condition persists, consultation with a urologist is recommended.  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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