AboutArthur Goldstein, M.D. Expertise Any problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, impotency, etc.
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 male impotence and endourology.
Organizations American Medical Association, American Urological Association, American College of Surgeons
Question Dr. Goldstein, I am a 43 year old male from Old Greenwich, CT diagnosed with BPH suffering from frequency/urgency and irregular bowel movements that seem to trigger the urgency (GI doctor thinks my prostate is causing spasms in my colon). There are times when I can go 2 hours without any urge but as soon as I have a bowel movement, the irritation starts and I spin into a cycle of every 15 minutes. I had a CT abdomen and pelvis contrast which showed bladder wall mildly thickened, prostate gland enlarged and heterogeneous (I think it is 43cc); my local urologist who did a cystoscopy and found defects in the diatal ureter which may be calculi or air bubbles with backflow evident, anterior urethra normal, prostatic urethra 2.5 cm with a quite significant median lobe sticking up into the floor of the prostate, minimal lateral lobe enlargement was seen; prostate massage yielded a lot of fluid. A boston doctor did a urodynamic study- basic findings were mild impression on base of bladder, presumably from enlarged prostate, mild diffuse narrowing of prostatic urethra, large post void residual.
my local urologist immediately said laser surgery was needed and said 80% chance of success. my boston urologist said laser surgery isnt the answer and if he were to do surgery it would be TUI, but he said odds are 50% and both have retrograde ejaculation as side effects.
I am taking Uroxatral, which has limited benefits and doing some pelvic therapy (PT and relaxation). What would your thoughts be- Im perplexed and not getting any clear cut answers from anyone, which is frustrating. 50% odds are not good in my book, and the laser surgery sounds drastic.
Thanks,
Jim Brooks
Answer Jim, before anything is done to your prostate, it is necessary to determine, as best one can, the source of your symptoms. Stones in the lower ureter often cause frequency and urgency. A stone can be ruled out either with an intravenous pyelogram (IVP) or high speed CAT scan. If you have a stone, have it removed and see if you symptoms disappear. Likewise, many types of inflammatory bowel disease can cause your symptoms. The treatment, in this case, would be treating the bowel problem. In my experience, although it can occur, it is much more unusual for prostate problems to cause bowel symptoms than the reverse. Both these possibilities should be ruled out before having prostate surgery of any kind. If you are not satisfied with the explanations you have been given, consider second opinions with another urologist and gastroenterologist.
It is unusual for men age 42 to require prostate surgery for obstruction. By far the most common prostate problem causing these symptoms at your age is an inflammation of the prostate, so called prostatitis. 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, 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 – betwixt the “wind and the rain”). The prostate is the organ that produces the majority of the semen in response to sexual stimulation. At the time of orgasm, the prostate contracts and forces its fluid into the urethra (urinary canal) where it mixes with sperm and seminal fluid (that come from the ejaculatory duct) to make up the semen. Since the
ejaculatory ducts actually empty into the prostatic urethra, it is common
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. Sometimes vigorous gym activities may strain muscles in the area (cremaster muscles) producing similar pain in the testicle. One should avoid any of the above that apply and ejaculate in moderation (about once or twice a week). 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. A daily warm bath for 10-15 minutes 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. This 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). Typically, pus cells and bacteria are found in the prostatic fluid.
Abacterial prostatitis has several varieties. In one, the prostatic fluid demonstrates pus cells but no bacteria. In the other, called prostadynia, 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 usually responds to the general measures mentioned above. Medications that sometimes help include the over-the-counter natural supplement saw palmetto 320 mgm daily and alpha blockers (such as Flomax, Hytrin & Cardura). The latter require a prescription from you physician if he thinks it is indicated. Prostatitis may also be classified as acute (severe), subacute (mild), or asymptomatic. It may also occur as a single episode, be recurrent or chronic.
To follow, just for your information is some material I have written on BPH. 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 delicate balance can be upset by any factor that decreases
the bladder muscles abiltiy to contract with sufficient force to open the
prostate (such as drugs, anesthesia, too much alcohol, ignoring the desire
to urinate, etc.) or those factors that might cause the prostate to
suddenly swell (ie 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. Treatment is indicated to relieve symptoms and prevent complications. In many cases medications can be used. Alphas 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. Saw palmetto, a natural herbal product, often provides 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. 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, microwave (TUMP or transurethral microwave of the prostate), and radiofrequency (TUNA or transurethral needle ablation of the prostate).
Here is an explanation of a TUR of the prostate gland. The prostate is
composed basically of three parts which from inside to out are the prostatic portion of the urethra, 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 leaves a raw bed, which, over a period of 6-8 weeks, regenerates a new urethra! 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 surgery can be likened to coring out an apple from the inside leaving only the skin. 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!
