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
Background/History: I had a urethral stricture that was corrected when I was a young child[about 6 years of age]. My stream has never been very strong, and with some dribbling not being uncommon, subject to splitting of stream for as long as I can remember.
Urination becomes very difficult sometimes. This has become worse over the last several months. In 3 times in the last 3 months, I could not urinate. Note: These incidents all occured after I ejaculated. Hours afterwards, I still could not urinate despite obvious full bladder. On two occasions I want to emergency room. 1st time, they tried to pass a cathetar and failed to pass it -- so they tried to force it. The pain was beyond anything I can describe with words, but I could pass urine after this failed attempt to pass a cathetar. The 2nd time to ER, I could start to dribble and have a very weak stream at that last minute, so I then was able to avoid the cathetar. 3rd time I was ablel to repeat what happened the 2nd time, but I did not go to the ER. I have been to a urologist, which could not determine anything from a flexible endoscopy, except to confirm a stricture that he could not pass the scope through. Urine analysis is clean.
Now for the thread title issue: I went to have a retrograde urethrogram. I was told that this involves a very small tube inserted into the tip of the penis and a contrast dye is injected while X-rays are taken. However, upon actual procedure they inserted a standard cathetar several inches into the urethra, causing extreme pain, and then when they tried to inject the liquid, the pressure was too much for me to withstand.
Was this required for the retrograde urethrogram? I thought that a short tube was to be inserted into the tip of the penis only an inch or two? During the endoscopy, the injection of the liquid they used during the procedure was no problem. Perhaps the standard cathetar[with the side outlet for the opening on tip] was blocked against my urethra? Was this the standard procedure[using this tyupe of cathetar for this?]? I am now supposed to return for the procedure, but this time under anethesia due to the pain. However, I am concerned that perhaps they are doing the procedure in a needless fashion and may even possibly cause further trauma/damage to my urethra. I should note that after the last attempt, the pain was horrible for 2 days afterwards when urinating, and it was difficult to urinate -- more so than usual. I should also note: they intend to use a rigid endoscope in this second attempt while I am under anesthesia. Is this a good idea, considering all of this, and that the flex scope could not be passed without damage in the prior attempt? Any advice/help is deeply appreciated.
Christopher
Answer Christopher, you obviously have a recurrence of the urethral stricture. There are several ways to do retrograde urethrograms but all are similar. Some use a regular catheter passed partway into the urethra and others use a tapered nozzle type device in the meatus. It seems reasonable to do an endoscopy under anesthesia to find out the location and severity of the stricture. A rigid cystoscope may be able to pop through the stricture more easily than a flexible instrument. Doing a urethrogram at this time may or may not provide additional anatomic information. Personally, I would be prepared to do a minor procedure called an "internal urethrotomy" while you are anesthetized. This invovles identifing the stricture through a scope and incising it with a bayonet type blade. A catheter is left in for a few days to allow healing of the incision to occur. It generally works quite well but may have to be repaeted occasionally. Another option is just to dilate the stricture with instruments called sounds or with filiforms and followers. However, the later actually tear the tissue apart and the stricture tends to reform more rapidly than after a clean incision made during internal urethrotomy. Regardless, periodic dilation thereafter should be done at least on an annual basis. A last resort would be formal open surgery to repair the stricture but this is not usually necessary. As far as your symptoms flaring after ejaculation, this probably is related to some inflammation of the prostae gland so called prostatitis. To follow is some information I have written on prostatitis. By the way, after the stricture is dilated, your prostatitis will probably resolve as well.
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). 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. A urethral stricutre may prevent the prostate from emptying normally and predispose to prostatitis. 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. Therefore, if symptoms persist, consultation with a urologist should be scheduled. A man should learn to listen to his body. Good luck!
