Expert: Arthur Goldstein, M.D. - 1/3/2005

Question
I am 51 yo white male.  sometimes just as I finsh urinating I get an urgent feeling as if I still need to urinate and pass what appears to be semen.  I take effexor and welbutrin successfully for 3 years could the meds be causing this?  There is no pain involved and it doen't happen everytime I urinate but usually happens at least once per day.

I have a normal married sex life with no possibility of any VD or other STD.

My doctor has no idea and prostate checks are normal and PSA is normal.

Answer
Frank, the most common cause of this complaint is an inflammation of the prostate gland, 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). 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.  Drugs such as the two you are taking may also delay or in some cases prevent ejaculation swhich could lead to prostatitis.  The fluid at the end of urination is prostatic fluid that you are not totally eliminating with ejaculation.  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.  There are several types of prostatitis.  Sometimes prostatitis can be due to an infection of the gland with bacteria.  This usually requires a 4 week course of an appropriate antibiotic.  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,  recurrent or chronic.


To follow is some information on prostatic fluid discharge that mainly pertains to men who have problems ejaculating but the general principles apply to you as well.  
The prostate gland manufactures the major component of your semen in response to sexual stimulation.  When a man becomes sexually aroused (foreplay, dreams, fantasies, etc.) and does not ejaculate, this fluid accumulates in the prostate gland.  In such an instance, stool can push on the congested prostate causing a discharge of its fluid from the urethra (it acts like a massage of the gland).  Likewise, as one urinates, the bladder contracts to expel urine.  As the bladder squeezes out the last few drops, it also compresses the prostate.  If the latter is congested, prostatic fluid will appear at the end of urination.   The presence of this type of discharge is not in itself harmful.  However, chronic congestion of the prostate may predispose to inflammation of the prostate gland, so called prostatitis.  Periodic ejaculation in moderation will help to prevent this phenomenon from happening.

In conclusion, you need to see a urologist to be evaluated for prostatitis.  A normal PSA and digital examination of the prostate do NOT rule out prostatitis!  Treatment of your specific type of prostatitis should resolve your symptoms.  Good luck!