Many thanks to Dr David Ende for this excellent summary about urinary symptoms.
Dr David Ende is a Urologist with current appointments at St Vincent’s General Hospital, St Vincent’s Private Hospital and Clinic, St Luke’s Hospital, Blacktown Hospital (South Western Area Health) and Westmead Private Hospital.
Dr Ende completed his Urological training in 2000. He also completed a PhD in Cancer Medicine at Sydney University in 1996. His research focused on magnetic reasonance spectroscopy in evaluating the biochemical changes in colonic polyps and cancers. His interests include benign and malignant prostate disease, voiding dysfunction, stone disease/laser surgery and laparoscopic kidney surgery. Dr Ende also has experience with bladder cancers and neo-bladder formation. Dr Ende also participates in medical education as a Adjunct Senior Lecturer at the University of Notre Dame in Sydney, as well as Urology registrar training and lectures for nursing staff. Other interests include ongoing research into prostate cancer. He has also been involved in both the state and federal committees of the Urology Society Of Australia and New Zealand.
…..Over to David now for his explanations regarding commonly encountered urinary difficulties.
Voiding issues in men are extremely common at all age groups. Similar symptoms can occur in patients with many varying underlying causes. These symptoms are often termed lower urinary tract symptoms (LUTS). Interestingly, women with problems voiding often complain of similar symptoms to men but, obviously, the causes can vary greatly and in women they are rarely due to a blockage. In men lower urinary tract symptoms can be due to a blockage from the prostate or the bladder neck or even a urethral stricture. Similar symptoms can also be due to bladder over activity which can be associated with a stone, tumor or other foreign body within the bladder. Some men have considerable symptoms and often no underlying cause can be identified. It is the job of the Urologist to take a careful history from each patient and order appropriate investigations to determine the exact underlying cause and suggest appropriate treatment.
Lower urinary tract symptoms can be categorised several ways. One of the common methods is to consider obstructive symptoms and irritative symptoms. Obstructive symptoms obviously include a slow flow, hesitancy when trying to initiate voiding, post void dribbling and an intermittent flow. Irritative symptoms include frequency and urgency. Urgency can be so severe that it may be difficult to stop urine from leaking just prior to voiding. Passing urine at night, or nocturia, is another symptom frequently experienced by men and, in many cases, can be associated with a large prostate causing obstruction. Nocturia however can also be due to several other causes completely unrelated to the prostate or the bladder.
Obstructive symptoms that impede the ability to empty the bladder as well as the irritative symptoms that make it difficult to control the bladder can be scored on an international scale, called the International Prostate Symptoms Score. The higher the score the more severe the symptoms and the more likely a patient will need treatment.
Another way of assessing the need for treatment is to determine how significantly a patient’s symptoms impact on his quality of life. A man who is unable to sit through a movie without the need to void, may feel quite inconvenienced. A man who wakes 4 or 5 times to void at night may well have significant interruption to his sleep and feel tired during the day. Leakage associated with severe urgency obviously would have a major impact on day to day activities, especially if he needed to change his underwear or wear pads. Men may also limit their fluid intake and many are aware of the locations of public toilets when they go out.
It is also important to note that a large prostate is not always associated with significant symptoms or the need for intervention. Many men have very large prostates but are not inconvenienced by symptoms and manage to empty their bladders quite adequately. Conversely many men have small prostates but can have significant issues, especially if their bladder neck is narrow or if they have a prominent middle lobe that projects into the opening of the bladder. Treatment for outlet obstruction caused by the prostate or other blockage would always depend on the inconvenience to the patient and whether or not he is ready to accept treatment.
Some of the investigations that Urologists may use include a flow test, prostate and bladder ultrasound, urodynamics and even a cystoscopy where a camera is passed through the urethral tube in the penis to have a look at the prostate as well as the bladder. A flow test gives the Urologist an objective measurement of how fast a man passes urine and a bladder scan performed after voiding measures how much residual urine is left behind. An ultrasound scan allows a measurement of the size of the prostate and also will demonstrate abnormalities within the bladder such as stones or tumour that may account for the patient’s symptoms. Urodynamics is a specialized test that allows measurement of the flow and bladder pressure and is particularly useful in situations where a mans symptoms may seem unusual or disproportionate. These investigations, of course, will be arranged after the Urologist has examined the patient’s prostate to get an idea of its size and consistency.
It must be stressed that prostate cancer rarely causes symptoms as described above. Most prostate cancers are diagnosed early and are contained within the prostate. They are essentially asymptomatic, as they do not alter the size of the prostate. When a patient is being assessed for voiding symptoms the Urologist will need to try and exclude the presence of a prostate cancer before embarking on treatment. If a prostate cancer is identified, treatment would usually be directed toward the tumor rather than any symptoms associated with a blockage to the flow. Obviously the patient’s age would need to be taken into account as well as other factors such as the patient’s general fitness and other concurrent medical issues.
Many men with symptoms can be safely monitored without treatment. In the first instance, if required, treatment would usually consist of medications designed to relax the muscle tone and tension within the bladder neck and the prostate. These medications are generally termed alpha-blockers and there are several currently on the market. There are also medications that are aimed at reducing the size of the prostate and, more recently, alpha-blockers and prostate shrinking medications have been used in combination with good effect. There are generally two main side-effects associated with these medications, namely a possible lowering of the blood pressure and retrograde ejaculation. If patients cannot tolerate the medication they can simply be discontinued.
If symptoms due to obstruction persist despite medication, or if patients are unable to tolerate the medication, the next step would be some form of surgical intervention. Surgery may also be first line treatment in cases of impending total blockage/retention or complications such as kidney failure associated with a blockage. Surgery is aimed at debulking the prostate and opening up the bladder neck. Traditional methods use electro-cautery to shave strips of prostate away from the inside, much like taking out the core of an apple, (trans urethral resection prostate/TURP) but newer methods are also available where lasers are utilised to either enucleate or vaporise the prostate. These surgical procedures are extremely common and provide excellent symptomatic relief. Patients often comment following treatment that “they should have had the procedure performed years ago” as their life style has significantly improved.
As mentioned above, there are many other causes for men’s voiding symptoms that are not related to obstruction. Bladder stones cause irritation to the bladder and men often have symptoms of frequency and urgency associated with bleeding caused by inflammation of the bladder surface. Bladder stones are usually the result of an enlarged prostate causing incomplete emptying but it is not uncommon for men to have some resolution of their symptoms when the stones are removed without debulking the prostate. Bladder tumors can also cause irritative symptoms as the bladder can sense the presence of a foreign body. Bladder tumors, of course, are often also associated with bleeding. Lower urinary tract symptoms in the absence of any identifiable problem are not uncommon. Some men may have weak bladder contractions causing a slow flow. Some men have an irritable bladder in the absence of any stone, tumor or blockage. Many men have a symptom complex known as Prostatitis, a presumed inflammatory condition of the prostate which causes wide ranging voiding issues. In these cases, treatment is available to try and settle the bladder down once any other cause has been excluded.
Nocturia is often a very difficult symptom to try and sort out, especially when it occurs in isolation. Men (and women) often wake several times at night with an urge to pass urine. In men this can be associated with an enlarged prostate causing a blockage but often, in this situation, men deny any significant symptoms during the day. Non-prostatic causes of nocturia include sleep apnoea, excessive afternoon/evening fluids and poor sleeping habits. If men pass large volumes of urine overnight in the absence of any other obvious causes mentioned above it may be necessary to exclude underlying medical conditions.
In general, it is usually quite simple to investigate men’s voiding symptoms. Many men unnecessarily delay seeking help which can increase the risk of complictions, especially urinary retention or complete blackage. Treatment is usually straightforward and often results in a much-improved quality of life with few side-effects. While men are often fearful of an underlying prostate cancer, tumors are unlikely to be responsible for the symptoms that men experience.