Male Urinary Symptoms
Haematuria (blood in urine) is a common condition and one which must be taken seriously. Although in the majority of cases no sinister cause is found it must be investigated to exclude treatable disorders.
Haematuria is usually divided into macroscopic (visible) and microscopic (where the blood is found only on dipstick or microscopic examination). Further clinically relevant distinctions can be made between painful and painless haematuria, and haematuria of renal (medical) and post-renal (urological) origin.
Routine haematuria investigation usually involves flexible cystoscopy, to look at the bladder and a scan to look at the kidneys and ureters.
Investigations for Haematuria
General Physical Examination which includes blood pressure and digital rectal examination of the prostate.
Urinanalysis A mid stream specimen of urine for microscopy of red, white blood cells and bacteria. The presence of any crystals and the level of protein in the urine will be assessed. Urine may sometimes be inspected for the presence of cancerous cells as well.
Blood tests Routine blood tests may be required to assess kidney function, bleeding problems, anaemia or other related conditions.
Ultrasound Scan This test involved using a probe placed on the body surface to generate sound waves whose reflection off tissues is then converted into an image. It is painless, non-invasive and does not use radiation. As such it is the initial scan of choice for patients under 40 years of age.
CT Scan Computed Tomography scans are highly detailed x-rays that show the internal organs of the body. Dyes may be injected to help see the area more clearly. CT imaging is preferred for patients over 40 years of age and if abnormalities are detected at ultrasound.
Flexible cystoscopy In cystoscopy, a long, thin, flexible optical scope is inserted through the urethra and into the bladder. Visual examination of the urethra, bladder, and kidneys is undertaken to locate the site of bleeding. This is a 5 minute outpatient procedure that is performed under local anaesthetic and does not require an incision.
If either the imaging or flexible cystoscopy suggest a bladder lesion this will lead to examination under anaesthetic and operative removal of the lesion for both treatment and diagnosis. Other conditions may lead to other forms of investigation and treatment.
Points to consider about Haematuria (Blood in urine)
- Haematuria may not always be due to a problem that needs treatment
- It can occur due to urine infection
- Some medicines and foods can colour the urine red. This is not the same as passing blood
- It can occur following strenuous exercise
- Patients on anticoagulants whose control is in the normal therapeutic range and who have haematuria must be fully investigated as above, since haematuria is not a normal consequence of anticoagulation
Haematuria can originate from the kidney itself (eg glomerulonephritis) due to inflammation affecting the filtering units (glomeruli). When this is the cause of haematuria there are often other signs of kidney disease such as protein in urine, elevated blood pressure or abnormal renal function tests. This group of conditions is usually managed by a nephrologist (renal physician) and may be referred to as medical renal disease.
There are many conditions that may be associated with haematuria and some of the more notable are detailed below.
The commonest tumour arising in the kidney is renal cell carcinoma. It may present with haematuria, abdominal/flank pain or a mass however the majority are now detected coincidentally on scans performed for other reasons. Diagnosis is made by CT scanning and treatment is by surgical excision. Small tumours may now be treated by local excision with preservation of kidney function.
Stone disease is very common, with concretions forming in the renal collecting system. Renal stones tend to be asymptomatic but may cause haematuria by either infection or direct irritation of the mucosa. They may also cause renal pain if large enough or obstructing. Diagnosis is by imaging, usually CT scan. A number of treatment options are available for stone disease and the choice is influenced by patient and stone related factors
Glomerulonephritis tends to present with microscopic haematuria. While pain may be associated, most cases will have either no symptoms or may show signs of renal failure. Investigation is as outlined above.
Pyelonephritis (kidney infection)
Pyelonephritis results from bacteria infecting the kidney. Painless haematuria may occur but the symptom complex usually includes loin pain, fever and possibly septicaemia (generalized unwellness due to infection). Standard treatment of pyelonephritis is with antibiotics, pain relief and fluids. Surgery is reserved for complications of the infection (e.g. abscess formation, infection stones) or underlying problems that have led to infection.
Stones that form in the kidney may migrate into the ureter (the drainage funnel connecting the kidney to the bladder). They usually present with pain but may have haematuria as the only symptom. The presence or absence of obstruction, kidney function impairment, associated infection and the size of the stone will dictate management. Most ureteric stones will pass on their own but sometimes require one of several interventions.
Cystitis is inflammation of the bladder. It is typically painful and associated with a change in urinary symptoms such as frequency and urgency of urination. In men it may be related to inadequate bladder emptying due to outflow obstruction. Bacterial infection is the most common cause of cystitis Diagnosis is by urine microscopy and culture, other tests of urine flow or cystoscopic examination are occasionally required.
Most of the interest in painless haematuria stems from the desire to diagnose bladder tumours at an early stage.
Most bladder tumours are limited to the inner lining layers of the bladder at presentation and are managed by endoscopic (by scope without the need for an incision) surgery with or without the use of intravesical (chemicals placed in the bladder to reduce the risk of cancer recurrence) therapy. For invasive tumours the choice generally lies between radical cystectomy or radiotherapy. Metastatic disease may respond to platinum based chemotherapy.
Benign prostatic hyperplasia becomes more common with increasing age. It may cause haematuria directly or be complicated by infection that results in haematuria. More frequently it presents as increasing urinary symptoms. Diagnosis is by digital rectal examination, urinary flow assessment and bladder residual volume measurement. Treatment may be medical or surgical.
Prostate cancer is also more common with increasing age but can occur from middle age onwards. Haematuria in this setting is more often seen with advanced local disease or by coincidence with another condition present. Diagnosis is by PSA measurement, digital rectal examination and prostatic biopsy, under ultrasound control (TRUS). Treatment depends on the stage and grade of the cancer, but local disease may be suitable for radical prostatectomy or radiotherapy while advanced disease responds to hormonal manipulation.
Rare Causes of Haematuria
Arteriovenous malformations, trauma, tuberculosis and arteritis may all cause haematuria.
Benign Prostatic Hyperplasia
Benign prostatic hyperplasia (BPH) or benign prostatic hypertrophy is enlargement of the prostate gland. The word “benign” means non-cancerous. “Hyperplasia” means an increased number of cells.
The prostate gland encircles the urethra, so problems with urination can occur if the gland restricts urine flow through the tube. As the prostate enlarges, the layer of tissue surrounding it limits expansion, causing compression like a kink in a garden hose.
It is common for the prostate gland to become enlarged as a man ages. Though the prostate continues to grow through most of a man’s life, the enlargement doesn’t usually cause problems until later in life. BPH rarely causes symptoms before the age of 40 (other conditions are more likely to underlie the problem in this situation), but more than half of men in their 60s and up to 90% in their 70s and 80s have some symptoms of BPH.
The following changes occur over a period of time:
- The bladder wall becomes thicker and bladder function becomes more irritable
- The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination
- Eventually, the bladder weakens and loses the ability to empty itself so that urine is retained
Some problems associated with BPH include:
- Urinating more often during the day
- Being woken by the need to urinate frequently during the night
- Urinary urgency meaning the urge to urinate becomes strong and sudden to the point where you may not make it to the toilet in time
- Difficulty starting the urine flow
- Dribbling of urine after urination has finished
- A sensation that the bladder hasn’t fully emptied after urination
- A lack of force to the urinary stream which with spraying makes aiming more difficult
- The sensation of needing to go again shortly after urination
The International Prostate Symptoms Score (IPSS) is a useful questionnaire for assessing and following the level of urinary difficulties. It quantifies these symptoms and is used widely in urological practice.
You may notice symptoms of BPH yourself, or your GP may find that your prostate is enlarged during a routine check-up or examination for other problems. Further tests vary from patient to patient but the following are the most common.
Urine flow test and post void residual (PVR) measurement
A urine flow test involves voiding into a container modified to measure the rate and volume of urine passed. Both are often reduced in symptomatic BPH. Following completion of this test an ultrasound scan of the bladder is performed to measure the amount of urine remaining there.
A urine sample is taken to look for signs of blood and infection.
Digital Rectal Examination (DRE)
A gloved finger is inserted into the rectum to feel the condition of the prostate that lies close to the rectal wall. If an irregularity such as a lump is felt, further tests will be necessary to enable a more accurate diagnosis.
Prostate Specific Antigen (PSA) Test
A blood sample is taken to check for prostate specific antigen (PSA), which is produced by the prostate and is increased by cellular abnormalities within the prostate.
As men get older the prostate gland grows and so the PSA is likely to rise. A high PSA may indicate some type of prostate disease. The level can be raised due to inflammation of the prostate (Prostatitis) and enlargement of the prostate gland (Benign Prostatic Hyperplasia or BPH) as well as prostate cancer.
PSA is a useful tool for detecting and monitoring prostate diseases, but further tests are required to confirm which condition is present.
A thin flexible tube with a light and a camera lens is inserted into the urethra and up into the bladder. This test allows evaluation of the size of the gland, but it’s role is generally to rule out other underlying conditions that may present in a similar way such as urethral stricture disease (scarring in the outflow passage).
If symptoms are not particularly bothersome then ongoing monitoring without active treatment may be the best option. Simple measures such as modification of the volume and type of fluid intake or alteration of medications taken for other reasons may make an acceptable difference to the level of symptoms
There are 3 main groups of medicine used in the treatment of BPH related symptoms, each working through different mechanisms. By themselves or in combination these medications may be sufficient to reduce symptoms to an acceptable level.
Alpha blockers such as Tamsulosin, Doxazosin and Terazosin achieve their effect by relaxing smooth muscle fibres. Up to 50% of urethral pressure is due muscle tone and reducing this translates into improvements in flow rate and symptoms. This group of agents is derived from medicines designed to control high blood pressure and although made to be more selective for their effects on the urinary system, some 10% of men will notice some light headedness on standing up initially as their blood pressure drops temporarily. As this increases the risk of falls and injury, these medications may not be suitable for some men.
5 alpha reductase inhibitors such as finasteride and dutasteride inhibit an enzyme that converts testosterone to a more active compound responsible in part for BPH formation. This action will cause shrinkage of the prostate up to 30% over time and again translates into improvements in flow rate and symptoms. Further effects of these agents are an up to 50% reduction in PSA level and a reduction in the risk of being diagnosed with prostate cancer over time. They may be effective in reducing bleeding associated with BPH. These agents must be taken for at least six months to achieve their maximal effects.
Anticholinergics such as oxybutynin, detrusitol and vesicare inhibit the smooth muscle of the bladder causing it to become more relaxed. These agents may be useful in reducing the overactivity of the bladder in response to outflow blockage and therefore improve some of the symptoms such as urinary frequency and urgency but do not treat the outflow tract obstruction itself. Anticholinergics are less well tolerated than the other agents and are more likely to be stopped due to side effects. The most common of these are increasing retention of urine, dry mouth, blurring of the vision and constipation.
The most effective form of treatment for relief of symptoms related to BPH is surgical removal of the central prostatic tissue. This may be viewed as debulking of the prostate – in other words the exterior part of the prostate and it’s capsule are left intact compared with radical prostatectomy performed for cancer where the entire gland is removed. There are several different procedures performed for BPH including TURP, HolEP, BNI and open simple prostatectomy.
Transurethral resection of the prostate (TURP)
Long regarded as the standard treatment for BPH, TURP involves passing a cystoscope with a working electric cutting wire to trim away the central prostatic tissue. The operation is usually performed under spinal anaesthetic and takes around an hour to complete. After removing the tissue, a catheter is placed and irrigating fluid is introduced and drained through this to keep the bladder clear of blood clots. The catheter usually stays in place for 1-3 days and discharge from hospital occurs following removal of the catheter once voiding.
Following surgery there is an increased risk of bleeding for several weeks as the internal wound heals. Because of this risk, it is very important to avoid exertion in the form of sport, gardening, sexual activity or lifting (anything heavier than 5kg). Driving can be resumed at 2 weeks and normal activities at a month. Over this time constipation should be avoided by eating a diet high in fibre and fluid (2L fluid/day) as well as remaining mobile with regular walks. Laxatives may be helpful over this time as well. It is normal to expect urinary urgency, frequency of urination and discomfort on passing urine during the recovery phase.
Although successful at improving symptoms for the majority of men, some risks are associated with TURP. These include bleeding (even the need for blood transfusion for a small number of men), infection (despite routine use of antibiotics at the time of surgery) and temporary changes in the salt and fluid balance. Other uncommon side effects include incontinence (loss of control of the urine with leakage) and problems with erections (up to 10%). A common side effect is retrograde ejaculation (sperm travel backwards into the bladder at orgasm) this is not harmful but may impair fertility (although this cannot be relied upon as contraception).
Holmium laser enucleation of the prostate (HolEP)
HolEP is in many ways similar to TURP in that it is performed using a cystoscope with no external incision required. The point of difference is that this technique uses a laser fibre to dissect the tissue.
Tissue is vapourised at the point of contact with the laser fibre giving a generally less bloody result and avoiding some of the potential problems with salt and fluid imbalance that occur infrequently with TURP. Other risks seen after TURP are basically comparable following HolEP although hospital stay is often shorter. Once prostate fragments have been removed a catheter is placed for irrigation of the bladder. The catheter usually stays in place for 1-2 days and discharge from hospital occurs following removal of the catheter once voiding.
HolEP has largely been developed in New Zealand and is now a well established technique whose effectiveness has been confirmed in many surgical trials.
Bladder Neck Incision (BNI)
Bladder neck incision is performed for bladder neck dysfunction. The bladder “neck” which is found at the junction between the bladder and prostate fails to open appropriately. Men with this condition have often had voiding problems since relatively young and have very little in the way of prostatic growth.
BNI involves dividing the fibres of the bladder neck to improve flow. It can be performed with the same instruments used for either TURP or HolEP. Similar types of risks exist but are less frequently seen. Post-operative care is similar but hospital stay is generally only for 24 hours.
Open Simple Prostatectomy
The open simple prostatectomy involves an incision in the lower abdomen with a similar approach to radical prostatectomy (as performed for prostate cancer). The key difference is that the prostate is opened and the central obstructive tissue removed while leaving the outer shell of the prostate intact. This operation is therefore not a treatment for prostate cancer where the entire prostate is removed.
Although recovery time is similar to radical prostatectomy (i.e. around 6 weeks until fully functioning) the main post operative concerns seen following radical prostatectomy, those of urinary incontinence (leakage) and erectile dysfunction are significantly less frequent.
Open simple prostatectomy is an effective treatment for urinary symptoms due to BPH but takes longer and has a greater risk of bleeding and blood transfusion than TURP or HolEP. It requires hospital admission for 3 to 4 days and catherisation for a week. As such it is reserved for a small subgroup of patients for whom either TURP or HolEP is contraindicated (usually as a result of excessive amounts of prostatic tissue requiring resection).
Urinary Tract Infection (UTI)
Urinary tract infection (UTI) is a common condition that usually occurs when bacteria enter the opening of the urethra and multiply in the urinary tract. The urinary tract includes the kidneys, ureters (funnels that carry urine from the kidneys to the bladder), bladder, prostate and urethra (tube that carries urine from the bladder).
Under normal circumstances, bacteria in the urinary system are rapidly cleared, partly through the flushing and dilutional effects of voiding but also as a result of the antibacterial properties of urine and the bladder mucosa.
Urinary tract infections usually develop first in the lower urinary tract (urethra, bladder) and, if not treated, progress to the upper urinary tract (ureters, kidneys). Bladder infection (cystitis) is by far the most common UTI. Infection of the prostate is called prostatitis and of the urethra is called urethritis. Kidney infection (pyelonephritis) may require hospital admission for urgent treatment due to general unwellness.
Although urinary infection is more common in women, a subgroup of men with underlying urinary problems may present with urinary infection.
Any impediment to the free flow of urine (such as BPH, stricture, stone, or tumour) can result in an increased frequency of UTI. Infection superimposed on urinary tract obstruction in the kidney may lead to rapid destruction of renal tissue and sepsis. It is therefore important to bypass obstruction and drain infected urine if present.
Neurogenic Bladder Dysfunction
Interference with the nerve supply to the bladder, (as may be seen in spinal cord injury, multiple sclerosis, diabetes, and other diseases) may be associated with UTI. The infection may be initiated by the use of catheters for bladder drainage and is favoured by the prolonged stasis of urine in the bladder. An additional factor that can contribute in this situation is kidney/bladder stone formation which as acts as a reservoir for infection because antibiotics penetrate them poorly and therefore fail to clear all the bacteria.
Defined as reflux of urine from the bladder cavity up into the ureters and sometimes to the kidneys, vesicoureteral reflux occurs during voiding or with elevation of pressure in the bladder.
Vesicoureteral reflux is common among children with anatomic abnormalities of the urinary tract as well as among children with anatomically normal but infected urinary tracts. In the latter group, reflux disappears with advancing age. Vesicoureteral reflux is important in children as it may result in long term loss of functional renal tissue. It does not appear to be significant for adults whose kidneys are mature, with the possible exception of pregnant women in whom pyelonephritis may contribute to premature labour.
Bacterial Virulence Factors
Bacterial virulence factors are like personality traits for a bacterial infection. They have a strong influence on the likelihood that a given strain, once introduced into the bladder, will cause UTI.
Increasing evidence suggests that host genetic factors influence susceptibility to UTI. Other medical problems (e.g. Diabetes) and impaired immunity in hosts may also make infection more likely.
The first step in diagnosis involves testing a sample of urine for signs of infection then incubation to grow any bacteria. This is collected as a "midstream" sample in a sterile container. (The method of collecting urine helps prevent bacteria around the genital area from getting into the sample and confusing the test results). The bacteria grown are tested against different antibiotics for antibiotic sensitivity, to see which drugs kill them most effectively.
Further investigation is likely to involve physical examination, a urinary flow test and bladder scan for post void residual. If you have frequent infections, cystoscopy (visual inspection of the bladder, prostate and urethra with an optical scope) or imaging of the kidneys (often using ultrasound) may be necessary.
Management of recurrent UTIs for men focuses on excluding and treating important underlying conditions. The most likely of these is BPH related urinary outflow obstruction, which may require medications or surgery (such as TURP, HolEP or open prostatectomy). Another common cause may be in association with renal stone disease. Occasionally recurrent UTIs have no identified cause but require prophylactic antibiotics to prevent recurrence.
Urinary incontinence is the inability to control the flow of urine and is a common side effect of a number of Uro-oncology treatments, including surgery on the prostate and bladder as well Radiation therapy.
Physiology of normal bladder filling
Normal bladder filling depends on the elasticity of the bladder wall which allows it to increase in volume at a pressure lower than that of the control mechanism – the bladder neck and urethra (otherwise incontinence would occur). Despite provocative maneuvers such as coughing, bladder contractions and leakage do not occur. Emptying requires a lack of outflow obstruction, adequate bladder power and coordination of the emptying mechanism (relaxation of the control mechanism before bladder muscle contraction). With normal, sustained detrusor (bladder muscle) contraction, the bladder empties completely.
The Types of Urinary Incontinence
- Stress Leakage of urine during physical movement (coughing, sneezing, exercising) due to increased abdominal pressure being transmitted to the bladder
- Urge Leakage of urine at unexpected times, including during sleep, due to the bladder contracting despite not being told to do so
- Functional Untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet
- Overflow Unexpected leakage of urine because of an abnormally overfull bladder
- Mixed Usually the occurrence of stress and urge incontinence together
Both women and men can become incontinent from neurologic injury, birth defects, strokes, multiple sclerosis, and physical problems associated with aging. Urinary incontinence in men is often seen as a consequence of the bladder’s response to outflow obstruction as seen in BPH or following treatment of BPH or cancer.
The level of incontinence differs for each person and depends upon the treatments that they have had, however for some people it may be short lived while for a few it may be permanent.
There has however been a lot of progress in dealing with continence issues and there are a wide variety of aids and equipment for collecting urine, preventing infection and protecting the skin and surrounding area. There are also a number of exercises that can be done to strengthen the urinary sphincter muscle that controls the opening and closing of the bladder.
Exercising the Pelvic Floor
Pelvic floor exercises are an important and relatively easy way to improve bladder control. When done correctly they can build up and strengthen the muscles that help hold urine. The pelvic floor is made up of muscles stretched like a hammock from the pubic bone in the front through to the bottom of the backbone. These firm supportive muscles help to hold the bladder, prostate and bowel in place and also function to close the bladder outlet and the back passage. Pelvic floor exercises strengthen the muscles that support the pelvic contents and prevent the escape of wind, faeces or urine.
The aim of bladder retraining is to overcome urgency and stretch out the intervals between trips to the toilet. It is recommended when the underlying cause of urinary urgency and frequency is thought to be bladder sensation of fullness at an abnormally small volume without other abnormalities. The focus is to postpone the initial urge to void so that the bladder becomes used to holding larger volumes.
Different treatments will be appropriate depending on the type of incontinence present. Medications used for men with urinary continence issues are often those used in the treatment of BPH.
If the cause of incontinence is not immediately clear or simple treatment options have failed and surgery is being contemplated, urodynamic assessment may be recommended.
Urodynamics involve placement of pressure monitors and filling tubes into the bladder as a catheter, and into the bowel. The bladder is filled and pressure is measured during the process. This confirms the suspected diagnosis (or disproves it) but provides additional information to help tailor the right surgical procedure to the right situation.
Surgical Treatment for Urge Incontinence
Surgical intervention for overactive bladder leading to urge incontinence is not usually required. Occasionally if oral medications fail, cystoscopy with injection of BOTOX into the bladder muscle is used to paralyse some of the fibres. This is performed under anaesthetic as a day case. The effects last on average 6-12 months and therefore may require repeated procedures over time. The main risks of the operation are blood in the urine, infection and the possibility of temporary complete bladder paralysis with urinary retention. If the last of these occurs either placement of an indwelling urinary catheter or regular intermittent self catheterization will be necessary until the drug effect wears off.
More advanced reconstructive bladder operations (such as clam cystoplasty) exist but are rarely required and should be discussed only once less involved treatment options have failed.
Surgical Treatment for Stress Incontinence
Surgery for stress incontinence is relatively common for women but is uncommonly necessary for men. It is most likely to be required for the treatment of stress incontinence that has developed following surgical treatments for prostate cancer (such as radical prostatectomy) or BPH (such as TURP or HolEP). Many men will have a gradual return of continence over time in this situation with a combination of pelvic floor exercises and medications. As such surgical intervention is not undertaken early in the postoperative phase.
Several options exist and each may be more indicated under certain circumstances. These range from simple measures (including catheterization, use of a penile clamp or a bottle), to more invasive surgical options such as placement of a supportive sling under the urethra or a balloon cuff around the urethra which may be inflated and deflated as required.
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