LUTS / BPH / “Chronic Prostatitis”

This is a common condition which is poorly understood.  Men have a variety of urinary symptoms including:

  • Hard to start urinating (needing to strain or keep trying)
  • Hard to stop urinating (dribbling)
  • Sense of not having emptied the bladder
  • Slow urination (weak stream)
  • Urinating small amounts, frequently
  • Waking up a lot at night to urinate
  • Urinary Retention (can hardly urinate at all)

The condition used to be called “Benign Prostatic Hypertrophy” (BPH), because the prostate swells in virtually all older men.ย  But sometimes the prostate isn’t swollen, just congested, so they kept the abbreviation but changed the last word to “Hyperplasia.”ย  Sometimes we can’t even tell what’s happening in the prostate, so it may be called โ€œChronic Prostatitis,” or “Chronic Pelvic Pain Syndromeโ€.ย  See Diagram: Male Genital System.

Now, the tendency is to call the condition LUTS (“Lower Urinary Tract Symptoms”).  Nobody can argue with that term.  It’s more honest, since we don’t know exactly what’s happening.  Still, it’s common, and can cause significant effect on quality-of-life.  Personally, I still use the term “BPH” when I speak with patients, because it doesn’t quite make sense if a man tells me he has lots of โ€œlower urinary tract symptoms,โ€ and I say “The diagnosis is LUTS.”

Diagnosis is made completely on the basis of symptoms, plus a normal urinalysis.  An abnormal urinalysis would suggest actual Urinary Tract Infection.  Since this diagnosis is โ€œChronic,โ€ its definition implies symptoms lasting over 6 weeks.

Examining the prostate gland doesn’t help, because any enlargement may not be uniform. We can only feel 50% of the gland, the back half (since we examine it by finger through the rectum). But the back half may feel normal while the front half may be interfering with the urethra to cause symptoms. Conversely, the back half we examine may seem enlarged, yet there’s no problem urinating through the front section of the prostate.

Numerous studies have found no association with any bacteria, even obscure ones.ย  As such, I try real hard to avoid giving antibiotics.ย  However, there is some suggestion that combining an antibiotic (specifically ciprofloxacin) plus “alpha blocker” drugs like doxazosin [Carduraยฎ], terazosin [Hytrinยฎ], tamsulosin [Flomaxยฎ], etc., is statistically slightly helpful for Chronic Prostatitis.ย  Treatment time in studies was 6 weeks.ย  Long-term antibiotics make me uncomfortable, because they’re the cause of wide-spread drug resistance (and then, the medication won’t work when you or someone else really needs it). So I usually begin with just the alpha blocker alone, raising to maximum dose over a month (for safety’s sake). See Prostate Medications.

Some patients have it stuck in their minds that “only an antibiotic will help,” even if there’s no evidence of infection.  Since a study did find that one course might be successful, it’s not illogical to try.  And if we ever want to refer to a Urologist, they’ll start off by giving the prescription (which doesn’t necessarily mean it’s useful, but perhaps that the specialist hopes symptoms will go away on their own by then). If symptoms return afterwards, there is no evidence that the medication should be continued.  Long-term antibiotics aren’t good for people or society, except in very special circumstances (this isn’t one of them).

The most dangerous complication of prostate swelling or congestion is Urinary Retention.  If a man can’t empty the bladder enough, pressure can build up on the kidneys.  If they get damaged enough, kidney failure can develop, even requiring dialysis (also called renal failure, since “renal” = “kidney”).

An ultrasound can determine if there’s any kidney damage (“hydronephrosis,” which means swollen kidney).  It can also measure the amount of urine that remains in the bladder after urination (“post-void residual” or “PVR”).  If hydronephrosis is developing, or if there’s a large PVR, and medicines haven’t worked, a man might need an operation called Trans-Urethral Resection of the Prostate (TURP).

Note that swollen prostates have nothing to do with Prostate Cancer.

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