Abstract
We describe 5 men with urinary retention and indwelling urethral catheters who were treated with repetitive prostatic massage, antimicrobials, alpha blockers, and – in 2 cases – finasteride. We retrospectively reviewed the charts of all patients presenting to the genitourinary clinic with indwelling urinary catheters during a 1-year period. Five men (mean age, 70 years; range, 64–76; SD 4.47) presented to the Manila Genitourinary Clinic (Cebu Branch), Cebu, Philippines, wearing indwelling urinary catheters placed for acute urinary retention. Urologists had told all 5 men that they needed to undergo transurethral resection of the prostate (TURP). The Cebu genitourinary physician removed the catheters, instituted repetitive prostatic massage, and diagnosed all 5 patients with prostatitis. All 5 patients received repetitive prostatic massage, alpha-blocker medication, and antibiotic therapy, whereas finasteride was given to 2 patients. During treatment, statistically significant improvements occurred in global symptom severity scores, urethral white blood cell (WBC) counts, WBC counts of the expressed prostatic secretions (EPS), EPS red blood cell (RBC) counts, urinary WBC counts, and urinary RBC counts. Fluorescing Chlamydia elementary bodies disappeared in 3 of the 4 positive patients by the end of treatment. (One patient was not available for retesting.) Repetitive prostatic massage, antimicrobial therapy, alpha-blocker therapy, and – in 2 cases – finasteride enabled catheter removal in all 5 men (100%) as well as successful urination in all 5 men (100%). TURP has been prevented for a mean of 2.53 years (range, 16–38 months).
Introduction
Acute urinary retention is a disease of elderly men. One study of 72,114 men found the mean age of male patients with urinary retention to be 73 years.[1] A study by Meigs and colleagues[2] showed that 33% of men suffer acute urinary retention by age 89, and research by Peters and colleagues[3] found the incidence of that disorder to be 4.5/1000 man-years.
A large, randomized, double-blind, placebo-controlled study found that treatment with alfuzosin (Uroxatral) increased the likelihood of a successful trial without catheter in men with acute urinary retention, but even with continued alfuzosin therapy, 27.1% of those patients required surgery within 6 months.[4] Another study showed that 56% of men underwent surgery after trial without catheter and that the mean time to operation after the first episode of acute urinary retention (even in those treated with alfuzosin) was 1.85 years.[5]
Acute urinary retention is considered an indication for transurethral resection of the prostate (TURP), especially when medical therapy fails or patients experience difficulty with catheter removal.[6] However, patients who undergo TURP may experience significant short-term adverse effects, such as postsurgical pain, bleeding, infection, and complications from anesthesia. A study of 10,000 men indicated that the risk for urinary tract infection after TURP is 15.5%.[7] TURP can also cause significant long-term complications, such as the need for reoperation (1.9% to 6% of patients) or transurethral resection to correct bladder neck contracture (2.4%) or the formation of urethral strictures that require surgical correction (1.7%).[8] TURP can also result in retrograde ejaculation, infertility, sexual dysfunction, and incontinence.[9,10] In one study, 67% of the men who underwent TURP experienced sexual dysfunction,[11] and other research indicated that satisfaction with sex decreased in 44% of men after TURP.[12]
One prior case report appears in the literature of a 69-year-old man who was spared TURP and experienced improved sexual function by undergoing repetitive prostatic massage and antimicrobial therapy.[13]
Patients
Approximately 4–8 male patients with urinary retention present to the Manila Genitourinary Clinic (Cebu Branch), Cebu, Philippines (the Cebu Genitourinary Clinic), each year. We performed a retrospective chart review of the 6 patients presenting with a urinary catheter for the treatment of acute urinary retention during 2000 to the Cebu Genitourinary Clinic. The study subjects did not exhibit diabetes mellitus, congestive heart failure, or neurologic or musculoskeletal disease. All patients were self-referred to our clinic upon recommendations from other patients. None of the patients had undergone prostatic massage with expressed prostatic secretion (EPS) collection prior to being treated at our clinic. One patient was anemic and was admitted to the hospital for gastrointestinal bleeding and blood transfusions. He was never treated at the clinic, bringing our study number down to 5 patients.
Certified laboratory technicians performed all laboratory tests and reported their results independently of the treating physician. Urethral smears were obtained from all patients by pressing a glass slide against the urethral mucosa of the penile meatus, after which the smears were gram-stained. Each slide was scanned via light microscopy to identify the field with the lowest and highest number of urethral white blood cells (WBCs).
Prostatic massage was then performed on each patient every day for 4 days and thereafter 3 times per week. The same physician performed each massage. The drop of EPS remaining at the end of the penis after massage was used to determine WBC and red blood cell (RBC) counts. The remaining prostatic fluid was sent for culture.
After EPS collection, a cotton swab was inserted 1 cm or more into the urethra to collect urethral mucosal cells for Chlamydia testing. Chlamydia testing was performed by direct fluorescent antibody (DFA) technique (bioMérieux, Marcy-l'Étoile, France). We considered the test results positive if any fluorescing elementary bodies were seen and recorded the number. A previous study[14] and our ongoing clinical experience suggest that even 1 fluorescing elementary body found by DFA may be significant. The manufacturer, however, recommends that 10 or more fluorescing elementary bodies be considered a positive test result. The Chlamydia test was performed immediately after the first prostatic massage in all 5 men.
Next, each patient was asked to urinate the first 10 mL of urinary flow into a sterile container for urinalysis.
Because the data had no outliers that changed our conclusions, we used the mean as the measure of central tendency. We compared the first and last treatment values when the values tended to decrease in a straight-line fashion. Because our previous work showed that the WBC count in prostatic fluid usually peaks not at the first prostatic massage but somewhere between the fourth to sixth massage,[15] we compared the peak and last values of WBC counts and RBC counts in samples of the subjects' prostatic fluid. Statistical analyses were performed with SPSS software (Statistical Package for the Social Sciences, version 11.0, SSPS Inc., Chicago, Ill). The staff at the Cebu Genitourinary Clinic record each patient's global symptom severity score at each clinic visit. Scores range from 0 (no symptoms) to 10 (worst possible symptoms). First and last symptom scores were compared with the paired t test. To determine whether there was a significant change in other values during treatment among the 5 patients, the nonparametric Wilcoxon signed-rank test (2-tailed) was used because we did not assume a normal distribution for the data. A P value of < .05 was considered statistically significant.
Patient 1
Patient 1, a 68-year-old man with urinary retention, presented to our clinic after having worn an indwelling urethral catheter for 1 month. His former physician had removed the catheter twice; each time, obstruction recurred and the catheter was replaced. Patient 1 had a history of nocturia and dysuria. Results of prior transrectal ultrasound (TRUS) revealed a 92.8-g prostate.
Patient 2
A 70-year-old man with acute urinary retention presented to our clinic after wearing an indwelling urethral urinary catheter for 2 months, and was not receiving treatment with any medication. Patient 2 reported nocturia 4–5 times per night before he had undergone catheterization, and complained of difficult urination of 4 years' duration.
Patient 3
A 76-year-old man presented to the Cebu Genitourinary Clinic after wearing an indwelling urethral catheter for 1 month. His prior physician had attempted to remove the catheter 4 times, but each time the patient was unable to void and a new catheter was subsequently placed. Patient 3 complained of dysuria, urinary frequency, and nocturia 5 times per night before the onset of his acute urinary retention. His current medication was terazosin 2 mg 4 times daily. He supplied his clinic physician with the results of prior transabdominal ultrasonography, which revealed a prostate weighing 16 g.
Patient 4
A 73-year-old man presented to our clinic after wearing an indwelling urethral catheter for 21 days. His symptoms included low back pain, testicular pain, nocturia, and suprapubic pain when his bladder was full, all of which he had experienced before the onset of his acute urinary obstruction. This patient was on oral terazosin 2 mg 4 times daily and oral finasteride 5 mg 4 times daily.
Patient 5
A 64-year-old man had worn a urethral catheter for 3 weeks before his presentation at our clinic, at which time he reported a history of frequent urination and nocturia. His medications consisted of terazosin (2 mg orally once daily) and oral finasteride (5 mg once daily). He had completed a 1-week course of oral norfloxacin 400 mg twice daily when he first underwent catheterization.
Data Summary
Before presentation to the Cebu Genitourinary Clinic, patient 1 had failed 2 catheter removal challenges, and patient 3 had failed 4 catheter removal challenges. None of the 5 men in this study, by their reports, had received prostatic massage or EPS collection prior to arrival at the Cebu Genitourinary Clinic. In our study, EPS were collected 79 times from the 5 patients in 100% of attempts. The mean number of prostatic massages with EPS collection per patient was 15.80 (range, 5–30; SD 9.01).
Patients 1, 2, 4, and 5 were able to urinate after 1 prostatic massage. Patient 3 was straight catheterized his first night and then was able to urinate after his second prostatic massage.
Patients 3, 4, and 5 were treated only once for acute urinary retention. Patient 1 reobstructed 6 months after treatment and underwent a second round of therapy. Patient 2 reobstructed 7 months after therapy and underwent a second round of therapy. Each retreatment was successful in that both patient 1 and patient 2 improved and continued to avoid surgery. Below, we compare the data from the first rounds of treatment for all 5 men.
Symptoms
All the men complained of nocturia prior to their first episode of acute urinary retention. Three of the 5 patients had their frequency of nocturia documented prior to treatment at the Cebu Genitourinary Clinic, and the frequency of nocturia decreased in those 3 men. Besides nocturia, the men complained of other symptoms (extracted from the medical records), such as dysuria; frequency of urination; and low back, rectal, and testicular pain (Table 1).
Table 1.
Symptoms
| Patient Number | Nocturia | Dysuria | Frequency | Low Back Pain | Rectal Pain | Testicular Pain | Suprapubic Pain With Full Bladder |
|---|---|---|---|---|---|---|---|
| 1 | Yes | Yes | NR | Yes | Yes | NR | NR |
| 2 | Yes | Yes | NR | NR | NR | NR | NR |
| 3 | Yes | Yes | Yes | NR | NR | NR | NR |
| 4 | Yes | NR | Yes | Yes | NR | Yes | Yes |
| 5 | Yes | NR | NR | NR | NR | NR | NR |
Urethral Bacteria
Urethral bacteria disappeared in all 5 men over the treatment period (Table 2). This table shows the number of times different bacteria were present in the urethral gram stains, with the number of specimens taken as the denominator. Bacteria were seen in 22 of the 30 urethral smears. Both bacteria and WBCs disappeared in each patient's urethral smear over the course of treatment. Gram-positive cocci were most common.
Table 2.
Urethral Bacteria
| Urethral Bacteria | GPC/Specimens | GNC/Specimens | GPB/Specimens | GNB/Specimens |
|---|---|---|---|---|
| Patient 1 | 0/5 | 0/5 | 0/5 | 0/5 |
| Patient 2 | 9/10 | 0/10 | 0/10 | 0/10 |
| Patient 3 | 4/5 | 0/5 | 0/5 | 1/5 |
| Patient 4 | 4/5 | 0/5 | 0/5 | 0/5 |
| Patient 5 | 4/5 | 0/5 | 0/5 | 0/5 |
GPC = gram-positive cocci; GNB = gram-negative bacilli; GPC = gram-positive cocci; GNB = gram-negative bacilli
Statistically Significant Data
The global symptom severity scores in the 5 men decreased dramatically (Figure).
We compared the first and last symptom scores in the 5 men. The mean first symptom score was 9.80 (SD 0.45), and the last mean symptom score was 2.6 (SD 1.34). This decrease was significant (P < .0005).
The mean urethral WBC high peak was 27.60 (range, 20–36; SD 6.88), and the mean urethral WBC high last value was 0.00. This decrease was significant (P = .043).
Patients 1 and 4 had their highest EPS WBC high counts at their first massage, whereas patients 2, 3, and 5 had EPS WBC high peaks at their sixth, fifth, and third massages, respectively. The mean peak EPS WBC high count was 43.40 (SD 16.36). The mean last WBC EPS high count was 13.40 (SD 5.73). This decrease was significant (P = .043) (Table 3).
Table 3.
Expressed Prostatic Secretion (EPS) White Blood Cell (WBC) High Counts
| Patient | First | Peak | Last | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 50 | 50 | 23 | 50 | 40 | 40 | 18 | 6 | 22 | 15 | 28 | 36 | 6 | 12 | 18 | 31 | 23 | |
| 2 | 40 | 40 | 9 | 40 | 31 | 33 | 35 | 32 | 45 | 39 | 27 | 24 | 19 | 13 | 9 | 7 | 18 | 27 |
| 3 | 5 | 50 | 9 | 5 | 22 | 31 | 46 | 50 | 45 | 8 | 14 | 8 | 35 | 10 | 11 | 9 | 9 | |
| 4 | 60 | 60 | 13 | 60 | 60 | 60 | 45 | 50 | 40 | 45 | 30 | 40 | 38 | 30 | 24 | 21 | 20 | 20 |
| 5 | 6 | 17 | 13 | 6 | 13 | 17 | 15 | 13 | ||||||||||
| Mean | 32.20 | 43.40 | 13.40 |
| Patient | First | Peak | Last | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 50 | 50 | 23 | |||||||||||||||
| 2 | 40 | 40 | 9 | 16 | 21 | 32 | 35 | 30 | 25 | 25 | 12 | 16 | 24 | 28 | 32 | 37 | 35 | 9 |
| 3 | 5 | 50 | 9 | |||||||||||||||
| 4 | 60 | 60 | 13 | 13 | ||||||||||||||
| 5 | 6 | 17 | 13 | |||||||||||||||
| Mean | 32.20 | 43.40 | 13.40 |
EPS WBC high counts, first, peak, last, and all data points
The mean peak RBC high count was 39.00 (SD 28.81). The mean last EPS RBC count was 0.00. This decrease was significant (P = .039).
The mean urine RBC high count peak was 39.40 (SD 28.23). The mean last urine RBC high count was 2.00 (SD 1.22). The decrease from the mean urine RBC high peak count to the last was significant (P = .042).
The mean urinary WBC high count peak was 43.40 (SD 17.54). The mean last urinary WBC high count was 6.40 (SD 4.88). The change from the peak urinary WBC high count to the last urinary WBC high count was significant (P = .042).
EPS Cultures
All 5 men had a culture of their first EPS specimen. Patients 1 and 4 had 1 repeat set of EPS cultures, whereas patient 2 had 4 sets of EPS cultures. All 5 patients were positive for Staphylococcus species. Patients 2, 3, and 4 also cultured positive for gram-negative bacteria (Table 4).
Table 4.
Expressed Prostatic Secretion (EPS) Cultures
| Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 | |
|---|---|---|---|---|---|
| Staphylococcus epidermidis* | Present | Present | Present | Present | |
| Staphylococcus intermedius* | Present | Present | |||
| Staphylococcus saprophyticus* | Present | ||||
| Serratia liquefaciens* | Present | ||||
| Escherichia coli* | Present | Present | |||
| Proteus mirabilis* | Present | Present | |||
| Citrobacter freundii* | Present |
Organisms that grew in the cultures of EPS
Chlamydia DFA
Four of the 5 men tested positive for 5–10 fluorescing Chlamydia elementary bodies by Chlamydia DFA at their first presentation. In 3 of these 4, the Chlamydia DFA test turned negative for any fluorescing elementary bodies after undergoing treatment with repetitive prostatic massage combined with antibiotics. It is not known whether the fourth case turned negative because patient 5 never returned for a repeat Chlamydia DFA test (Table 5).
Table 5.
Chlamydia Direct Fluorescent Antibody (DFA)
| Patient | First Chlamydia DFA* | Repeat Chlamydia DFA* |
|---|---|---|
| 1 | 10 | 0 at 15th massage |
| 2 | 8 | 0 at 15th massage |
| 3 | 7 | 0 at 15th massage |
| 4 | 0 | 0 at 15th massage |
| 5 | 5 | Lost to follow-up |
Number of fluorescing Chlamydia elementary bodies seen at the first test and at the repeat test
Ultrasounds of Patient 1 and Patient 2
Over the course of repetitive prostatic massage, the Cebu Genitourinary Clinic physician noted palpable changes in the men's prostates, with the prostates becoming smaller and more normal in consistency over time. In 2 patients, ultrasound data, within the limitations of technique and interpretation, supported this finding. There is 1 prior case in the literature of ultrasound-documented reduction of prostate size by repetitive prostatic massage.[16] Patient 1 underwent abdominal ultrasound prior to arriving at the Cebu Genitourinary Clinic, and his prostate was 92.8 g. After therapy, his prostate was reported as 26.6 g by TRUS. Patient 2 underwent TRUS at his fourth massage, and his prostate was reported as 74 g. At the end of his therapy, his prostate was reported to be 54 g by TRUS. Because there were differences in technique – one ultrasound being transabdominal instead of transrectal – and differences in machines, examiners, and timing, we present the ultrasound data without making any conclusions (Table 6).
Table 6.
Ultrasounds
| Ultrasound Before Massages Completed | Ultrasound After Massages Completed | |
|---|---|---|
| Patient 1 | 92.8 g (transabdominal) before all massages | 26.6 g (TRUS) after 14 massages |
| Patient 2 | 74 g (TRUS) on day of 4th massage | 54 g (TRUS) 3 months after third round of therapy |
TRUS = transrectal ultrasound
Two patients underwent before and after ultrasounds of the prostate, which showed a reduction in prostate size.
Discharge
At discharge, Patient 1 was prescribed alfuzosin and finasteride. Patient 2 was prescribed alfuzosin, finasteride, and itraconazole. Patient 3 was prescribed itraconazole. Patient 4 was not prescribed any medication, and Patient 5 left treatment still taking erythromycin and minocycline.
Discussion
The 5 men in this study have avoided surgery for acute urinary retention for an average of 2.53 years at last follow-up (Table 7).
Table 7.
Last Follow-up
| Patient | Elapsed Time (months)* |
|---|---|
| 1 | 27.00 |
| 2 | 38.00 |
| 3 | 16.00 |
| 4 | 35.00 |
| 5 | 36.00 |
| Mean | 30.40 |
| (2.53 years) |
Number of months that patients have avoided having to undergo transurethral resection of the prostate at last available follow-up
All subjects in our study had been advised to undergo TURP. Urologists have traditionally used acute urinary retention as an indication to perform TURP in one of its many forms, especially if medical therapy fails and catheter challenges are unsuccessful.[17]
The complications from TURP are well known, but the medical management of acute urinary retention is also less than perfect. Alpha blockers can produce adverse effects, such as dizziness or orthostatic hypotension,[18] sexual dysfunction (especially retrograde ejaculation[19]), and dry mouth.[20] Finasteride, which can produce sexual dysfunction by causing a reduced amount of semen per ejaculation, is associated with impotence, ejaculation disorders, and decreased libido.[21] Both finasteride and alpha blockers prescribed to treat benign prostatic hyperplasia must be taken continually, and noncompliance often occurs.[22]
Prostatic massage has been described in the literature since at least 1906.[23] However, to our knowledge, no controlled studies have compared the effects of prostatic massage alone or with antibiotics against surgery for acute urinary retention, or for benign prostatic hyperplasia.
In our study, all 5 men were diagnosed as having prostatitis, according to the established criterion for that disorder.[24] EPS was collected in 100% of attempts in these men. Theoretically, in the successful treatment of prostatitis, the WBC count in the EPS should decrease during treatment or should peak and then decrease. Both results occurred in our subjects.
Our study suggests that repetitive prostatic massage drains the prostate of pus and improves the likelihood of urination after acute urinary retention. Our results indicate that several prostatic massages are needed to obtain the most purulent EPS specimen for disease classification and microbial testing. We found that repetitive prostatic massage is not traumatic, because the RBCs in the EPS decreased to zero during the course of therapy. Prostatic massage has not been properly studied with controls, and questions exist whether urologists and other physicians perform it effectively.[25]
Limitations
Because none of our subjects had undergone prostatic massage and EPS collection prior to catheterization, we do not know whether their prostatitis predated the placement of their indwelling urinary catheters, although their symptoms were suggestive. In addition, controls were not included in this study.
Conclusions
Five elderly men with histories of acute urinary retention and an indwelling urethral catheter presented to our clinic for treatment. Each patient had been advised by his urologist to undergo TURP, yet successful removal of their indwelling catheters was accomplished in each case, and all 5 men have avoided prostate surgery for at least 2.53 years. All 5 men were treated with repetitive prostatic massage, antimicrobial therapy, and alpha blockers, whereas 2 patients were also treated with finasteride. During the treatment period, statistically significant improvements occurred in several parameters, including global symptom severity scores, urethral WBC counts, EPS WBC counts, EPS RBC counts, urinary WBC counts, and urinary RBC counts. We suggest that men who suffer acute urinary retention resulting in an indwelling catheter should be tested for prostatitis. In these 5 cases, prostatitis was treated; urinary retention was resolved; and TURP has been avoided for a longer time period than typical in other studies.
Figure.
The global symptom severity score significantly decreased in all 5 subjects over the course of treatment.
Acknowledgments
The authors thank Rena Pedaria and Hazel Macandandang for their assistance with the statistics. This study was not funded, but the authors thank the Prostatitis Foundation (www.Prostatitis.org), a nonprofit organization that is devoted to publicizing and researching prostatitis.
Footnotes
Readers are encouraged to respond to George Lundberg, MD, Editor of MedGenMed, for the editor's eye only or for possible publication via email: glundberg@medscape.net
Contributor Information
Bradley R. Hennenfent, Prostatitis Foundation, Smithshire, Illinois.
Alfred R. Lazarte, Manila Genitourinary Clinic (Cebu Branch), Cebu, Philippines.
Antonio E. Feliciano, Jr., Manila Genitourinary Clinic, Manila, Philippines; e-mail: aef@prostate.com.ph.
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