The Ins and Outs of Gay Sex (31 page)

Some men develop urinary retention even without an enlarged prostate.
Any surgery is a common cause of urinary retention, because narcotic pain medications tighten the bladder sphincter and abdominal muscles hurt too much for you to push out urine.
Urinary retention is especially common after rectal surgery, when the area around your urethra swells and constricts flow.
I tell patients after rectal surgery to avoid all narcotic pain medications (Tylenol and aspirin are fine) until they urinate.
Running water helps, but getting into a warm bath is even better.
It relaxes you, so stay there until you finish urinating.
(Don’t worry, it’s sterile.
) If you try to get up to use the toilet, your bladder sphincter might go back into spasm.
I have heard patients in urinary retention after hemorrhoid surgery say that their overflowing bladder hurt more than the surgery.

Some men also have problems urinating when confined to bed.
They need to stand to pee, and this also contributes to urinary retention.
Other men drink heavily and pass out.
While asleep their bladder overfills, stretching the muscle beyond its limits, and it cannot contract when they awaken.

If someday you cannot urinate, and none of your old tried-and-true remedies, such as running the water or doing multiplication tables, works, get to a doctor.
Your bladder has overdistended and its stretched muscles have lost all tone.
If you wait, it can overfill to the point of
exploding.
You’ll need a catheter inserted, but you’ll feel so much better for it.
Most often once your bladder empties and is allowed to rest, it regains its strength.
Then the catheter is removed and you can pee again.
Having a catheter inserted for urinary retention does not require hospitalization, even if it needs to be left in for several days.
A bag attached to your leg collects urine, and no one needs to know.
It may not sound pretty, but it sure beats a hospital stay.

If you get past your first episode of urinary retention with just a temporary catheter, it may be only a matter of time until it happens again.
On the other hand, if surgery or medications pushed you over the edge, you might be fine as long you never need it again.

It is always best to see your doctor before you reach the stage where you can’t urinate.
BPH is a gradual process:
The adenoma grows over many years, giving you plenty of time to stall its progression.
A urologist evaluates your prostate several ways.
First and foremost comes a rectal exam, which indicates to your doctor how large your prostate is (its size may not correlate with your degree of symptoms) and if it contains any hard lumps, which may point to prostate cancer rather than BPH.
Expect to urinate into a machine that measures the strength of your stream—a poor stream indicates a blocked urethra.
Your doctor may finish the evaluation by doing an ultrasound of your bladder or passing a catheter into it to measure your “postvoid residual” (how much urine is left after you finish urinating).
A high postvoid residual means that an enlarged prostate stopped the urine flow before your bladder emptied.
If your stream is weak or your residual high, your urologist will probably recommend treatment.

Until the 1990s, the only good treatment for BPH was surgical.
Now, fortunately, there are medications that improve urination and offer an effective alternative to surgery.
Medications fall into two basic classes:
those that help relax muscle and open your urethra and those that actually shrink your prostate.

Medications often used to treat high blood pressure, because they relax muscle fibers lining arteries, known as alpha adrenergic antagonists (alpha blockers), belong to the first class.
When the muscle fibers in arteries contract, your blood pressure rises, and when they relax, it falls.
What does this have to do with your prostate?
Prostate adenomas contain large amounts of muscle cells, which tighten and further constrict your urethra.
An alpha blocker will relax muscle in the adenoma, and your urine flow will improve.
Three alpha blockers are currently available:
terazosin hydrochloride (Hytrin), doxazosin mesylate (Cardura), and tamsulosin hydrochloride (Flomax).
(See
Table 8.
2
for dosages.
) Because these drugs lower your blood pressure, doctors recommend a small dose starting at bedtime, which can be increased gradually as needed.
While taking this type of medication, monitor your blood pressure to be sure it doesn’t fall too low.
Other side effects include dizziness (especially when you stand up suddenly) and fainting.

Once I saw a patient with bruises all over his body.
Upon questioning, he told me that his morning ritual of jumping out of bed to begin each day on a note of renewed vigor was suddenly complicated by brief fainting spells.
(Hence the bruises.
) Clearly, the alpha blocker his urologist prescribed caused this problem, but the man refused any dose adjustment.
For the first time in years he was peeing so well.
In the end, he just eased his way out of bed and kept from passing out.

Benign prostatic hyperplasia will not occur without testosterone.
Testosterone enters the prostate and is converted by a special enzyme called 5-alpha reductase to a more active form that stimulates prostate growth.
While castration is certainly a solution, most of us would rather keep our testicles and deal with BPH if it becomes a problem.
Fortunately, a medication called finasteride (Proscar) blocks the conversion of testosterone to its active form.
(See
Table 8.
2
.
) Your prostate thinks you’ve been castrated, but the the rest of your body doesn’t!
Side effects are minimal and most notably include a decreased volume of ejaculate.
Proscar works by gradually shrinking your prostate; it may take weeks to months before you see a pronounced improvement in urination.
Many doctors combine an alpha-blocking medication with Proscar so that you see more immediate results.

TABLE 8.
2
MEDICATIONS TO TREAT BENIGN PROSTATIC HYPERPLASIA

If you notice your stream weakening or perhaps you now get up twice a night instead of once, what can you do
short of going on prescription medications?
Health food stores sell various plant extracts, including saw palmetto berry and
Pygeum africanum,
that help alleviate symptoms and improve urine flow.

Most physicians begin treatment for BPH with medication, either alpha blockers or 5-alpha reductase inhibitors, or a combination of both.
If medications don’t work or if your symptoms progress, your doctor might recommend a number of options short of actually removing your prostate.

Balloon dilatation was met with a flurry of interest when first introduced in 1984.
In this procedure, either a urologist or a radiologist passes a small deflated balloon up your urethra to your prostate.
When the balloon is inflated, it pushes away your enlarged prostate and stretches your narrowed urethra.
Then the balloon is removed, and your stream may improve.
Although the procedure is relatively simple to perform, results have not been that good and most doctors don’t recommend it.

Newer and more successful therapies involve heating the prostate immediately surrounding your urethra to the point where a portion of it burns away.
The heat does not penetrate more than a few millimeters from your urethra, so most of your prostate is left intact.
The dead tissue falls away, creating a wider opening for urine flow.
Transurethral needle ablation (TUNA) heats your prostate with radio-frequency waves transmitted through a fine needle passed down your urethra into the prostate.
Lasers also have come into vogue for destroying enlarged prostate tissue.
The Yag laser was one of the first employed but is now being supplanted by the Indigo laser, which heats the prostate immediately surrounding your urethra to the boiling point (212 degrees F, or 100 degrees C) in three minutes.

Although technically a surgical procedure, prostate heat ablation has many advantages over standard surgery.
It can
be performed with minimal anesthesia either in a urologist’s office or on an outpatient basis, and blood loss is negligible.
Because most of your prostate is left intact, complications such as retrograde ejaculation, incontinence, and impotence seen after standard prostate removal are much rarer.

If you have a very large prostate or fail one of the simpler ablative procedures, you’ll probably need an open prostatectomy.
This type of surgery has a much higher success rate for improving urination in men with large prostates.
It can be accomplished either through your urethra or through a cut in your lower abdomen.

Transurethral prostatectomy (TURP) is commonly called a scraping.
Your urologist passes a cystoscope down your penis to the prostate and then cuts enough of it away to open up your urethra.
This surgery requires hospitalization, and bleeding can be heavy.
Most men experience retrograde ejaculation as a side effect after this type of prostatectomy, but impotence and incontinence are rare.

If your prostate is very large and your surgeon does not think enough can be removed via a TURP, you’ll need an open prostatectomy.
Again hospitalization is required, but because your entire prostate is removed through an incision just above your pubic bone, the success rate for improving urination approaches 100 percent.
However, your risks of retrograde ejaculation, incontinence, and impotence are higher than with a TURP because the surgery is more extensive.

If you have early symptoms of prostate trouble, see your urologist to be sure that you don’t have cancer.
If you just have BPH, consider one of the natural remedies first before progressing to prescription medications.
If medications fail, prostate heat ablation can be very effective for small adenomas.
If these methods don’t work or if your prostate is too large, most urologists try a TURP before an open prostatectomy.

Just the name is frightening.
And it should be.
Outside of skin cancer, this is the most common cancer in men, and almost 20 percent of us will have it at some point in our lives.
For blacks, the incidence is twice as high as it is for whites.
That’s the bad news.
The good news is that it is a relatively slow-growing cancer that takes many years before it can spread and kill you.
Most men with prostate cancer die of something else long before their tumor would have killed them.
Even with slow growth, however, prostate cancer is the second-leading cause of male cancer deaths (over 40,000 in 1997), but survival rates are improving through early diagnosis and better treatment.
Today doctors estimate that over half of all prostate malignancies are discovered before they spread outside of the prostate.
The five-year survival rate in these cases approaches 100 percent.

Most prostate cancers begin in the more peripheral regions of the gland, where smaller nodules can be felt on rectal examination.
Doctors estimate that it takes fifteen years for these earliest prostate tumors to grow and spread throughout the body.
As the tumor grows, it breaks through the prostate’s capsule (outer wall) and invades the seminal vesicles and bladder.
Finally it spreads to the pelvic lymph nodes, bones, liver, lungs, and brain.

Clearly doctors would like either to prevent prostate cancer or to diagnose it while it is still curable.
As far as prevention is concerned, some evidence suggests that vitamin E supplements may help.
Doctors hope to learn whether hormone therapy or 5-alpha reductase inhibitors used to treat BPH might also offer protection against cancer.

Early prostate cancer, unfortunately, produces few signs and symptoms.
By the time men have symptoms of bone
pain or blood in their urine, it may already be too late.
To diagnose prostate cancer early, doctors rely on a good rectal examination and measuring the prostate-specific antigen (PSA) level in the blood.
With a rectal examination, the doctor carefully feels your prostate for any suspicious nodules.
In BPH, the entire prostate tends to enlarge; malignant tumors are often solitary, small, hard lumps within the gland.