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Reduced urinary flow a reality for older men

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In March 1958, the Journal of the Maine Medical Association reported, "A successful non-surgical treatment for enlarged prostate gland is cause for rejoicing among the thousands of mature men who yearly face the possibility of becoming a victim of this painful and dangerous affliction." Since that time, there have been major advances in the non-surgical treatment of enlarged prostate glands (benign prostatic hypertrophy).

Normally, during male urination, the size of the urinary stream is about one-quarter of an inch. But as men age the prostate gland enlarges, squeezes the urethra (urinary tube) and may reduce its size to one-sixteenth of an inch. If it reaches zero, emergency surgery is required.

Benign prostatic hypertrophy (BPH) is almost like getting grey hair. In Canada, it's estimated 25 per cent of men over 50 have BPH, 40 to 60 per cent over the age of 60, and of those over 80, more than 80 per cent have this problem. Fortunately, this common trouble does not result in malignancy. But it's possible to have BPH and cancer at the same time.

As a ship's surgeon, I encountered my first case of acute urine retention in an elderly sailor. All I could do was insert a urinary catheter to relieve his agony until we reached port. But most cases of BPH cause slow blockage of the urinary stream.

Most patients complain of urinary frequency, often at night, leakage, dribbling, hesitancy, straining to void and being aware they have not completely emptied their bladder. Although prostate enlargement is a common sign of BPH, the severity of symptoms is not directly related to prostate size.

Restricting the flow of urine is not as dramatic as stopping the flow of Niagara Falls. But chronic urinary retention, by leaving some urine in the bladder, often leads to urinary infection, just as a stagnant pond becomes infected. Patients with BPH are also more prone to bladder stones and infections involving kidneys.

BPH can also have a negative impact on a patient's quality of life. For instance, men often suffer from sexual dysfunction, insomnia and decreased ability to carry out daily tasks. And if BPH is associated with obesity and hypertension, they are more likely to complain of severe lower urinary tract symptoms.

Today, about 15 per cent of prostatectomies are required to relieve urinary obstruction. Improved surgical techniques have made this operation less hazardous. But as I've stressed for years, medical treatment should also be considered first, except in emergency situations where there is sudden, complete urinary obstruction.

One of the problems of past medication has been its dual effect on both the prostate gland and the circulatory system. This has resulted in an improved urinary flow but in addition to relaxing the prostate muscle, it has also caused a dilatation of blood vessels and a fall in blood pressure. Moreover, it was necessary to have a waiting period between meals and dosing.

Dr. Leonard S. Marks at the University of California at Los Angeles reports a study involving 821 patients in the Journal of Urology. He said there's a drug that circumvents this problem by specifically targeting smooth-muscle receptors of the prostate and urethra, causing them to relax without having a significant effect on the circulatory system.

During the nine-month study, there were no cardiac problems, and dizziness occurred in only 2.6 per cent of patients. But this symptom was also present in those not receiving this medication.

One complaint was retrograde ejaculation. This happens during orgasm when semen is discharged into the bladder rather than through the urethra. Retrograde ejaculation also occurs when surgical removal of the prostate is performed. It's not life-threatening and the majority of those using the drug realized this bothersome problem was a small price to pay for being able to void normally.

Dosage is one pill a day. I wish the drug had been available when I was ship's surgeon, as it increases urine flow within two to six hours. During the next year, overall improvement in BPH symptoms takes place.

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Twitter: @GiffordJonesMD

Republished from the Winnipeg Free Press print edition January 25, 2013 A23

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