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.
