The last in a series of guest blogs this Urology Awareness Month focuses on men who experience urinary symptoms and all too often suffer in silence.
Mark Stott, Consultant Urologist at Royal Devon and Exeter NHS Foundation Trust explains how urinary symptoms are very common in older men, so much so they are often accepted as part of the natural aging process and become the cause of much humour and joshing.
Nearly all men know they have a prostate gland but few know what it actually does. Despite the lack of any real knowledge, it gets blamed for a huge variety of symptoms, though often these are quite unrelated.
Most men tend to ignore their lower urinary tract symptoms (LUTS), putting up with, or even working round their symptoms rather than declaring them to a GP or nurse. In reality little real harm usually comes from this. However, given the fact we now have many effective and well tolerated non-surgical treatments, it is a pity so many choose to suffer in silence for so long.
The reasons for ignoring symptoms are numerous – they are insidious, developing gradually over many years. Even in 2017 there is often a feeling of embarrassment or possibly fear that the symptoms may be due to cancer. Past memories of an elderly relative who ‘was never the same again’ after prostate surgery comes to mind. People forget that medical treatment and surgical technology has advanced enormously with newer and less invasive treatments becoming available all the time.
So why do men eventually seek help?
The most important agent here is a wife or partner. We all know that women tend to seek advice for health related issues earlier than men and it may be a partner or wife who takes the bull by the horns and cajoles the man into seeing his GP. In some case this may simply be due to symptom severity, the partner being fed up of incessant toilet seeking, the excessive time taken to pee or by being woken several times in the night by their husband. They are doubly irritated if said husband can get back to sleep again immediately whilst they remain awake for some time.
Other triggers are the diagnosis of prostate cancer in a neighbour, or a friend going into retention. Otherwise a near miss with near retention arising, (often after too much alcohol and/or prolonged sitting) may call for action.
Men may experience a number of problems. They may have voiding symptoms namely struggling to start passing urine which is called hesitancy, or storage symptoms, peeing frequently by day and night, often with some urgency or even leaking before they reach the toilet.
From a medical point of view, the situation is quite confusing as the prostate is a rather enigmatic gland. Notably prostate enlargement affects over 50% of the older population but often causes no obstruction or symptoms. Even in the presence of mild or moderate obstruction the man may notice no symptoms.
Logically an obstructing prostate should cause hesitancy (difficulty starting to pee) or a slow stream. In reality whilst some men do get just hesitancy and a slow stream, a much larger number complain of the secondary symptoms which develop after the obstructed bladder gets trigger happy and contacts without due warning – a condition called the over active.
To make matters more complicated, urgency and frequency might arise if the man has developed an over active bladder not due to prostatic obstruction, but as part of the aging process as it might in an older woman.
In some cases getting up at night may be due to excess urine production overnight rather than anything to do with the bladder or prostate. Again this is something we see in men and women as they get older.
All is not lost – there is good news!
Firstly GPs and Urologists now know a lot more about urinary problems in older men and women. We do not know exactly what causes these changes nor why the bladder becomes overactive when faced with obstruction, and why it does so only in some men and not others.
It is unknown why night time urine production is excessive in some men and women, but it is a potent cause of symptoms and needs treatment directed at urine production not the prostate. Even if we do not understand all the causes, we are aware of these different components and so can make a much more detailed assessment and diagnosis in men with waterworks symptoms, resulting in more personally tailored treatment. It is no longer a case of prostate surgery or nothing.
Bladder and prostate symptoms do not usually imply serious disease. However men with blood in their urine must seek prompt advice from their GP. Prostate cancer seldom causes urinary symptoms so men with symptoms should not automatically infer that they have prostate cancer. If they are worried or curious as to whether they have cancer they need a prostate examination by their GP and a blood test, called a PSA level.
Few men with LUTS develop retention of urine – the inability to pass urine, which is very painful and needs urgent relief with a catheter. And rarely does prostate enlargement affect the kidneys. This can happen but is rare and is only seen when bladder emptying is markedly impaired. Apart from wetting the bed or leakage at night such men often have very few symptoms. Men experiencing this must seek urgent advice from their GP.
Not all men with prostate trouble need or want treatment. Many are happy with explanation and reassurance that there is nothing serious underlying their symptoms. Some can improve their symptoms with exercises and bladder training, or avoiding some drinks which stimulate the bladder.
The last bit of good news is that we now have a range of tablets that work for many men with LUTS and those who need or would benefit from surgical treatment can access a less invasive but effective treatment for prostates of all sizes.
Thus, there is not good reason for men to defer seeking advice. Prostate symptoms are common but do not usually imply anything serious. If they are intrusive then men should see their GP for assessment and if necessary referral. Any subsequent treatment is easy and very effective in the majority of cases.
Author: Mark Stott, Consultant Urologist at Royal Devon and Exeter NHS Foundation Trust