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Dr. Lin's Quest beyond Medication and Surgery                    

    Troubling Urination in Men
    - most of concept and practice are applicable for voiding problem in females also

    Life is a constantly changing and adjusting dynamic process of struggle to cope with reality, certainty, and uncertainty of daily living for
    survival, growth, and continuation from inception to eternity; this fact is applicable to every aspect of life and how men urinate over lifetime
    bears no exception.

    This article is to address some day-to-day concerns about how to take care of annoying voiding in a realistic way, not everything about
    urology in this field.

    To build up the foundation of understanding the reality of life and disease, please peruse and mull over the lists of Facts of Life - 1, 2, and 3
    by clicking the corresponding BUTTONs on the LEFT side of the HOME page of this webside - www.ForMeFirst.com.

    Hereinafter are those deemed useful according to my 46-yr-long study and practice in medicine - urology - focusing on the  voiding
    disorders.  The focused subjects follow:
    1. Confused with medical terminology?
    2. What is LUTS (lower urinary tract symptoms)?
    3. What does urinary tract consist of?
    4. What and how does urinary tract work?
    5. What make lower urinary tract become not working well?
    6. What should you do when you feel having LUTS – lower urinary tract symptoms?
    7. How to collect the voiding symptoms?
    8. What are the reasons delaying diagnosis of LUTS until bladder damage becomes irreversible by long-term ignored overwork
       for years or decades? What are the few frequently misunderstood voiding symptoms?
    9. What is the goal for caring for LUTS?
    10. How to ask right questions to induce useful answers and to deduce correct diagnosis before being too late?
    11. What are the common tests and studies specifically for LUTS?
    12. What are the right steps to take care of urinary retention?
    13. What are the available options of medical care for LUTS?
    14. What are the available options of surgical procedures to help bladder empty better?
    15. A list of some common misunderstantings among urination, bladder, prostate, kidneys, and their relationship?
    16. Have there been some herbal pills to help improve LUTS?

    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    1. Confused with medical terminology?
    Many medical terminologies like prostatism, silent prostatism, benign prostate hyperplasia (BPH), bladder outlet obstruction(BOO), lower
    urinary tract symptoms (LUTS), etc. have been coined over six decades trying to best describe men's voiding trouble which may develop and
    evolve over lifetime as mentioned above. However, no one has perfectly serve its duty to depict the clinical profile of men's voiding trouble;
    hence, the above have been designated, tried, and evolved to the currently most commonly adopted one, that is, lower urinary tract
    symptoms (abbreviated as LUTS).

    2. What is LUTS (lower urinary tract symptoms)?
    LUTS has been becoming the current "final" product of decades-long professional struggle and debate to denote the symptoms for
    troubling urination for men but could be also for women; yet, further modification in LUTS may evolve, but so far so good in its use.

    Clinically, LUTS may be categorized into two groups: obstructive and irritative:
    a. Obstructive voiding symptoms include slowing urine flow, straining to void, taking a longer time to complete a urination,
        feeling not emptying well, dribbling after peeing, etc.
    b. Irritative voiding symptoms may include going to pee more often than used to be, urgency (going to pee in a hurry), burning
       urination (dysuria), unwanted leaking urine, i.e., urinary incontinence - urge or stress or over flow or mixe urinary incontinence,
       etc.

    3. What does urinary tract consist of?
    For clinical application, urinary tract has two parts: Upper urinary tract consisting of kidneys and ureters; lower urinary tract consisting of
    bladder and urethra, although both parts are connected as a functional unit to produce and propel urine from kidneys through ureters to
    bladder and out of urethra. In adult females, urethral length is about 3.5-4.5 centimeter; in adult males, urethra consists of posterior urethra
    including prostate urethra and membranous urethra, and posterior urethra which is the part distal to membranous urethra to the opening
    (meatus) of urethra.

    4. What and How does urinary tract work?
    Kidneys are the key organs contributing to maintenance of water, electrolyte, and blood pressure,  production of red blood cell, and excretion
    of the wastes of metabolism.

    Ureters are active peristaltic tube to propel the urine excreted from kidneys to the bladder for temporary storage serving personal
    convenience of daily living.

    Bladder is an expandable and contractible sphere-shaped hollow organ to temporarily stone urine for the convenience of daily living;
    otherwise, we will pee like birds.

    Prostate gland is the initial part (segment) of male urethra with its length like that of female urethra but acts like a functional gatekeeper of
    bladder and the resource for sperm nourishment and survival so to enhance men's fertilizing ability; yet, much is still unknown in its
    functionality.

    Urethra is a conduit (except its initial 3-3.5-cm segment acting as a urinary sphincter for active timely urine control) to bring urine out of the
    body. In females, its length is about 3.5-4 cm; in males, about 10-14 inches or 25-35 cm.

    The sequential line-up of kidneys, ureters, bladder, and urethra to the outside works in its one-way coherent fashion so we maintain a
    healthy balance of water, electrolytes, blood pressure, red blood cell, vitamin D, etc. and daily convenience.

    For more difference in male and female urinary tract, go to http://theydiffer.com/difference-between-male-and-female-urinary-system/.

    5. What make lower urinary tract become not working well?
    Any alteration in the sensory and motor function of bladder and urethra will induce irritative and obstructive symptoms of troubling urination
    which may result from slow expected aging effects or diseases commonly being infection, inflammation, inborn defect, injury, surgery,
    prostate enlargement, etc.

    At this moment, it is worthwhile to remember:
    - Any illness is aways a process of lifelong making, always results from multiple factors, and always displays on its own pattern of full
              spectrum from its early mildest to its late worst fashion. Hence the degree of symptoms can widely vary among individuals and along the
     path of life.

            - As well, it is important to realize and accept that, in medical practice, doctors have never cured anything, but just modify something for         
someone to some degree with or without drugs and/or procedures hoping for optimal functional improvement and recovery with personal
residual strength.

    6. What should you do when you feel having LUTS - lower urinary tract symptoms?
    Simple and straight forward. First, identify what may be the underlying causes; second, follow with most reasonable treatments with or
    without drugs or procedures at reasonable time in reasonable way to reasonable patient. How? Follow instructions as described in http:
    //formefirst.com/eNewsletter06.html. Thereby you gain much insight on how to work better and closer with the doctor, preferably urologist, to
    reach most possible diagnosis for right treatment, care, and counseling than ever.

    7. How to collect the voiding symptoms?
    As always, it is important and essential to collect and report the detailed specifics of all related voiding symptoms by qualifying and
    quantifying every symptoms and laying out the sequence of events over time.

    Some examples of questions and their desirable answers:

    Q1 - How often your pee in the daytime, that is, urinary frequency?
    A1 - About 5-6 times, not very often;

    Q2 - How often you pee at night, that is, nocturia?
    A2 - About 2-4 times in 7 hours of sleep, not very often or all the time;

    Q3 - Do you need to wait before starting urine flow, that is, urinary hesitancy?
    A3 - I need to wait for few seconds or minutes in about 4 out of 10 times, not saying "Yes, quite often or all the times, etc.;

    Q4 - Do you have to go in a hurry or can you hold your urine until you reach toilet to pee, that is, urinary urgency? How often?
    A 4 - Yes, I have to go to bathroom in a hurry in some 5-6 out of 10 days, that is, about 55% of times, not saying, "Often or all the
            time, etc.;

    Q5 - Have you emptied your bladder after you pee?
    A5 - Yes, I emptied my bladder in about 6 out of 10 times, that is, about 60% of times, not all the time.

    Why is it important to answer in such specific ways? Doing so will help doctor to sense what is the current clinical significance of your
    symptoms? So, be specific; do not use uncertain and vague description.

    8. What are the reasons delaying diagnosis of LUTS until bladder damage becomes irreversible by long-term
    ignored overwork for years or decades?  What are the few frequently misunderstood voiding symptoms?
    A:
    In my >46-year observation, the two are importantly responsible for not seeking timely medical attention as follows:
    1. Slowness and quietness of developing LUTS may have eluded patients' attention for years to decades until reaching its ending stage,
    for which the affected men start seeking medical attention for intolerable or unbearable personal inconvenience, embarrassment, and
    suffering like running to bathroom all the time but with less voided urine volume from each voiding, severe slow urine flow, straining to void,
    incomplete emptying, etc.

    2. Acceptance of slowing urine flow as an aging normalcy has unduly forged and heightened personal tolerance to cope with quiet
    progressive LUTS until....

    Of note, LUTS always takes a period of years to decades to develop without discerning its coming because of not feeling any discomfort but
    quiet slowing urine flow on its path of slowness and creepiness. Hence, the affected men would not go to see doctors until accumulating
    enough amount of personal inconvenience, embarrassment, and suffering, and even reaching urinary retention-worse yet, irreversible
    bladder damage.

    Besides, it is useful to know: Since life is a one-way street of accumulation, modification, and continuation, we
    have to pay attention to every step of self-care in right way at right time. Being right time and right way is the essence of conducting medical
    practice, which comprises correctly processing a series of decisions-making and actions-taking, if one wishes to have a best possible
    outcome from medical care. To materialize this highly effective way of care, we need to pinpoint and treasure the golden time window of care
    before a disease becomes irreversible.

    Unfortunately, some men have been not just fooled by misunderstanding slowing urine flow naturally comes with age but also infatuated by
    magical herbs and pills.

    In life reality,  It is true that slowing urine flow naturally comes with age - often after retirement. Most men and even some medical  
    professionals accept and quietly bear with it because developing slow urine flow is a very insidious process without any hurting until its
    related complications, which may be urinary tract infection, urinary retention, kidney damage, etc., emerge along its quiet long path over a
    period of years and decades.

    9. What is the goal for caring for LUTS?
    A:
    Goal of care of LUTS is to help make urinary bladder able to store and empty urine as good and long as possible like that of general
    medical care is to help make the body able to function in its best possible fullness as good and as long as possible.

    Reality of medical care is to observe, realize, and accept that doctors have never cured anything for anyone, but at most and at best is to
    modify something for someone to some degree with or without medications and / or procedures at reasonable time in reasonable way; this
    is life reality. How to fulfill this reality to its potential limit? Follow the steps and instructions as described in http://formefirst.
    com/eNewsletter06.html.

    10. How to ask right questions to induce useful answer and to deduce correct diagnosis before being too
    late?
    A:
    For most men, if being asked how they urinate, they will quickly reply by saying, "I void well, no problem." before LUTS is reaching the ending
    stage of its development as detailed above in Section 8 of this article.

    But, if asked in different ways like "Have you noticed that you have been quietly standing closer and closer to toilet bowel to urinate over the
    last few years or last one to two decades?", surely, most of them will smile,  nod their heads, and say, "Yes, I do or I have been, but not
    hurting..."

    If asked if they have ever wondered why some 2 to 3 young men already walk in and out the bathroom after peeing but they might still stand
    tall and tilting head looking into the sky like a president pondering something and sigh. Similarly, they will grin and say yes.

    Furthermore, if asked if they have sat onto toilet bowel to urinate or pee, many of them would say, "Yes." If asked why, the standard answer
    to this question would be "I would not spread or dribble my urine onto toilet bowel so my wife would not complain of..." Of course,
    occasionally, few men have to sit to void because of physical disability.

    Thinking about or mulling over these 3 scenario may alert men and family to pay attention to LUTS, seek evaluation timely, and avoid
    reaching the irreversible non-return fate of bladder decompensation.

    11. What are the common tests and studies specifically for LUTS?
    1. Voiding chart: This is usually completed by patients although occasionally done by caretakers for someone mentally and
       physically impaired. How to do it? Simple, without changing how you usually drink and pee, you serially write down how much
       you drink and pee (urinate) at what time (am or pm) every single (in ounce (OZ) or cubic centimeter (cc or ml) over a bduration
       of 24 hours for preferably 2 days. This is very useful for self confirmation and reassuring.

    2. Postvoid residual urine: This is to check how much urine left behind right after you pee, and done usually with bladder
       ultrasound scanning or with inserting a small catheter to drain and confirm by medical professional at office.

    3. Cystometrogram (CMG): This is to estimate how your bladder may work by observing and recording how your bladder may
       feel the sense of temperature and fullness, how your bladder may react to its being filling up so to define its stability, how
       much your bladder can accommodate its being filled up.

    4. Cystourethroscopy: Urologist uses a telescope (cystoscope) to look into your urethra and bladder so to define the degree
       and location of potential blockage as well as the degree of their aftereffect onto the bladder from its long-term overwork so to
       overcome the functional and anatomical narrowing of the bladder neck or urethra.

    5. Urine tests such as complete urinalysis, urine culture, etc.;

    6. Blood tests for renal (kidney) function.

    Do we need all these tests for every patient? No, usually only few are practically needed, but the high intensity of political correctness and
    commercialism has forced some professionals to do many tests marginally and unnecessarily  for more money-making under the shield of
    "I would rather be safe than sorry."

    12. What are the right steps to take care of urinary retention?
    A:
    Before starting treating urinary retention, we need to realize and accept that urinary retention is the very ending point of bladder overwork and
    exhaustion with eventual inability to empty, which can be categorized into two groups as follows:
    1. Chronic urinary retention (uro-retention) unfortunately occurred as an unfortunate endpoint of personal and professional ignorance in
    recognizing the slowness and creepiness of LUTS as described on the page of Why do the public and doctors overlook LUTS until reaching
    urinary retention - even irreversible bladder damage? .  

    2. Acute urinary retention (uro-retention) is usually caused by some identifiable precipitating factors like the conditions after spinal
    anesthesia or general anesthesia, after major pelvic surgery for bladder, colon, rectum, uterus, etc., after spinal cord injury or surgery, in
    mandatory supine position, with pain with or without pain medication, after taking medications with adrenergic or anticholinergic effects like
    oxybutynin, pseudoephdrine, antihistamine, etc.

    Note: The situation between chronic and acute uro-retention may be recognized as subacute uro-retention since every life event always
    displays on its pattern of full spectrum and doctors just see the patients at the certain point or moment of such full spectrum.

    Then, let us picture what the affected men may have to do, that is, to pee all the time to push a small amount of the spilled-over urine, which
    is called pending urinary retention, and eventually to constantly leak urine, that is, overflow urinary incontinence, for which they wear diapers
    (depends or pull-up) so to avoid wetting their underwears or pants. Of course, this condition is not what we want and should avoid it like
    escaping from a plague.

    Reaching this very endpoint of LUTS, what and how can we expect and make the bladder able to recover to resume its ability to store and
    empty urine?

    Known to us with common sense, If wishing to have a good outcome from medical care, medical professionals have to be able to decide
    when and how to make right decision to proceed with right action after mulling over the balance between medical necessity and
    professional possibility at every step along the course of delivering medical care.  

    With these in mind and common sense permits and prevails, I have conjectured the following two-step formula to take:

    Step 1 is to protect the said damaged bladder from further unwanted damage by recurrent over-distention.

    How?

    Three options:
    - CISC: With clean intermittent self-catheterization (CISC) or intermittent catheterization by the willing and able
     caretakers who may be spouse or any family member or attending nursing staff, or

    - Indwelling urethral catheter for constant catheter drainage by inserting catheter manually through the urethra or

    - Indwelling suprapubic tube established by surgically inserting catheter through suprapubic area into the
     bladder as called suprapubic cystoscopy.

    If CISC is taken, always keep the urine inside the bladder less than 15 oz or 450 cc at any given time including what the patient may void
    plus the residual urine right after spontaneous voiding (if he could).

    If constant catheter drainage is applied, two key points for its good care are mandatory; they are: 1. always keep the suprapubic tube
    properly taped or fixed so not to have undue traction onto the opening to prevent incidental catheter pulling-out or bladder spasm as well as
    to avoid unwanted catheter obstruction and bladder overdistention by kinking or twisting, which may lead to septic symptoms from forcing
    bacteria and its toxin into blood stream, and 2. always keep the drainage back below the level of urinary bladder so to avoid inducing
    unwanted bladder distention and potential spasm.

    Step 2 is decide when to do surgery if urological intervention is necessary. Although many patients may experience some recovery in
    bladder function after the care with the actions in Step 1 and become able to urinate by themselves, they should be still under a close watch
    so to avoid c proceeding to chronic urinary retention because the patients in acute retention, more or less, have some of the unnoticed
    underlying factors which are common as we age. If not able to resume spontaneous bladder voiding with "reasonable' stable low postvoid
    residual urine, surgical intervention is needed.  

    13. What are the available options of medical treatment for LUTS?
    A:
    There are two groups of drugs to help bladder emptying:

    Group 1 is one of alpha-blockers to help relax the urinary sphincter (bladder neck and prostate urethra) like alfuzosin (Uroxatrol), doxazosin
    (Cardura), prazosin (Minipress), silodosin (Rapaflo), tamsulosin (Flomax), or terazosin (Hytrin); If effective, one may see urine flow
    improvement within 1-3 days after taking such drug.

    Group 2 is one of 5-alpha reductase inhibitors to help shrink the prostate like finasteride (Proscar) or dutasteride (Avodart).

    At times, the drugs in group 1 and 2 may be selected and used together to maximize the effect to improve urine flow and ease voiding
    symptoms; example - dutasteride + tamsulosin (Jalyn) . If working, urine flow may be improved within 1-3 days and optimized in 1-3 months
    after their combined use.

    Exception: Tadalafil (Cialis) is the only one documented PDE-5 inhibitor to work for erectile dysfunction (ED) as well as for BPH/LUTS. But
    its high cost oftentimes prohibits its regular use; instead, the combined daily use with one of alpha-blockers and on-demand use of one of
    PDE-5 inhibitors is preferred.

    If you tolerate these drugs well to help improve urination, make sure to take them indefinitely.

    Despite taking drugs, the voiding symptoms of LUTS may expectedly worsen slowly because the drugs only help modify how bladder and
    urethra work and would not stop continual accumulation of undesirable ill effects of aging.

    14. What are the available options of surgical procedures to help bladder empty better?
    A:
    Over the past 6 to 7 decades, a long list of procedures have been designed, tried, and used to testify their glorying ups and frowning downs
    reflecting their related safety, easiness, and durability.

    The list includes - does not limit -  the following:
    - TURP (transurethral resection of prostate),
    - TUIP (transurethral incision of prostate or bladder neck),
    - balloon dilation of prostate urethra,
    - stent of prostate urethra,
    - open prostatectomy (to remove the obstructing part of the prostate),
    - TUNA (transurethral needle ablation),
    - TUMT (transurethral microwavetherapy),
    - laser enucleation of obstructing part of the prostate,
    - PVP  (photoselective vaporization of the prostate) with laser,
    - vaporization with electrocautery,
    - Internal tucking and compressing prostate tissue with Urolift,...

    Among these, TURP has led the pack and still remains as the gold standard of procedures for LUTS, and PVP follows.

    Which procedure will be used among urologists? The decision reflects equipment availability and support of institutions and professional
    proficiency and confidence in performing the procedures.

    In my hands, nowadays, I have exclusively used PVP. Over the past 8 years, I have performed PVP in >750 patients with laser usage up to
    1,300,000 joules usually under 180 watts, and with >90% of patients discharged home the same day of procedure with indwelling catheter
    and its self-pulling-out as instructed in 2-5 days, and with return visit in 3-4 months. There has been no concern or issue for blood loss and
    water over-absorption. In fact, no one needs blood transfusion or develop fluid overload despite vaporizing prostate tissue up to 250-300 cc.

    Yet, not every urologist would feel comfortable in performing a procedure like PVP. For instance, I have introduced my favorable PVP to three
    urologists over the past 7 years, but no one did well and stuck with it; they simply abandoned it in 6 months.

    Of note, please do not think PVP is a magic procedure. Although it lacks intraoperative and immediate postoperative complication, it still has
    its own delayed complications from my experience such as: delayed bleeding which is usually inconsequential; bladder neck contracture,
    which may occasionally occur few months or even 1-2 years after PVP; some encrustation (stone formation attached to the rugged tissues
    after laser vaporization leading in some 0.35% of cases).  

    Finally, I would like to remind that surgery like PVP is always considered as the last resort of care after failing to all available conservative
    options including expectation adjustment, behavioral modification, and use of related drugs, so would give no guaranty to return normal
    urination, which is highly related with bladder function before procedure.

    A Case in Point:
    In 1990s, I saw a 83-y-o man, who presented himself with urinary frequency to a local emergency room where he was evaluated and
    confirmed renal failure with serum creatinine up to 12.5 mg/dl resulting from post-renal urinary obstruction by slowly developed urinary
    retention up to >3,500 cc. This man was taught to do clean intermittent self-catheterization (CISC) for >11 months before I performed TURP
    (transurethral resection of the prostate) for him when he began self voiding with some postvoid residual urine. After TURP, he has been
    happy in how he voids despite still having some residual urine of 150-200 cc with creatinine at 1.5-1.75 mg/dl.

    This case illustrates the importance on when and how to decide and act at reasonable time in reasonable way to reasonable patient as
    discussed before.

    15. A list of some common misunderstandings about urination, bladder, prostate, kidneys, and their
    relationships?
    A:
    My lifelong professional observation confirmed:

    1. The size of prostate is not linearly proportional to the degree of LUTS. In other words, a large prostate does not mean always having
       trouble to void and a small prostate does not mean always being free of voiding trouble, although a larger prostate is more prone to have
       problematic urination.

    2. Good or bad kidneys have nothing to do with being good or bad in bladder and urination since kidneys are meant for managing water,
       electrolytes, blood pressure control, red blood cell production, vitamin D production, etc., and urinary bladder is merely for personal
       convenience in storing and emptying urine.

    3. The degree of visual blockage of prostate urethra as seen in scope examination is not necessary to reflect its potential effects onto the
       bladder wall as commonly shown with trabeculation, cellule, saccule, diverticulum; these in turn reflects the fact that we were not born
       equal.

       The degree of bladder wall irregularity from bladder outlet obstruction as visualized on cystourethrsocpy (scope exam of urethra and
       bladder) reflects individual variation in the strength and structure of bladder wall in attesting that we are not born equal like the condition
       of developing inguinal hernia in some without any strenuous physical activity as opposed to some other who would never develop an
       inguinal hernia despite their lifelong hard physical work.

    16. Have there been some herbal pills to help improve LUTS?
    A:
    Herbal pills have not consistently been found and proven to help improve LUTS, The ingredients in all kinds of prostate supplements
    available online have been about the same including saw palmetto berries, the bark of pygeum africanum, panax ginseng, and other herbs
    including cough grass, damiana, hydrangea, nettles as well as some multiple vitamins like vitamins A, B1, B2, B3, B5, B9, B12, C, D, E, K,
    or minerals like zinc or lycopene-rich foods like guavas, watermelon, tomatoes (cooked), papaya, grapefruit, sweet red peppers (cooked),
    asparagus (cooked), Red(purple) cabbage, mango, carrots, etc., and vitamins-rich foods like fish, dark leafy greens, seeds, etc.  

    In reality, can any man keep up with so much information on prostate-health-related herbs, foods, vitamins, minerals, etc.? I doubt if there is
    anyone who can follow everything as touted online under the sun for money-making with controversial outcome. So, eat in moderation as
    described in http://formefirst.com/eNewsletter03.html.

    Conclusion:
    Now, I end the discussion on LUTS and its care for now with the concept and practice that I have observed, collected, analyzed, and
    summarized for you; I have used these informations to effectively counsel my patients and their family. So, I believe the same or similar
    impacts will take place in many willing souls like you.

    Of course, all what I presented and discussed is open for criticism and scrutiny so the realistic benefits of medical care for the public could
    be heightened and maximized. Your contribution and testimony will contribute to this never-ending endeavor.

    If you have more questions and if you are the patients inside Salem VAMC, prepare and bring a list of your concerns to see me In Uro-A
    Clinic; if not veterans, contact me at www.HealthTap.com/dr-Lin with RQPWJC to log in - using audio and video goes faster and learns more
    than text chat, or shoot me your questions to realinct2002@yahoo.com.
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