Recurrent episodes of dysuria in lower urinary tract
54-year-old male that Since the age of 35 years seeks medical help for Lower urinary tract symptoms mainly of irritative nature. Urological, Neurological, Orthopedic & Psychiatric aspects of his symptoms were evaluated. The patient was treated with a variety of drugs with marginal benefit.
What diagnosis would you suggest?
What therapy would you propose?
Are there Centers of Excellence in the patient’s area?
Is there any correlation between the hemorrhoid and urinary pathologies?
Would it be useful to assess diet also?
54-year old male.
1988Initial symptoms of stranguria, pollakiuria and hematuria were resolved in part with urinary antiseptics.The diagnosis was chronic prostatitis, for which therapy was undertaken with cycles of antiphlogistic medication.
1990: New episode of stranguria, pollakiuria, fever and pain in kidney beds.Also presence of bladder and rectum tenesmus.The patient underwent a rectal examination, which was within normal limits, urine culture and urine tests, which were within normal limits.The results of a transrectal ultrasound were within normal limits.
1992Another episode of perianal and testicular burning, with a feeling of weight and difficulty walking, for which the patient received antibiotic and antiphlogistic treatments.The specialist who examined the patient at the time identified a major somatic component in the symptoms.The onset of pain often began in combination with a sore throat.
1996: Symptoms became acute periodically and the urologist ordered orthopedic, neurology and immunology assessments.All assessments were negative, including the Rheuma test and neurology examination.Urology assessment results continued to be negative, except for the finding of a congested prostate, sometimes with abundant EPS (urine culture, prostate ultrasound, routine blood chemistry tests, sperm fluid test, all within normal limits).
1998: The patient's testosterone levels were also tested and were within normal limits.Thyroid test results were within normal limits.TPHA and VDRL were negative.The cytology test did not document the presence of acute or chronic phlogistic material in the prostate secretion.The patient had a neuropsychiatric assessment that revealed an obsessive-compulsive personality with significant somatization.In addition to the symptoms described above, the patient also reported significant perspiration and persistent constipation.
2000: The patient was assessed at the coloproctology and anorectal physiopathology units.The results of tests were largely within normal limits.He received alfa-lytic therapy and his symptoms improved slightly, but reappeared during an episode of pharyngodynia.
Uroflowmetry was pathological due to the presence of urinary residue in the bladder.
2003: The patient had a urography that showed the presence of a significant residue following urination.A subsequent urodynamic test showed a normal bladder with no signs of forcing.However, detrusor hypocontractility of unknown origin was observed.There was no obstructive cause, but during a physical examination anal sphincter hypertone was observed.No therapy was prescribed.
2005: Following recurrent episodes, as mentioned above, the patient had another urology assessment.He was prescribed another cycle of alpha-lytic medication, serenoa repens and valerian, although these were only beneficial initially.
2006: The symptoms became increasingly worse.The patient reported polyuria, constant burning and urinary symptoms that made it difficult for him to leave his home.
Clinical diagnostic update from May 2006 to present.
May 2006 Ultrasound of upper abdomen:negative.
Oct. 2006 Pelviperineal neurophysiological study:the tests showed symptoms of S2 S3 right sacral radicular problems producing a slight abnormality in somatosensory conduction between the posterior tibial nerve and the pudendal nerve, which explains the perineal disestesic symptoms.
Nov. 2006 Physiatric assessment as follows:
X-ray of cervical spine with standard + dynamic projection showed a marked arthritic osteophyte C4 -- > C7 with a foraminal reduction, limited metameric shift and no slippage.
An MRI showed a somatic disc protrusion C5 -- > C7, mainly right posterolaterally with compression of perimedullary fat.
Therefore, the patient was advised to have a cycle of cervical kinetic massage therapy (Pompages maneuver, opening foramens, neuromotor treatment for radicular adhesion, postural treatment with extension of anterolateral chains).
Nov. 2007 X-ray of lumbosacral spinal column:slightly left convex extensive scoliosis of lumbar spine with initial signs of spondilosis, characterized by marginal somatic osteophytosis mainly anterior to L3-L4.Slight reduction in disc space between L5-S1.
The patient had numerous urology specialist visits, the most significant of which were as follows:
June 2006 Main complaint:“A problem for many years with urinary frequency during the day.The patient’s urinary diary was within normal limits.Disestesic symptoms in pelvic and urethral areas, with no abnormalities in urethral and bladder morphofunctional profile”.Recommended therapy:Alanerv 1 tablet twice a day for 1 month and then 1 tablet a day for 10 days a month.A neurophysiological study of perineal pelvis was recommended and carried out on Oct., 2006 (as described in previous paragraph).
Nov. 2006 Sensory abnormality in bladder and perineal pelvis.Minimal S2-S3 right radicular abnormality.Therapy prescribed:Lyrica 75 mg 1 tablet in the morning.A psychological assessment was advised, which the patient had on Dec. 2006. This basically concluded as follows:“The clinical picture does not exclude the presence of a clinically significant psychological component in the construction of reported symptoms.At present there is no apparent possibility of developing a path for further clarification.”
Dec. 2006 The patient was advised to increase the dose of Lyrica to 75 mg 1 tablet twice a day.Based on his psychological assessment, the patient was advised to seek psychological support.
Aug. 2007 The patient was advised to have electrostimulation treatment of the dorsal nerve of the penis based on the sensory abnormality of the perineal pelvis.This was combined with Spasmomen 1 tablet in the morning.After the summer, symptoms characterized by frequency and burning were reviewed for possible endoscopic assessment under anesthesia.
Currently, the patient essentially reports the following in his urinary system:
Constant burning, a feeling of constriction, latent pain, often feels that his body temperature is higher than usual, he perceives any emotion in this area of the body;
Very frequent need to urinate, some days even every half hour, especially in the morning, which is extremely limiting to the patient’s lifestyle.
In addition, the patient reports having hemorrhoids, as well as cervicalgia and backache from time to time.
As advised by the patient has had sessions with a psychologist for over a year, but these have not been beneficial.
Voiding Diary January 13 – 17, 2007
Day Time Amount Voided (in ccs) Notes
1 8.15 350
1 1.00 300
1 12.15 300
1 13.15 250
1 15.00 450
1 18.30 300
1 19.30 320
1 21.00 200
2470 Daily Total Amount
2 1.00 300
2 Record not completed
2 11.40 200
2 13.15 300
2 15.00 250
2 16.00 150
2 17.30 250
2 19.30 250
2 21.00 100
2 21.40 100
2 23.00 120
2020 Daily Total Amount
3 0.30 50
3 6.15 450
3 7.40 200
3 10.45 200
3 13.00 520
3 13.30 200 approx. (Not measured)
3 15.00 400
3 17.00 100
3 19.00 320
3 19.40 100
3 21.00 150 approx. (Not measured)
3 0.00 150
2840 Daily Total Amount
4 7.15 300
4 10.50 300 (Bladder soreness)
4 11 .50 50
4 13.00 450 (Urge to void)
4 13.30 300
4 14.00 20
4 17.50 250 (Internal bladder soreness)
4 18.30 20
4 19.30 200 approx. (Not measured)
4 20.50 180
2070 Daily Total Amount
5 0.30 100 approx. (Not measured)
5 02.00 100 approx. (Not measured)
5 05.00 250
5 8.15 200
5 10.50 350 Soreness diminishes after voiding
5 12.10 400
5 13.20 50
5 15.00 50
5 15.30 20
5 18.30 150 approx. (Not measured)
5 21.40 200
5 23.00 200
5 0.50 50
2120 Total Daily Amount
There were a few positive findings we need to consider:
1. Voiding diary (January 2007) with 10 -12 urinations per day. Urine volume was normal, daytime frequency is notable. This frequency is not consistent with previous urodynamic studies (2003) that revealed detrusor hypocontractility.
2. Neuropsychiatric assessment (1998) revealed obsessive-compulsive personality with significant somatization.
3. Cervical & lumbar discopathy
At present the patient complains of severe frequency, urgency and dysuria.
He has hemorrhoids and pain from his cervical and lumbar spine.
It has been recognized that interstitial cystitis (IC) in males is a more common clinical entity than was previously thought. Further, increasing evidence suggests clinical and pathogenetic similarities between male IC and chronic nonbacterial prostatitis (CP)/chronic pelvic pain syndrome (CPPS). Many lately published manuscripts highlight the similarities and differences between male IC and CP and review the presentation, diagnosis, and treatment of IC in men, with particular attention to those who have received an initial diagnosis of CP. (Forrest JB , Urology 2007 Apr; 69(4 Suppl):60-3. F.) Patients with CPPS present withpain or discomfort that lasts several months, and often longer. It is usually at the base of the penis, and around the anus and lower back. Sometimes the pain spreads down to the tip of the penis and/or into the testes. Ejaculation may be painful. The pain may vary in severity from day to day. The patient might have dysuria an urgent desire to pass urine at times, some hesitancy when trying to pass urine and a poor urinary stream. I do believe that the patient belongs to this category of patients.
I recommend repeating PSA, uroflow studies, urinalysis & urine culture, urine cytology and random bladder biopsies (unless done within the last 6 months). In case all these studies will not reveal an underlying disease the patient should be sent to the Pain Clinic for further management.