Saturday, January 09, 2016

Guys - It may not be your prostate

kw: opinion, medicine, prostate health, kidneys

Gross Alert: Frank medical terminology ahead.

I frequently get up at night to urinate. Not always, but sometimes for a week or more at at a time. Other times, weeks go by without it. Interestingly, my wife pays a nighttime visit to the bathroom almost as frequently as I do. We are both rapidly approaching 70 years old. Thus, I have been pondering the "overnight express" phenomenon in older people in general, not just men. I am about to explain that not all nighttime urination is because of your aging prostate. But we're going down a rather windy garden path here…

We are bombarded with advertisements about "prostate health", typically promoting one nostrum or another that is supposed to make things better (and, they say with a wink and a nod, it "could" make your love life better). It is well known that the male prostate gland gradually grows throughout life. However, some grow more quickly than others, and if the statistics are correct, about half of men who are over 80 years old also have prostate cancer.

The ads seldom say anything about cancer. They address the more "normal" growth that has a cute medical term, BPH or Benign Prostate Hypertrophy. Those three words literally mean "not dangerous", "prostate gland", and "getting bigger". What ads don't mention is that some men's prostate glands have a harder "shell", and some have a softer shell. For the "hard shell" gang, growth of the tissues inside increases pressure on the urethra (the tube from the urinary bladder to and through the penis). So even when you pee at 3AM you have to push to feel emptied. For the "soft shell" guys (I am one), the gland just grows larger. Mine started out larger than average, and is now the size of a Jonathan apple, nearly twice the diameter of a normal prostate. If I had a hard-shelled gland, I'd have needed the "roto-rooter" operation by now.

A few years ago, I had a new doctor perform my yearly physical exam. She is blessed with long fingers, so a digital rectal exam is pretty easy. (I got rid of a short-fingered doctor who had to push so hard to reach the prostate that it hurt. And I got the sneaking suspicion that he kinda liked that, also.) The new doctor was concerned about my prostate, particularly because it felt a little off-center to her. I asked whether it is possible to do ultrasound to visualize the entire gland. She sent me to a Urologist with instructions to ask him that question.

The Urologist had me get a bladder ultrasound, one for which you drink a quart of water, wait an hour (it gets agonizing), and have an ultrasound test of the bladder. Then you get to pee, and the tech does another ultrasound to measure any residual urine in the bladder. I noticed that the ultrasound screen showed red and blue colors at times. I asked about it. The machine uses a Doppler technique to see motion in the urine, which shows the kidney pumping. It was doing so about once a minute. Did you know the kidney is a muscular organ? I had never thought of it. The active kidney during the test is a critical piece of information here.

The upshot: The technician measured 50cc of "residual urine", that I supposedly had not "voided". Back at the Urologist's office, he decided to repeat the test himself. I wondered inwardly why he didn't just do it the first time and spare Medicare some expense. Anyway, he got the same result, a 50cc "residual". He put on a rubber glove and felt my prostate, and said that, though it was large, it was soft and didn't feel like it should be causing trouble. He then wanted to do two things, a cystoscopy to look inside the tubes and the bladder, and a "Urodyne" test, which I'll explain in gross detail in a moment.

Firstly, the cystoscopy felt weird, like peeing in reverse as the tube went in. The doctor declared my bladder shows no signs of overpressure, and that the prostate was not tightening down on the urethra. He still wanted to go ahead with a Urodyne test.

Secondly, I did a lot of searching at sites like Medline, and found that there is no cause for concern until the amount of "residual" urine in such a test exceeds 100cc. I almost canceled the test, but went ahead. It was instructive, if uncomfortable on several levels!

The Urodyne test involves a different kind of catheter, that can be attached to a pump. It starts with having a thorough pee, then the catheter is put in and any "residual" is emptied through it. There was no residual in my case (another clue!). Then the pump was attached, and I was told to announce when I first felt "something in there", then when it felt like I "ought to go", then when it felt really urgent, "as much as I could stand". The nurse took all this down. Then she disconnected the catheter from the pump, told me I could pee freely into a measuring flask next to me, and left the room. She had performed the test unsupervised, which led me to doubt the doctor's judgement.

Once I was decently clothed again, the doctor and I talked. He said I had voided completely after the test, so there seemed to be no problem with my prostate. And he asked, "What was your original complaint?" I said, "I didn't have one. My PP sent me to you because she felt my prostate was off center or malformed." He got a look on his face like, "Oh, Sh**, he's gonna sue me!", but I said, "I'm glad everything seems to be in working order," and he looked relieved. He had me make an appointment with the clerk to return in a year, which I did, but the next day I called from home to cancel it. Less drama than just refusing to make it in the first case.

So what is the upshot? There is one more piece of medical evidence: the way our kidneys work and how that changes with age. From the time we gain nighttime "bladder control" at some age between two and ten, our kidneys greatly reduce their output when we are asleep. They resume normal operation when the light increases, and if we are not already awake, we soon wake up to rush to the bathroom. Here is all the evidence in one list:

  • At the ultrasound tests, both of them, the time from getting to pee and the tech beginning the ultrasound measurements of urine in the bladder was 10-15 minutes. At the rate a kidney produces urine when you've had a lot to drink in the past hour or two, that is plenty of time to generate 50-100cc of urine. I think that is why 100cc is the threshold of concern for Medline.
  • The Urodyne test showed I am able to void completely.
  • The cystoscopy showed I have not been over-pushing to urinate against prostate back-pressure.
  • It also showed that there was no tightness where the urethra passes through the gland.
  • Normal, young kidneys slow down at night, then speed up about sunrise. This is probably mediated by Melatonin.

My conclusion? In older people, most if not all, the kidneys don't slow down at night. At least, they don't slow down as much as they did decades earlier.

Fellas, if you are over 50, whether your prostate is "tight" or not, you probably will be getting up to pee at some early-morning hour like 3AM. The crux of the matter is whether you have to push hard to feel like you're getting emptied out. The need to push is the main evidence of a possible prostate problem. If you can just relax and the bladder empties out and you feel quite OK, you're probably OK. And gals, if you are getting along in years and getting up at night to pee, of course you don't have a prostate to blame. It's just aging kidneys that don't take a rest like they used to.

If you talk to a doctor about this, there's half a chance he or she will look at you like you are from Mars. If that happens I suggest you print out this blog post, pass it along and say, "See if you can prove this guy is wrong, then." I'll be interested to learn of any professional feedback!

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