When you just can't go

My patient, a 63-year-old stockbroker, recalled his experience with acute urinary retention.

"I had this great urge but no matter how hard I strained, nothing happened except for a drop or two," he said. "I tried everything: letting the faucet run, even taking a warm bath. Nothing helped. I was miserable." For the next 6 hours he kept trying to urinate. When the pain became unbearable and he was near exhaustion, his wife drove him to an emergency room.

Today, he remains "eternally grateful to that young urology resident who mercifully catheterized me and drew off well over two quarts of urine." He was told that his prostate gland was so enlarged that it interfered with the release of urine from his bladder. He was sent home with a catheter and leg bag in place and given the name of a urologist to see the next day.

Acute urinary retention is a frequent reason for emergency-room visits. That's because noncancerous enlargement of the prostate gland, or benign prostatic hyperplasia (BPH), is such a prevalent disorder. Its incidence increases markedly with age. Research has shown that BPH occurs in 15 percent of men ages 55 to 59; 28 percent in men ages 60 to 64; and 36 percent in men ages 65 to 69. The rate leaps to 55 percent in men ages 70 to 74. For men more than 90 years old, BPH is nearly guaranteed.

The prevailing notion is that the symptoms of BPH are caused by a narrowing of the bladder outlet and its effect on the bladder wall muscle, but there are many clinical observations that make such cause and effect seem simplistic.

For instance, only about half of men with BPH develop symptoms that warrant treatment and when they do those symptoms might not correlate with the degree of prostate enlargement. And sometimes symptoms mysteriously improve without medication, surgery, or other intervention.

It was once a given that when BPH symptoms had progressed to the point of acute urinary retention, surgery was inevitable. Not now, thanks to two classes of drugs—alpha-blockers and 5-alpha-reductase inhibitors, used singly or together. Those, respectively, help to relax the muscles in the bladder and to shrink the prostate. See our Best Buy Drugs recommendation for the drugs used to treat an enlarged prostate gland. 

Medical treatment of BPH has not completely eliminated the need for surgery and various laser alternatives, but it has had a major impact.

The stockbroker had been scheduled for surgery but got a second opinion and was rescued by a urologist who started him on generic doxazosin (an alpha-blocker) and finasteride (Proscar), a reductase inhibitor. Now he has a teenager's stream and a prostate half its former size, yet he vividly remembers that nightmarish day when a normal function malfunctioned.