A number of conditions can affect the smooth flow of urine in men. This leaflet will give you a brief explanation of how the urine system in men works, and what can go wrong with it.
The prostate gland
The prostate gland (which in the rest of this leaflet is just called 'the prostate') is located just beneath the bladder. It is only found in men, It makes a fluid that is one of the components of semen. It starts to get bigger after the age of 50. In some men it can become large enough to cause pressure on the urine pipe (urethra) which runs through it. This can result in a number of lower urinary tract symptoms (LUTS).
One of the most troublesome symptoms associated with an enlarged prostate is urinary retention. This means that the urine flow is either reduced to a trickle or stops completely. It can happen suddenly ('acute urine retention') or gradually over time ('chronic urine retention').
Conditions affecting the prostate
Benign prostatic hypertrophy
Most enlargements of the prostate are due to changes which occur as you become older. This is known as benign prostatic hypertrophy. It is called benign because it has nothing to do with cancer. Hypertrophy just means enlargement.
Just because you have an enlarged prostate it does not mean you will have symptoms. Only about a quarter of men with benign prostatic hypertrophy experience problems with their urine flow. Also, it doesn't work out that the larger the prostate the more likely you are to have symptoms. It all depends how much of the gland is pressing on the urethra.
This is a condition in which the prostate becomes infected with a germ (bacterium). It's usually the germs that live in the bowel that are involved. They pass from the skin around the anus into the tube along which urine flows (the urethra) and up into the kidneys. The kidneys, bladder , prostate and urethra together are known as the urinary tract and an infection anywhere along this system is known as a urinary tract infection. Sometimes the infection settles just in the prostate; sometimes other parts of the urinary tract are involved. Anything which slows up urine flow, such as kidney stones or an enlarged prostate, increases the risk of prostate infection.
Less common causes include damage to the prostate during surgery, insertion of a tube (a catheter) to drain the bladder and infection spreading from other areas of the body.
Symptoms may include those of a urine infection, pain in the area of the prostate (anus, testicles, bladder and lower back), a thick discharge from the penis, and a high temperature (fever). Examination by a doctor (by inserting a gloved finger into the back passage) may reveal a tender prostate.
You may need a urine test, X-rays and scans to sort the problem out.
Usually a course of antibiotics clears the infection. You might need some painkillers and laxatives to soften the stools (faeces).
Occasionally, the infection doesn't clear with treatment and a condition called chronic prostatitis develops (see below). Other complications may include sudden stoppage of the urine (acute urinary retention) and prostate abscess.
Chronic prostatitis is the term usually used when symptoms of prostatitis last longer than three months. There are two types:
Chronic bacterial prostatitis results from the germ causing acute prostatitis not completely clearing with antibiotics. If you develop chronic bacterial prostatitis you may keep having urinary tract infections, with pain passing urine and with frequency. You may also have pain in the prostate, with discomfort at the base of the penis, anus, pubic bone and lower back. In between flare-ups, you may continue to have mild pain and urine symptoms. Antibiotics tend to improve the symptoms but unless they clear the original infection, further flare-ups may occur.
Chronic non-bacterial prostatitis/chronic pelvic pain syndrome (CPPS)
Symptoms are similar to bacterial prostatitis except there are no germs in the prostate.
No one is sure what causes it. Theories include infection of the prostate gland with an unidentified germ, a problem with the nerve supply to the prostate gland, problems with the immune system, or inflammation from urine being squirted in the wrong direction. It's not even sure if the prostate gland is involved, so some doctors prefer to use the term 'chronic pelvic pain syndrome', abbreviated to CPPS.
Usually a doctor will examine your prostate gland (by putting a gloved finger into the back passage). You will also need a urine test and possibly a kidney scan to check for underlying causes. You may also need other tests to rule out other causes of your symptoms. This may involve a trip to a specialist to have a prostate massage. Gentle massage of the prostate through the back passage squeezes fluid which then comes out of the urethra for testing.
The treatment is usually courses of antibiotics and, if required, painkillers and laxatives. Medicines designed to relax or shrink the prostate have also been tried. Some men end up having surgery to remove the prostate.
It may take you a while to respond to treatment. Most men improve within six months, but sometimes it can take up to two years.
Prostate cancer develops in older men. It usually develops over the age of 65. The lifetime risk for being diagnosed with prostate cancer in the UK is about 1 in 8 men. Cancer cells can exist without causing any problems at all and some men may have cancer for years without realising it. If it does occur, it is often a very slow-growing condition.
If symptoms do develop they are usually similar to those of benign prostatic hypertrophy.
Prostate cancer is diagnosed by:
- An examination of the prostate (the doctor inserts a gloved finger through the back passage (the anus) into the rectum to feel the back of the prostate gland.
- A prostate specific antigen (PSA) test. This is a blood test to see whether you have prostate cancer. It is also used to check whether you are responding to prostate cancer treatment. See separate leaflet called Prostate Specific Antigen (PSA) Test for more details.
- Taking a tissue sample - a procedure called a prostate biopsy.
Further tests such as scans may be needed to assess any spread of the cancer.
Treatment options include surgery, radiotherapy and hormone treatment. Chemotherapy is also occasionally used. The treatment offered varies from person to person and depends on many factors, including whether the condition is early or advanced, how old you are and whether you have any other illnesses.
The urethra - the tube that urine flows out of from your bladder - can sometimes become narrowed. This is usually due to scar tissue forming around the tube. Damage or infection are often the cause. Poor urine flow, pain passing urine, and a number of other symptoms can occur. Long-term infections and, rarely, cancer can be complications of this condition. Treatment options include long courses of antibiotics, stretching the urethra and surgery.
Other causes of urethral pain
Urinary tract infection
One of the most common causes of urethral pain is urinary tract infection. It is usually accompanied by other symptoms such as a frequent and urgent need to pass urine.
This is inflammation of the urethra. It's usually due to an infection which has been acquired sexually, most commonly gonococcus. Again, other symptoms often accompany urethral pain, such as a discharge from the penis or pain passing urine.
The most common type of injury to the urethra is by the insertion of a tube to drain the bladder (a catheter). You may require this procedure if you develop urinary retention, usually as a result of swelling of the prostate.
Bleeding from the urethra
Urethral bleeding may have a number of different causes.
- Infection is a common cause - either in connection with a urinary tract infection or associated with urethritis. It often presents as blood in the urine (haematuria) rather than blood oozing from the urethra.
- Trauma - injury from a catheter can cause bleeding as well as pain.
- Cancer - urethral cancer is very rare in men. Cancer of the bladder or kidney is more common. You may notice bleeding from the urethra, or blood in the urine. Treatment of urethral cancer is usually surgical. It may be necessary to remove the penis entirely, although in some cases it can be preserved.
Further reading and references
Guidelines on Prostate Cancer; European Association of Urologists (2016)
Guidelines on the Management of Non-Neurogenic Male Lower Urinary Tract symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO); European Association of Urology (2015)
Lee YJ, Kim SW; Current management of urethral stricture. Korean J Urol. 2013 Sep54(9):561-9. doi: 10.4111/kju.2013.54.9.561. Epub 2013 Sep 10.
Urethritis - male; NICE CKS, July 2015 (UK access only)
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.