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Old 09-23-2012, 10:12 AM   #1
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Very High Urine Post Void Residual – Why? What to do?

I have a very high level of PVR after urination which has been increasing from about 200mL to over 500mL over the past 3-4 years as tested by ultrasounds.

- Have you had a similar condition and how you have been treated?
- What is the mostly likely cause of such a high PVR?
- How to distinguish a high PVR caused by an obstructive BPH from a bladder dysfunction eventually neurological in nature? Have you or your doctor ever considered this?

Here in short my history:

I am 57, fit, eating well and moderately active. Regularly testing, consulting doctors and urologists in particular. Regularly tracking PSA, free PSA, DRE since at least 8 years.

I was put on tamsulosin 0.4mg/d and now doubling the dose, due to re-test PVR in a couple of months. Yet, my bladder does not empty well! The urologist might envisage TURP or equivalent. I am also considering finasteride to shrink the prostate.

I recently reintroduced soy in my diet, also supplementing with prostate health support nutrients (saw palmetto, stinging needle, pigeum, I3C, lycopene. beta sitosterol, zinc, selenium and others), successfully reduced general inflammation (CRP=0.1) but all of this seems useless to reduce PVR.

I can also report:

- a kidney stone event 25+ years ago which triggered a high fluid intake, largely water, and do recollect cases of high urgency and high difficulty to retain
- other mild symptoms of BPH (next to the high PVR)
- a very high BUN/creatinine ratio in the urine (spot) and moderately high in the blood.

Thank you for your advice!

Last edited by albedo1; 10-18-2012 at 02:39 PM.

 
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Old 10-18-2012, 02:29 PM   #2
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Re: Very High Urine Post Void Residual – Why? What to do?

For an additional opinion I visited a good friend of mine also urologist. Did ultrasound scan of bladder prior and post voiding, measurement of flow peak/profile and DRE.

From about 1.5L pre-voiding I could only void 50% to about 0.7L post-void (PVR) ! He said, considering the historic, I might be suffering of a chronic retention and even the top dose of tamsulosin (2x0.4mg/d) does not seem to help.

However, the somewhat discordant fact is that, despite the huge PVR, the voiding profile and peak is reasonable (he was expecting much worse) and looks typical of BPH.

He said that even after a TURP it is not sure the condition of a bladder lacking tone could be solved. Do you know more about this condition and how it could be treated?

He typically would recommend tamsulosin + finasteride for 6 months after which, if no effect, TURP would be the gold standard.

I am not fully convinced as I feel too young for such high PVR and very concerned by the TURP potential side effects, mainly incontinence.

I will return to my current urologist in a couple of months and I think he will recommend a cystoscopy and/or urodynamic test to check the bladder condition first.

I wonder if you have had a similar condition and how you managed. Your comment, any comment, is greatly appreciated.

Last edited by albedo1; 10-20-2012 at 09:32 AM. Reason: correcting dose of tamsulosin

 
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Old 10-21-2012, 04:00 PM   #3
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Re: Very High Urine Post Void Residual – Why? What to do?

Hello,

Because I have a neurogenic bladder, I also retain high residuals after voiding which created a condition perfect for urinary tract infections. I used to retain about 350 ml's. I would be a little leary of a TURP as they can leave you incontinent.

My urologist started me doing a Clean Intermittent Catheterization (CIC) and that eliminated my problem. I have been doing this since 2004 and wish I had started many years ago.

I hope this helps.

Last edited by Millard; 10-26-2012 at 10:23 AM. Reason: Enlarge font.

 
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Old 10-22-2012, 01:36 AM   #4
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Re: Very High Urine Post Void Residual – Why? What to do?

Quote:
Originally Posted by Millard View Post
Hello,

Because I have a neurogenic bladder, I also retain high residuals after voiding which created a condition perfect for urinary tract infections. I used to retain about 350 ml's. I would be a little leary of a TURP as they can leave you incontinent.

My urologist started me doing a Clean Intermittent Catheterization (CIC) and that eliminated my problem. I have been doing this since 2004 and wish I had started many years ago.

I hope this helps.
Thank you Millard for your very interesting reply (and btw the great J Wayne's quote :-)). Do you mind sharing which is your current level of PVR after so many years of CIC? Also, how the neurogenic bladder condition was diagnosed and treated?

 
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Old 10-26-2012, 10:33 AM   #5
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Re: Very High Urine Post Void Residual – Why? What to do?

Well, to start with I am a SCI. Neurogenic bladders are very common with this type of injury. My PVR was determined by a urodynamic test. (Very invasive!) After starting with a CIC program, I do not have any leakage and can go several hours between cathing. My urologist tried many muscle relaxing drugs for the bladder muscle. With a neurogenic bladder, there is a problem with the bladder muscle and bladder nerves communicating. The nerve will transmit that the bladder is empty and the spincter would close too soon.

I hope I answered your questions.

Note: I wish I had started CIC long ago.

 
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Old 10-26-2012, 11:41 AM   #6
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Re: Very High Urine Post Void Residual – Why? What to do?

Quote:
Originally Posted by Millard View Post
Well, to start with I am a SCI. Neurogenic bladders are very common with this type of injury. My PVR was determined by a urodynamic test. (Very invasive!) After starting with a CIC program, I do not have any leakage and can go several hours between cathing. My urologist tried many muscle relaxing drugs for the bladder muscle. With a neurogenic bladder, there is a problem with the bladder muscle and bladder nerves communicating. The nerve will transmit that the bladder is empty and the spincter would close too soon.

I hope I answered your questions.

Note: I wish I had started CIC long ago.
Thank you Millard. This starts to be a real expert discussion which unfortunately I am not, I am sorry of naive questions here!! I understand that a urodynamic test would be needed to check for obstruction and bladder pressure. If I have obstruction, as I probably have, then they want me on TURP. I can ask about CIC but that I guess was prescribed because you are SCI and high PVR. If you were (prostate) obstructed then you would maybe have gone for TURP.

Last edited by albedo1; 10-26-2012 at 11:43 AM. Reason: adding (prostate)

 
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Old 10-26-2012, 12:26 PM   #7
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Re: Very High Urine Post Void Residual – Why? What to do?

A TURP would be my absolute last choice as I do not want to wear a condom catheter and leg bag the rest of my life. If needed for health reasons, I guess I would have no choice.

Good luck with your urodynamics testing.

 
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Old 12-12-2012, 02:55 PM   #8
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Re: Very High Urine Post Void Residual – Why? What to do?

Just had cysto + urodynamic. No major pain but of course uncomfortable (mostly the cysto). I was quite concerned by risk of acute retention after the process as I could not urinate at all. I recommend asking for a prophylactic dose of cyproflaxin 500mg before and after intervention, away from foods, to avoid UTI. Also maybe stay near a hospital ER just in case you make a retention needing catheterization. However everything was fine for me, not really a big deal. After already 12 hours I got much better and 24 hours almost ok despite some burning at the end of voiding.

Tests confirmed an obstructive prostate (3cm) and a quite damaged trabeculated bladder due to the huge retention (they took out almost 900 mL!). Clear I am suffering chronic retention with hypercompliant bladder which silently is decompensating.

B-TURP (bipolar TURP) is recommended by now almost 3 urologists (average of 1500 TURP each); they do not look much at other techniques (e.g. greenlight etc..). Of course reading the various posts I am concerned and decision is hard to take but clearly need to do something for the residual.

Being on drugs to shrink the prostate will likely only delay the surgery.

Is B-TURP the right approach? CISC seems to be really for abnormal situations (such as neurogenic) and greenlight laser if coagulating problems or when high cardiovascular risks, which I don’t.

Deciding is very hard. Please keep feeding with experience and comments!

Last edited by albedo1; 12-12-2012 at 02:57 PM. Reason: defining B-TURP

 
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Old 04-13-2013, 05:28 AM   #9
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Re: Very High Urine Post Void Residual – Why? What to do?

In meantime I had (bipolar) TURP in January and recovered well w/o complications. At 1-month check up with ultrasound my PVR was still high but 50% lower that before TURP. I am due to re-test by end of month.

I also found a method to probably void the PVR: standing and after the first urge and urination, I bend my upper body almost 90 deg and also apply a gentle pressure on the pelvic region above the penis. I then return straight and gently strain to further void. For some reason (rising liquid level in the bladder and triggering some nervous reflex??) I am able to void a little more, impossible otherwise. Repeating several times I feel I can void almost all my PVR.

E.g. if I do this process before going to bed, non only I have no nocturia but have very small urine in the morning.

Any comment? Can this be a good simple way to help bladder shrinking and further help after the TURP (done because of PVR)?

 
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Old 04-13-2013, 06:05 AM   #10
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Re: Very High Urine Post Void Residual – Why? What to do?

this is great news ... you are getting more urine out,
the bladder has a better chance to shrink/adjust.
I know I have more retention after my bladder neck,
I think the structure of the bladder is changed,,, the bladder neck is opened
and also effect the trigone , the part above the bladder neck is
also widened. So in effect , the size of the bladder volume is increased
through increase in the size of this area from the inicison or turp in your case.
I think I am slowly getting better with the retention in that I can feel it better and void it better on a second try.
When I stand a certain way, I can drain more like you can.
My hunch is that over 3-4 months , things will improve.
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Old 04-27-2013, 02:23 AM   #11
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Re: Very High Urine Post Void Residual – Why? What to do?

Also in the line of trying and get my bladder "re-educated" I am drinking regularly during the day (overall I am getting 2L fluid intake in average largely water, green tea and maybe 1 coffee - re coffee I try to avoid taking it too often but need to get also my brain working ;-) btw, I recollect also some studies showing some benefit for bladder conditions) and scheduling urinating every 2-3 hour max even if no real urge. I read this schedule might help. Any comment?

 
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Old 04-27-2013, 05:30 AM   #12
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Re: Very High Urine Post Void Residual – Why? What to do?

the benefit is to dilute the urine so that it is not irritating to the scar.
You should pee often, I would say every 1 hr for you to empty the bladder
residual.
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Old 04-27-2013, 05:55 AM   #13
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Re: Very High Urine Post Void Residual – Why? What to do?

Quote:
Originally Posted by bhp02 View Post
the benefit is to dilute the urine so that it is not irritating to the scar.
You should pee often, I would say every 1 hr for you to empty the bladder
residual.
mhh .. tks but every hour see to me a bit too frequent, I will look into it. I can search again for the 2 hrs evidence but posting web addressees here is not permitted.

Yes for the scar irritation, definitively.

Do you think really you can get the bladder re-educated and shrinked? Look to me logical. As you know I am trying doing it and will check with doc next week he has something against the process. You seem agreeing it is a good idea. However, I did not find so far much evidence studies.

 
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Old 04-27-2013, 02:35 PM   #14
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Re: Very High Urine Post Void Residual – Why? What to do?

yes, try to pee every hour. I am not telling you to do this for the rest of your life,, just while trying to shrink bladder.
sometimes there may not be much Comming out, or nothing, that is fine.
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Old 05-03-2013, 02:29 PM   #15
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Re: Very High Urine Post Void Residual – Why? What to do?

Quote:
Originally Posted by albedo1 View Post
In meantime I had (bipolar) TURP in January and recovered well w/o complications. At 1-month check up with ultrasound my PVR was still high but 50% lower that before TURP. I am due to re-test by end of month.

I also found a method to probably void the PVR: standing and after the first urge and urination, I bend my upper body almost 90 deg and also apply a gentle pressure on the pelvic region above the penis. I then return straight and gently strain to further void. For some reason (rising liquid level in the bladder and triggering some nervous reflex??) I am able to void a little more, impossible otherwise. Repeating several times I feel I can void almost all my PVR.

E.g. if I do this process before going to bed, non only I have no nocturia but have very small urine in the morning.

Any comment? Can this be a good simple way to help bladder shrinking and further help after the TURP (done because of PVR)?
Good progress to report and quite happy how things are evolving!

At 3 months from surgery (bipolar TURP) I did my second test to check PVR and the maneuver described in the post I am quoting (sorry to quote myself!).

I arrived to doc with full bladder. At urge, I could void w/o difficulty 630 mL with a Qmax of 26-27 mL/sec and normal profile which is very good. At the ultrasound a PVR of about 280-300 could be measured ... mhhh ... I then applied my method and could void an additional 420mL. Doc measured again PVR which was happily at <20mL which confirmed basically what was previously just an impression. Looks like I unintentionally re-discovered what is known as the Credθ's maneuver which can be used to void bladder. I intend to repeat it at least 2x/day in the hope to "re-educate" bladder. I am still checking for a specific physiotherapy which can also be recommended.

Hopefully things are going to improve even further.

Barring long terms complications, still possible, so far the (bipolar) TURP has been a success and based on my experience I could recommended it in similar conditions (mine was not obvious as pretty asymptomatic) provided the caveat of doctor experience and a previous pressure-flow and cystoscopy support to diagnostic.

Other actions are in the pipeline to check PSA at 6 months, lower inflammation with nutrition intervention and supplementation. Continuous monitoring (including PSA, I do not believe the absurdity of several recent panels recommending not to screen) and not dropping guard. However, I feel equally important is not being obsessed and live happily.

 
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