Male Urinary Issues

Urine trouble?
We can help.

Urinary symptoms may develop as you age, but you don't need to live with it.

Male urinary symptoms are very common, especially as men get older. Your symptoms may include urinating too frequently, needing to run to the bathroom, not emptying your bladder completely, straining, slow stream, urinary tract infection (UTI), or burning with urination.

Why am I having these problems?
There are many reasons to have issues with urination as you grow older, but the most common is due to growth (enlargement) of the prostate gland which leads to blockage (obstruction), making it more difficult for your bladder to empty - this is referred to as BPH (benign prostatic hyperplasia). This can lead to some (or all) of the symptoms listed above. Other less common causes of urinary problems include cancer, scar tissue, and infection.

What happens at my initial visit?
Dr. Chertack reviews your symptoms and medical history. Depending on the situation, you may require a genital or rectal exam. Your urine is checked for blood/infection (this result is not usually available until after your visit) and the clinic staff perform a “bladder scan” to make sure you are emptying your bladder. You often will fill out an “AUA Symptom Score” to assess your symptoms.

How will my symptoms be treated?
Urinary issues are often managed with three categories of treatment: behavioral changes, medications, and surgeries.

What behavioral changes can I make?
Some recommended behavioral changes are listed, but they do not work for every patient.

Timed voiding: Set an alarm to get up and use the bathroom every 1-3 hours to ensure your bladder is empty. This prevents urgency and leakage.
Double voiding: Use the bathroom, wash your hands, then use the bathroom again. This may decrease your frequent urination and help you better empty your bladder completely.
Voiding diary: This has been provided as a separate handout to record your daily fluid intake and voiding habits, fill this out and bring to your next visit.
Fluid management: It is a good idea to stay hydrated, most patients should drink 2-3 liters of water daily, although every patient is different (and some patients have restrictions).
Avoid constipation: Having hard, infrequent stool can worsen your symptoms. Try to have a soft bowel movement every day. Dr. Chertack highly recommends Metamucil, Miralax (if you don’t drink very much water), or Citrucel - these can all be purchased without a prescription.

What if I am urinating too much at night?
Nighttime urination (known as “nocturia”) can be a separate issue that requires different treatments. Try some or all of these methods to minimize nighttime urination.

Minimize fluids before bed: Do not drink anything 3 hours before bed besides small sips with pills. Anything you drink close to bedtime will end up in your bladder while you sleep!
Go to the bathroom before bed: Don’t forget to empty your bladder before going to sleep.
Elevate your legs: If you notice your legs are swollen at the end of the day, elevate your legs with a recliner or pillows for 1-2 hours before bed.
Use a CPAP machine: Sleep apnea can worsen nighttime urination, use your CPAP or get evaluated with a sleep study if you snore or have difficulties sleeping.

I am interested in medications, what are my options?
Dr. Chertack usually starts patients on a medication called tamsulosin (brand name Flomax). This medication helps to relax the bladder outlet to allow urine out easier. Patients occasionally get some mild dizziness but this is very uncommon. This medication does cause you to have decreased/no semen when you orgasm, known as “retrograde ejaculation.” Take this medication before bed for best effect. There are similar medications, but due to efficacy and cost Dr. Chertack finds tamsulosin works best for most patients.
Other medications include finasteride, bladder relaxants, and tadalafil (brand name Cialis), but Dr. Chertack can discuss the benefits of these at future visits.

Are there any natural options or supplements I can take?
Dr. Chertack does not recommend any natural remedies or supplements due to lack of strong evidence.

What about surgery?
Surgery may be recommended for patients with persistent symptoms despite medications, catheter use, UTI, prostate bleeding, bladder stones, or kidney injury. Pre-surgery testing includes cystoscopy and prostate size measurement. Once this is completed, Dr. Chertack can discuss which surgical options are best for you.

What about prostate cancer?
Prostate cancer is common as men age and is slow-growing. It's treatable when confined to the prostate, but side effects of treatment can be significant. Dr. Chertack will discuss PSA testing and review your prior PSA results to screen for prostate cancer, depending on your age, family history, and other medical conditions. Please see the separate section on prostate cancer management for further information.

What if my urine test shows blood?
Further workup may be required to identify cancer or other concerning causes of blood in your urine. Cystoscopy and kidney ultrasound or CT scan may be recommended. If it shows infection, treatment is required only if you have symptoms.

Pelvic pain in men of all ages is suprisingly common.

Many men are shocked to find out that pelvic pain, although not normal, is extremely common in both young and old. Occasionally this is due to underlying concerns, but more often it can be managed without too much issue.

What happens at my urology visit?

Dr. Chertack discusses your symptoms and your medical history, and usually performs a genital exam to make sure there were no complicating factors. If you had any labs or imaging previously, this was discussed as well. If you are having any issues with urination, we may check a urine sample and make sure you are emptying your bladder completely.

Why am I having pelvic pain?

There are many reasons why men have pelvic pain. It can be due to your urinary system (bladder, prostate, urethra), your genitals (penis, testicles, scrotum), or your GI system (intestines, rectum, anus). One of Dr. Chertack’s jobs is to make sure none of these systems are causing your pain.

What else could it be?

A very common cause of pelvic pain is actually the pelvic floor muscles. These form a “hammock” inside your pelvis and connect to the muscles that prevent urine and stool leakage. Unfortunately when these muscles get tight, sore, or painful, they can cause a variety of symptoms. These include testicular pain, pain with urination, painful erections, pain with ejaculation, and painful bowel movements. This is known as pelvic floor dysfunction.

What is the best way to treat this?

Just like you would see a physical therapist for issues with your arm or leg muscles causing soreness and pain, there are specialized physical therapists for treatment of pelvic floor dysfunction. This is the best place to start for this condition. Many patients find significant benefit from seeing a physical therapist prior to trying more invasive options.

What can I do for occasional scrotal pain?

If your pain is mildly bothersome or you have pain flares, you can manage this with a combination of tight-fitting underwear or scrotal support, ice packs (apply 20 minutes on, at least 20 minutes off, 3 times a day or more), and taking 400mg ibuprofen on a schedule every 6 hours for two weeks to treat the inflammation.

Transurethral resection of the prostate is still considered the "gold standard" treatment option.

After talking to Dr. Chertack, you may be a candidate for a transurethral resection of the prostate, or TURP.

Why do I need a TURP?

The prostate often grows larger as men get older, but more importantly it may squeeze and block the urethra. You may have tried medications to help with your symptoms but sometimes the medications are not enough and you need surgery to improve your symptoms. Some patients need a TURP because they have frequent blood in the urine, urinary infections, bladder stones, problems with kidney drainage, or need a catheter to drain the bladder.

How do I know if this is the right surgery for me?

Dr. Chertack will look inside your bladder to confirm that your prostate is causing a blockage and to rule out any other concerning findings within your bladder. He will also measure your prostate size with either a rectal ultrasound or using a CT or MRI that you had previously. Your prostate needs to be below a certain size to give you the best possible outcome. There are many other surgical options that can treat this problem, but Dr. Chertack feels that for the majority of patients the TURP will provide the best long-term results.

What happens during my TURP?

You will be asleep during this surgery. A camera will be inserted into your bladder. Dr. Chertack will “shave” down the prostate from the inside. The goal is to remove any tissue that is blocking the flow of urine until the channel is wide open, this will maximize your chances to urinate better after surgery. The surgery will take 1-2 hours, depending on the size of your prostate. No incisions are required for this type of surgery.

What should I expect during my hospital stay?

You will wake up with a catheter draining your urine. You may feel like you need to urinate, this is a common sensation with a catheter but you do not need to squeeze or strain. You will be monitored overnight in the hospital. The day after surgery your catheter will be removed and you will urinate 1-3 times to confirm you can empty your bladder before leaving the hospital. Some patients have difficulty after surgery and need the catheter replaced, usually it can be removed within one week.

What should I expect for my recovery?

It is normal to have some pain, burning, and occasional bleeding with urination for 6 weeks after surgery, this is normal while your prostate is healing from the surgery. For this reason you will see Dr. Chertack 6 weeks after surgery, not before!

Stay hydrated to prevent concerning bleeding and irritation.

There are no restrictions on your diet.

You can do most activities, but Dr. Chertack recommends against lifting >15-20 pounds for 6 weeks. He also recommends avoiding activities that put pressure on the prostate (like bike-riding) for 2-4 weeks.

Avoid sexual activity for 2-4 weeks until you feel more comfortable.

You are able to drive 24 hours after surgery.

What medications should I take?

You can take tylenol and ibuprofen for pain.

Dr. Chertack also recommends taking pyridium as needed to improve the burning sensation - this medication will make your urine orange!

Senna prevents constipation, take daily until you are having regular bowel movements.

You do not need narcotics after this type of surgery.

What are the risks of surgery?

Bleeding to the point of needing a transfusion is very uncommon.

There is a small risk of infection, you will get antibiotics in the operating room. If you have an infection before surgery, this will be treated prior to surgery.

The goal of the TURP is to improve your urination. Unfortunately some patients still have some issues with urination after surgery, this can often be managed with medications alone.

It is rare to have uncontrollable leakage or be unable to empty your bladder long-term after a TURP.

Scar tissue can form within the urethra after surgery and can cause blockages that need another surgery to remove, but this is very uncommon.

Occasionally prostate cancer is found within the tissue that is removed. Usually this does not require any further treatment and can just be monitored. Dr. Chertack will discuss with you if cancer is found in the tissue to discuss next steps.

A common side effect is “retrograde ejaculation,” this means when you have an orgasm none of the semen will come out the penis, it will actually go backwards into the bladder. Your sensation should not be changed and you can just urinate out the semen afterwards. This is not a dangerous or concerning side effect and will not affect your overall health.

What do I need to do to prepare for surgery?

Do not eat or drink anything after midnight the night before surgery. Any other restrictions regarding your medications will be discussed in advance with the anesthesia team.

Dr. Chertack and your other doctors will discuss temporarily stopping any blood thinner medications that you may be taking.

You will be tested for urine infection prior to surgery, if this is present you may need to take antibiotics for a few days before surgery.

Please provide a urine sample 2 weeks before surgery to give time to treat any infection.

What is my follow-up?

You will see Dr. Chertack in 6 weeks to assess your symptoms. If everything is going well, he will see you 6 months after surgery, then you can follow up as needed!

Green light laser surgery is a great option for patients on blood-thinning medications.

After talking to Dr. Chertack, you may be a candidate for a green light laser prostatectomy, also known as a photovaporization of prostate (PVP) or KTP.

How is this different from a TURP?

A TURP uses an electrified wire to shave down the prostate bit by bit. A green light laser prostatectomy uses a special type of laser to vaporize the prostate tissue. This gets rid of the obstructing tissue while minimizing the bleeding risk.

What are the benefits of a KTP?

Since the laser vaporizes the tissue, there is much less bleeding. Therefore it is the recommended treatment option for patients on blood thinners. It helps decrease the bleeding risk not only during surgery, but in the weeks after surgery during the healing process. Because the bleeding risk is lower, patients can be discharged home afterwards with a catheter in place, instead of staying overnight.

What should I expect for my recovery?

You will be discharged with a catheter, this will be removed 3-5 days after surgery. It will be removed in clinic to make sure you can void after surgery. Your recovery course will be similar to that of a TURP - it is normal to have some pain, burning, and bleeding with urination for 6 weeks after surgery while your prostate is healing.

How do I know if laser surgery is right for me?

Every urologist will give you slightly different recommendations. Some urologists recommend laser surgery for the majority of their patients. Dr. Chertack tends to recommend TURP for most patients because he believes it provides the greatest long-term benefit to patients. However, he recommends the laser surgery for patients that are on blood-thinning medication. Also for those patients that do not want an overnight hospital stay, they can undergo the laser surgery and go home the same day.

Larger prostates require a little more help to fix the problem.

For patients with prostates above a certain size, a different surgery needs to be performed to make sure enough tissue is being removed to provide you with benefit. If you have a prostate greater than 100g, Dr. Chertack recommends a robotic simple prostatectomy (RASP).

Why do I need this surgery?

This surgery is recommended for patients with prostates greater than 100g and have issues arising from the prostate that do not improve with medication alone, or symptoms that are bothersome despite taking the medication. There are three different surgeries available for prostates of this size, this is Dr. Chertack’s preferred technique. The prostate has two parts, which Dr. Chertack compares to an orange and the surrounding orange peel. As the orange (not the peel) is the cause of your urinary issues, the surgery will scoop out the “orange” while leaving the peel behind.

What happens during my RASP?

During this surgery, the inner portion of your prostate (the “orange”) will be removed through an incision in the bladder, while leaving the outer portion (the “peel”) behind. Dr. Chertack usually performs this surgery with the DaVinci robot. This allows him to perform the surgery through 5 small incisions instead of one large incision. The surgery takes around 3-4 hours to complete. A catheter will be left after surgery, the bladder will be closed with stitches and this will allow the bladder to heal.

What do I need to do before surgery?

You will need to complete the labs and imaging that Dr. Chertack orders.

Stop smoking - this is the best thing you can do to improve your recovery after surgery!

You will need to see your primary care doctor to confirm that you are as safe as possible to undergo surgery in order to decrease your risks.

If you take any blood thinner medications, Dr. Chertack will discuss stopping this prior to surgery.

You will need to take a laxative the night before surgery to empty your intestines, this helps make the surgery more straightforward.

What is considered normal after surgery?

You will stay in the hospital for one night after surgery, but almost all patients are able to go home the day after surgery. Make sure someone is able to drive you home and help you at home after surgery.

It is normal to be sore after surgery! You will be prescribed pain medications during your hospital stay, this will help get your pain to a manageable level.

After surgery, you will only be able to drink certain liquids. Usually the day after surgery these restrictions will be lifted and you can eat and drink whatever you want.

You will have a catheter to drain your urine after surgery. You will be sent home with this catheter, it will stay in for 3-7 days.

Sometimes you may have a small drain in your belly to monitor for bleeding but this is almost always removed before you leave the hospital.

You are able to walk immediately after surgery. Walking and moving around is the best thing you can do for your recovery! The more you walk, the easier and faster your recovery will be.

Often patients have some difficulty will bowel movements after surgery. You do not need to poop or fart before leaving the hospital. You will take stool softeners to help with pooping after surgery.

What should I expect when I leave the hospital?

You will be sent home with medications for pain. Narcotics are almost never required for pain control.

You will be sent home with stool softener medications, take every day until you are having regular bowel movements without straining.

There are no diet restrictions, you can eat whatever you want.

You should stay active to help with your recovery. However, no lifting more than 15-20 pounds for 6 weeks after surgery to make sure your incisions heal.

You can shower starting 2 days after surgery. Do not take a bath until your incisions are completely healed.

Please let Dr. Chertack know in advance if you need any paperwork for your employer.

What are the risks of the surgery?

It is NORMAL after this surgery to have some pain, burning, and small amount of bleeding for 6 weeks after surgery. This is a part of the healing process! As long as you are able to empty your bladder and feel comfortable, do not be alarmed.

The risk of bleeding is low but not zero, occasionally patients do need a blood transfusion after this surgery.

The risk of infection is uncommon, usually you do not need antibiotics before or after this surgery.

Any surgery inside your belly has a risk of injuring your other organs, Dr. Chertack will be extremely careful to avoid any potential injuries!

The goal of the surgery is to improve your urination. Unfortunately some patients still have some issues with urination after surgery, this can often be managed with medications alone.

It is rare to have uncontrollable leakage or be unable to empty your bladder long-term.

Scar tissue can form within the urethra after surgery and can cause blockages that need another surgery to remove, but this is very uncommon.

Is there anything I need to watch for after surgery?

Notify the clinic if you are having pain not controlled by medications, fever, severe nausea/vomiting.

When will I follow up?