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Urethral discharge, constipation, and hemorrhoids New syndrome with report of 7 cases
URETHRAL
DISCHARGE,
CONSTIPATION,
AND HEMORRHOIDS New Syndrome with Report of 7 Cases AHMED
SHAFIK,
M.D.
From the Department of Surgery, Faculty Medicine, Cairo University, Cairo, Egypt
of
ABSTRACT - A new syndrome in which 7 cases share common clinical features of urethral discharge only at defecation, constipation, and hemorrhoids is reported. The discharge occurred only with constipation. The relationship between urethral discharge, constipation, and hemorrhoids is discussed. The concept that hemorrhoids lead to prostatic venous congestion is put forward. The urethral discharge at defecation seems to be the result of “milking” of the congested prostate by the hard stools. The mechanism of fecal and urinary “milking” of the prostate is discussed. The role of the congested prostate in infertilogenesis is presented. It seems that metabolic accumulation in the prostatic, vesicular, and ampullary secretions affected the spermatogenic activity as it similarly does in varicocele. Permanent disappearance of urethral discharge and improvement of semen quality were achieved on anoprostatic decongestion by medical treatment, hemorrhoid injection, or hemorrhoidectomy. The syndrome of prostatorrhea, constipation, and hemorrhoids should be considered in patients with idiopathic urethral discharge and in infertile patients.
Case Reports
A vast number of men are afflicted with discharge per urethra, persisting or recurring despite all therapeutic efforts. Urethral discharge could be due to gonococcal or nongonococcal urethritis, chronic bacterial prostatitis, or prosurethritis results from a tatosis. l Nongonococcal variety of conditions including allergy, Candida albicans, Trichomonas vaginalis, intraurethral condyloma or chancre, and herpesvirus hominis.’ About 30 to 50 per cent of cases of nongonococcal urethritis are caused by Chlamydia trachomatis, whereas many of the remaining cases not due to Chlamydia are caused by urea plasma urealyticum; however, in a number of patients the cause is uncertain.* In the latter patients, thorough urinary tract examination fails to reveal a causative organism, and numerous forms of treatment have been proposed but no permanent cure has been achieved. In the 7 cases with idiopathic urethral discharge presented herein, the causation could be and successful treatment was acdefined, complished.
UROLOGY
/ AUGUST 1981 / VOLUME
XVIII, NUMBER
Case 1 A forty-two-year-old male patient presented with urethral discharge of five years’ duration. The discharge was opalescent and occurred at end of defecation. When voiding at defecation, the discharge would appear at micturition end. The discharge occurred only when the patient was constipated, whereas no discharge appeared in constipation-free periods. The patient had mild difficulty at voiding but no other urinary symptoms. Defecation was always accompanied and followed by anal pain. There was no history of acute prostatitis, gonorrhea, or other venereal diseases. The patient had been under medical treatment with antibiotics, urinary antiseptics, and prostatic massage for five years before presentation, with temporary disappearance of discharge. Findings on physical examination were unremarkable. Rectal examination revealed a normalsized but turgid and slightly tender prostate.
2
155
Proctoscopy showed congested anal mucosa with third-degree hemorrhoids. Examination and culture of urine before and after prostatic massage, urethral discharge, expressed prostatic secretions, and semen showed negative findings. Excretory urogram was normal, with no residual urine. Cystourethroscopy was normal apart from mild posterior urethral and bladder neck congestion. On grounds of the sole complaint that the urethral discharge occurred at defecation only when the patient was constipated, it was assumed that the discharge resulted from the “milking” action of the hard fecal column on the congested prostate and also, that the prostatic congestion is a sequel of the anorectal congestion induced by hemorrhoids. In view of this concept, both constipation and hemorrhoids were thought to be the cause of the urethral discharge, and were treated accordingly. During medical treatment with aparients, hot baths, and anal decongestants, the discharge disappeared but recurred on discontinuation of treatment, especially when the patient was constipated. Hemorrhoidectomy was then performed. The urethral discharge stopped completely. The patient is now four and one-half years after operation with no discharge and with no hemorrhoid recurrence. Case 2 A thirty-four-year-old male patient complained of a twelve-year whitish urethral discharge at end of micturition which would appear separately (without urine) at defecation only when the patient was constipated. There was mild difficulty at voiding with some urgency and frequency. The patient had anal pain at, and for some time after, defecation. Erection had been weak for five years; he was infertile. There was no history of acute prostatitis or venereal disease. The patient had been treated for chronic prostatitis for a long period and received repeated courses of antibiotics, urinary antiseptics, and prostatic massage without improvement of either symptoms or semen quality. Results of physical examination were normal. Rectal examination revealed a slightly enlarged, turgid, and tender prostate. Proctoscopy showed third-degree hemorrhoids. Microbiologic examination of urine, prostatic secretions, and urethral discharge were normal. Repeated semen examination showed characteristically high volume (4-7.5 ml.), fluctuating sperm count (between 26.5 and 63.6
156
million/ml.) and constantly diminished sperm motility; abnormal sperm forms were within normal limits. The patient had normal findings on thyroid, adrenocortical, and pituitary gonadotropin function tests. The known causes of male infertility, mentioned by Dubin and Amelar,3 were excluded; other causes such as absent dartesticle,5 constrictive altos,4 aligamentous buginitis,(j and scrotal lipomatosis7 were not present. Urogram findings were normal. Cystourethroscopy showed marked bladder neck congestion which extended to the trigone. The patient was put under medical treatment for constipation and hemorrhoids. The discharge disappeared to recur after treatment cessation. Hemorrhoidectomy was performed. The urethral discharge and urinary symptoms disappeared. Normal semen quality was achieved eight months after the operation. The patient, now in his fourth postoperative year, is free of symptoms and has a stable normal semen pattern His wife conceived sixteen months after the operation. Case 3 A twenty-eight-year-old male patient had a three-year history of urethral discharge at defecation. The patient had chronic constipation, pain at defecation, and mild difficulty at voiding. He was treated for chronic prostatitis during the three years with temporary improvement. Results of physical examination were normal. Rectal examination revealed slightly tender but otherwise normal prostate. Proctoscopy showed second-degree hemorrhoids. Examination and culture of urine, prostatic secretion, urethral discharge, and semen were normal. Excretory urogram findings were normal. Cystourethroscopy showed mild bladder neck congestion. After failure to achieve permanent cure of urethral discharge by medical treatment, the hemorrhoids were injected. The discharge increased for one month after the injection before it stopped completely. The patient, now in his fourth year after hemorrhoid injection, is without urethral discharge. However, he is still under treatment for obstinate chronic constipation. Case 4 A twenty-one-year-old male patient had urethral discharge at defecation over a period of two years. He complained of chronic constipation and rectal bleeding at defecation. There
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were no urinary symptoms. There was no history of venereal disease. The patient did not receive any treatment. Results of physical, laboratory, and radiologic examinations were normal. Cystourethroscopy showed mild bladder neck congestion. The prostate was normal but slightly tender. He had first-degree hemorrhoids. The patient received medical treatment for constipation and hemorrhoids. The discharge stopped completely. Case 5 A thirty-year-old male patient complained of urethral discharge of six years’ duration and three years’ infertility. The discharge occurred at defecation either separately or at end of voiding. He had chronic constipation with anal pain at defecation, and a little difficulty at micturition with urgency. There was no history of venereal disease. The patient received medical treatment over a period of six years on the assumption the condition was chronic prostatitis but with no improvement either in the symptoms or semen quality. Results of physical, laboratory, and radiologic examinations were normal. Rectal examination revealed slightly tender and turgid prostate as well as third-degree hemorrhoids. Repeated semen analysis showed constantly high semen of oligovolume (4-7 ml.), varying degrees spermia, diminished sperm motility but normal sperm morphology. His last semen report was: volume 6.2 ml., sperm count 12.6 million/ml., motile sperms 45 per cent, and abnormal forms 16 per cent. Cystourethroscopy showed a congested bladder neck. All known causes of male infertility were excluded. Hemorrhoidectomy was performed. The urethral discharge and urinary symptoms disappeared. Normal semen pattern was obtained fourteen months postoperative, and the patient’s wife conceived five months later. Case 6 A thirty-six-year-old male patient presented with intermittent urethral discharge at defecation of four years’ duration. The discharge occurred during bouts of constipation. He experienced pain and fresh blood at defecation. He had mild dysuria and frequency of micturition. Rectal examination revealed slightly tender but normal-sized prostate as well as second-degree hemorrhoids. Findings on physical, laboratory, and radiologic examinations were normal. Cystourethroscopy showed congested bladder neck and posterior urethra,
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Since medical treatment of the hemorrhoids gave temporary improvement, they were injected. Patient, two and one-half years after injection, is rid of symptoms. It was noted that during a period of five weeks after injection, discharge and urinary symptoms increased, after which time they vanished entirely. Case 7 A thirty-two-year-old male patient complained of urethral discharge at defecation of six years’ duration. He was infertile for four years. He had chronic constipation and anal pain at defecation. There was a little difficulty at voiding together with urgency and frequency. The patient had been under continuous medical treatment for assumed chronic prostatitis but without improvement. Results of physical, laboratory, and radiologic examinations were normal. Rectal examination revealed slightly enlarged and tender prostate, as well as third-degree hemorrhoids. Cystourethroscopy showed congested bladder neck and posterior urethra. Repeated semen examination showed high semen volume, oligospermia, and diminished sperm motility with sperm morphology within normal range. The last semen report before presentation was: volume 5.3 ml., sperm count 26.8 million/ml., motile sperms 58 per cent, and abnormal forms 15 per cent. Hemorrhoidectomy was performed one and one-half years ago. Urethral discharge and urinary symptoms disappeared. Normal semen quality was achieved at the ninth postoperative month and thereafter. Comment These 7 cases have common clinical features: urethral discharge at defecation, constipation, and hemorrhoids. In all patients, the discharge occurred at defecation, either separately or at Neither was there urinary end of voiding. trouble apart from slight difficulty and, in some cases, urgency and frequency, nor did a history of venereal disease or acute prostatitis exist. Physical, laboratory, and radiologic examination results were normal. Hemorrhoids, encountered in all patients, were of the first degree in 1 patient, second degree in 2 patients, and third degree in 4 patients. The prostate was slightly tender and turgid but of normal size in 5 patients and slightly enlarged in 2. Cystourethroscopy showed mild bladder neck congestion in all cases with extension to the posterior urethra in 3 patients and to the trigone in 1.
157
prostatic plexus extends on the lateral surface of the prostate and the bladder. The laterovesical and lateroprostatic veins tend to converge and unite posteriorly. They receive, at the posterior prostatic surface, the vesiculo-deferential and rectal veins. Accordingly, rectal venous congestion could lead to prostatic and vesiculodeferential congestion. The encroachment of the congested prostate on bladder neck and posterior urethra would explain the difficulty at micturition in such patients. The congested bladder neck resulting from prostatic congestion could cause the frequency and urgency of urination. The urethral discharge occurring at defecation with hard stools seems to be the result of “milking” down the congested prostate by both the fecal column and the urinary stream if voiding occurs at defecation.
FIGURE 1. Fecal and urinary “milking” of prostate. Force of fecal descent in lower rectum directed downward and forward toward base of prostate, seminal vesicles, and vasal ampullae, and leads to fecal “milking” of these structures. Urinary stream in posterior urethra causes urinary “milking” of prostate.
Three patients were infertile. Semen showed high volume, diminished sperm motility, but normal sperm morphology. In 2 of the 3 patients, the sperm count was persistently oligospermic, whereas in 1 it showed fluctuations between the normal and oligospermia. All patients had been treated previously for chronic prostatitis for periods varying between two and twelve years, yet with no permanent cure. Syndrome
of prostatorrhea,
constipation,
Fecal
and
The constancy of urethral discharge with constipation and hemorrhoids in all cases points to a relation between these conditions. It is known that chronic constipation predisposes to hemorrhoids. The latter seems to promote the development of venous congestion not only in the lower rectum and anal canal but also in the Drostate. seminal vesicles, and vasal amDullae. This is due to the fact that the rectal, Gesical, plexuses anastomose and prostatic venous to Farabeuf, lo the vesicofreely. 8,g According
Normal Prostitic
of prostate
At defecation, the hard fecal column repeatedly “milks” down the congested prostate by which action its secretions are expressed into the urethra to appear as urethral discharge at the end of defecation. The factors predisposing the prostate to be affected by fecal “milking” need to be discussed. Anatomically, most of the prostate lies behind the posterior urethra in direct relation to the lower anterior rectal wall and anorectal junction.g The seminal vesicles and vasal ampullae lie between the bladder base and the lower rectum (Fig. 1). At defecation, the force of descending stools in the lower rectum is directed downward and forward toward the prostatic base, seminal vesicles, and vasal ampullae (Fig. 1). At the anorectal junction, the fecal column changes its direction downward and backward to
hemorrhoids
Congested
“milking”
Prostate
Prostate \’
secietions-3 -5c
/
,
ConFIGURE 2. Congested prostate and seminal vesicles encroach on lower rectum and anorectal junction. gested prostate encroaches on bladder neck and posterior urethra. (Dotted line represents congested prostate and seminal vesicle.)
158
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2
Rectum
FIGURE 3. Full urinary bladder pushes both seminal vesicles and vasal ampullae back toward lower rectum and anorectal junction. (Dotted line represents full bladder and displaced seminal vesicles. )
FIGURE 4. Rectal angle brings lower rectum and prostate, seminal vesicles, ted line represents rectum
straightening at defecation anwectal junction close to and vasal ampullae. (Dotat defecation.)
C
A
FIGURE 5. Mechanism of urinary “milking” of congested prostate. (A) Normal prostate and posterior urethra. (B) Congested prostate encroaches on bladder neck and posterior urethra with resulting narrowing which increases force of urinary stream that rubs prostate. (Dotted line represents congested prostate, posterior urethra, and bladder neck.) (C) Urine passing through constricted bladder neck sets up turbulence within posterior urethra which results in sufficient lateral pressure to cause prostatic “milking” (arrows represent urine rubbing inner aspect of prostate).
the anal canal. Since the anorectal junction represents a kink and the site of change offecal direction, it and the related posterior prostatic surface sustain the maximal force of fecal descent. This would result in repeated “milking” down of the prostate and perhaps the seminal vesicles and vasal ampullae, especially if (1) these structures are congested to encroach on the anorectal junction (Fig. Z), (2) th e urinary bladder is full as to push these structures backward toward the lower rectum and anorectal junction (Fig. 3), and (3) the fecal column is hard (constipated). Moreover, lower rectum straightening at defecation1’*12 would bring the fecal column closer to the prostate, seminal vesicles, and vasal ampullae thus augmenting fecal “milking” of these congested structures (Fig. 4).
UROLOGY
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Urinary
“milking”
of prostate
It seems that during voiding at defecation, the current of urine passing through the posterior urethra effects prostatic “milking,” especially when a resulting narrowing of the bladder neck and the posterior urethral lumen from the encroachment of the congested prostate would increase the urinary stream mechanical force that rubs the inner aspect of the congested prostate (Fig. 5). In addition, the urine passing through the narrowed bladder neck would set up turbulence within the posterior urethra which results in sufficient lateral pressure to cause prostatic “milking” (Fig. 5C), a condition similar to the poststenotic turbulence occurring in arteries and leading to aneurysmal dilatation.
159
Meanwhile, straining at urination, the result of the congested narrowed bladder neck and posterior urethra, would augment not only the pelvic and in turn the prostatic congestion but also the urinary stream force that massages the prostate. The congested prostate is thus “milked” down both externally by the hard fecal column and on its inner aspect by the constricted forcible turbulent urinary stream. Sandwiched between the fecal and urinary currents, it would express its secretions into the urethral lumen to appear as urethral discharge (Fig. 1). infertility
and congested
prostate
The disordered semen quality and infertility encountered in 3 patients require special mention. The characteristic high semen volume could be the sequel of the congestion of prostate, seminal vesicles, and vasal ampullae, especially since these patients had no endocrinal or clinical defects, notably varicocele, to explain the high semen volume. The varying degrees of oligospermia as well as the diminished sperm motility could be the result of the toxic effect of metabolic accumulation in the secretions of the congested prostate. It seems likely that the congested prostate, seminal vesicles, and vasal ampullae act on the spermatogenic process in a way similar to that of the congested testicle in varicocele. The only difference probably lies in the sites and times of action of these metabolites. In varicocele, they act in the testicle at the time of spermatogenesis with a resulting sperm maturation arrest, l3 whereas in the congested prostate, the metabolites seem to act on the mature sperms. Both varicocele and the prostatic congestion syndrome are identical as to high semen voland diminished sperm ume, oligospermia, motility. They differ in the abnormal sperm forms which are increased in varicocele and are within normal in prostatic congestion. Presumably this is because the sperm maturation is arrested early in the former and completed in the latter. Improvement of semen quality after prostatic decongestion could be due to the same factors leading to improved semen quality after testicular decongestion by a varicocele operation. Pelvic decongestion Permanent disappearance of the symptoms and the urethral discharge with improvement of semen quality in infertile patients was achieved
160
in all cases after pelvic decongestion by medical treatment, hemorrhoid injection, or hemorrhoidectomy. This could be further evidence of a relationship between the urogenital manifestations and hemorrhoids. The temporary increase in urethral discharge following hemorrhoid injection in Cases 3 and 6 is probably the result of the temporarily increased anoprostatic congestion induced by the irritant sclerosant. This also indicates a relationship between anoprostatic congestion and urethral discharge. In Case 3, the fact that the patient was free of urethral discharge after hemorrhoid injection despite the remaining constipation points to prostatic congestion as a prerequisite for the urethral discharge to be expressed by the hard stools. On the other hand, the absence of the urethral discharge in the constipation-free periods, despite prostatic congestion, indicates the necessity of hard stools to effect prostatic “milking” and discharge expression. To conclude, urethral discharge at defecation, constipation, and hemorrhoids constitute a syndrome that should be considered in patients with idiopathic urethral discharge as well as infertile patients. 2, Talaat Harb Street Cairo, Egypt References 1. Meares EM: Bacterial prostatitis vs “prostatosis,” a clinical and bacteriological study, JAMA 224: 1372 (1973). 2. Holmes KK, and Kiviat MD: Urethritis, in Harrison JH, et al. (Eds): Campbell’s Urology, -. ed. 4, Philadelphia, W. B. Saunders Co., 1978, vol. 1, pp. 538-556. 3. Dubin L, and Amelar RD: Etioloeic factors in 1.294 consecutive cases of male infertility, Fertil. Sreril. 22: 469 (I971). 4. Shafik A: Absent dartos, Br. J. Urol. 50: 354 (1978). 5. Shafik A, and Olfat S: Aligamentous testicle. New clinicopathological entity in genesis of male infertility and its treatment by orchiopexy, Urology 13: 54 (1979). 6. Shafik A: Constrictive albuginitis: report of 3 cases, J. Ural. 122: 269 (1979). 7. Shafik A, and Olfat S: Scrotal lipomatosis, a new clinicopathological entity in the genesis of male infertility, Br. J. Ural. 53: 50 (1981). 8. Cunningham D: Cunningham’s Manual of Practical Anatomy, ed. 12, London, Oxford University Press. 1960, vol. 2, p. 429. 9. Last RJ: Anatomy, Regional and Applied, ed. 5, The English Language Book Society, and Churchill-Livingstone, Edinburgh and London, 1973, pp. 512, 524. 10. Farabeuf LH: The Blood Vessels of the Genitourinary Organs of the Perineum and the Pelvis, Paris, Masson, 1995, p. 212. 11. Shafik A: A new concept of the anatomy of the anal sphincter mechanism and the physiology of defaecation. II. Anatomy of the levator ani muscle with special reference to puborectalis, Invest. Urol. 13: 175 (1975). 12. IDEM: A new concept of the anatomy of the anal sphincter mechanism and the physiology of defaecation. VIII. Levator hiatus and tunnel. Anatomy and function, Dis. Colon Rectum 22: 539 (1979). 13. IDEM: Venous tension patterns in cord veins. I. In normal and varicocele individuals, J. Urol. 123: 383 (1980).
UROLOGY
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AUGUST
1981
/
VOLUME
XVIII, NUMBER
2
DISCHARGE,
CONSTIPATION,
AND HEMORRHOIDS New Syndrome with Report of 7 Cases AHMED
SHAFIK,
M.D.
From the Department of Surgery, Faculty Medicine, Cairo University, Cairo, Egypt
of
ABSTRACT - A new syndrome in which 7 cases share common clinical features of urethral discharge only at defecation, constipation, and hemorrhoids is reported. The discharge occurred only with constipation. The relationship between urethral discharge, constipation, and hemorrhoids is discussed. The concept that hemorrhoids lead to prostatic venous congestion is put forward. The urethral discharge at defecation seems to be the result of “milking” of the congested prostate by the hard stools. The mechanism of fecal and urinary “milking” of the prostate is discussed. The role of the congested prostate in infertilogenesis is presented. It seems that metabolic accumulation in the prostatic, vesicular, and ampullary secretions affected the spermatogenic activity as it similarly does in varicocele. Permanent disappearance of urethral discharge and improvement of semen quality were achieved on anoprostatic decongestion by medical treatment, hemorrhoid injection, or hemorrhoidectomy. The syndrome of prostatorrhea, constipation, and hemorrhoids should be considered in patients with idiopathic urethral discharge and in infertile patients.
Case Reports
A vast number of men are afflicted with discharge per urethra, persisting or recurring despite all therapeutic efforts. Urethral discharge could be due to gonococcal or nongonococcal urethritis, chronic bacterial prostatitis, or prosurethritis results from a tatosis. l Nongonococcal variety of conditions including allergy, Candida albicans, Trichomonas vaginalis, intraurethral condyloma or chancre, and herpesvirus hominis.’ About 30 to 50 per cent of cases of nongonococcal urethritis are caused by Chlamydia trachomatis, whereas many of the remaining cases not due to Chlamydia are caused by urea plasma urealyticum; however, in a number of patients the cause is uncertain.* In the latter patients, thorough urinary tract examination fails to reveal a causative organism, and numerous forms of treatment have been proposed but no permanent cure has been achieved. In the 7 cases with idiopathic urethral discharge presented herein, the causation could be and successful treatment was acdefined, complished.
UROLOGY
/ AUGUST 1981 / VOLUME
XVIII, NUMBER
Case 1 A forty-two-year-old male patient presented with urethral discharge of five years’ duration. The discharge was opalescent and occurred at end of defecation. When voiding at defecation, the discharge would appear at micturition end. The discharge occurred only when the patient was constipated, whereas no discharge appeared in constipation-free periods. The patient had mild difficulty at voiding but no other urinary symptoms. Defecation was always accompanied and followed by anal pain. There was no history of acute prostatitis, gonorrhea, or other venereal diseases. The patient had been under medical treatment with antibiotics, urinary antiseptics, and prostatic massage for five years before presentation, with temporary disappearance of discharge. Findings on physical examination were unremarkable. Rectal examination revealed a normalsized but turgid and slightly tender prostate.
2
155
Proctoscopy showed congested anal mucosa with third-degree hemorrhoids. Examination and culture of urine before and after prostatic massage, urethral discharge, expressed prostatic secretions, and semen showed negative findings. Excretory urogram was normal, with no residual urine. Cystourethroscopy was normal apart from mild posterior urethral and bladder neck congestion. On grounds of the sole complaint that the urethral discharge occurred at defecation only when the patient was constipated, it was assumed that the discharge resulted from the “milking” action of the hard fecal column on the congested prostate and also, that the prostatic congestion is a sequel of the anorectal congestion induced by hemorrhoids. In view of this concept, both constipation and hemorrhoids were thought to be the cause of the urethral discharge, and were treated accordingly. During medical treatment with aparients, hot baths, and anal decongestants, the discharge disappeared but recurred on discontinuation of treatment, especially when the patient was constipated. Hemorrhoidectomy was then performed. The urethral discharge stopped completely. The patient is now four and one-half years after operation with no discharge and with no hemorrhoid recurrence. Case 2 A thirty-four-year-old male patient complained of a twelve-year whitish urethral discharge at end of micturition which would appear separately (without urine) at defecation only when the patient was constipated. There was mild difficulty at voiding with some urgency and frequency. The patient had anal pain at, and for some time after, defecation. Erection had been weak for five years; he was infertile. There was no history of acute prostatitis or venereal disease. The patient had been treated for chronic prostatitis for a long period and received repeated courses of antibiotics, urinary antiseptics, and prostatic massage without improvement of either symptoms or semen quality. Results of physical examination were normal. Rectal examination revealed a slightly enlarged, turgid, and tender prostate. Proctoscopy showed third-degree hemorrhoids. Microbiologic examination of urine, prostatic secretions, and urethral discharge were normal. Repeated semen examination showed characteristically high volume (4-7.5 ml.), fluctuating sperm count (between 26.5 and 63.6
156
million/ml.) and constantly diminished sperm motility; abnormal sperm forms were within normal limits. The patient had normal findings on thyroid, adrenocortical, and pituitary gonadotropin function tests. The known causes of male infertility, mentioned by Dubin and Amelar,3 were excluded; other causes such as absent dartesticle,5 constrictive altos,4 aligamentous buginitis,(j and scrotal lipomatosis7 were not present. Urogram findings were normal. Cystourethroscopy showed marked bladder neck congestion which extended to the trigone. The patient was put under medical treatment for constipation and hemorrhoids. The discharge disappeared to recur after treatment cessation. Hemorrhoidectomy was performed. The urethral discharge and urinary symptoms disappeared. Normal semen quality was achieved eight months after the operation. The patient, now in his fourth postoperative year, is free of symptoms and has a stable normal semen pattern His wife conceived sixteen months after the operation. Case 3 A twenty-eight-year-old male patient had a three-year history of urethral discharge at defecation. The patient had chronic constipation, pain at defecation, and mild difficulty at voiding. He was treated for chronic prostatitis during the three years with temporary improvement. Results of physical examination were normal. Rectal examination revealed slightly tender but otherwise normal prostate. Proctoscopy showed second-degree hemorrhoids. Examination and culture of urine, prostatic secretion, urethral discharge, and semen were normal. Excretory urogram findings were normal. Cystourethroscopy showed mild bladder neck congestion. After failure to achieve permanent cure of urethral discharge by medical treatment, the hemorrhoids were injected. The discharge increased for one month after the injection before it stopped completely. The patient, now in his fourth year after hemorrhoid injection, is without urethral discharge. However, he is still under treatment for obstinate chronic constipation. Case 4 A twenty-one-year-old male patient had urethral discharge at defecation over a period of two years. He complained of chronic constipation and rectal bleeding at defecation. There
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were no urinary symptoms. There was no history of venereal disease. The patient did not receive any treatment. Results of physical, laboratory, and radiologic examinations were normal. Cystourethroscopy showed mild bladder neck congestion. The prostate was normal but slightly tender. He had first-degree hemorrhoids. The patient received medical treatment for constipation and hemorrhoids. The discharge stopped completely. Case 5 A thirty-year-old male patient complained of urethral discharge of six years’ duration and three years’ infertility. The discharge occurred at defecation either separately or at end of voiding. He had chronic constipation with anal pain at defecation, and a little difficulty at micturition with urgency. There was no history of venereal disease. The patient received medical treatment over a period of six years on the assumption the condition was chronic prostatitis but with no improvement either in the symptoms or semen quality. Results of physical, laboratory, and radiologic examinations were normal. Rectal examination revealed slightly tender and turgid prostate as well as third-degree hemorrhoids. Repeated semen analysis showed constantly high semen of oligovolume (4-7 ml.), varying degrees spermia, diminished sperm motility but normal sperm morphology. His last semen report was: volume 6.2 ml., sperm count 12.6 million/ml., motile sperms 45 per cent, and abnormal forms 16 per cent. Cystourethroscopy showed a congested bladder neck. All known causes of male infertility were excluded. Hemorrhoidectomy was performed. The urethral discharge and urinary symptoms disappeared. Normal semen pattern was obtained fourteen months postoperative, and the patient’s wife conceived five months later. Case 6 A thirty-six-year-old male patient presented with intermittent urethral discharge at defecation of four years’ duration. The discharge occurred during bouts of constipation. He experienced pain and fresh blood at defecation. He had mild dysuria and frequency of micturition. Rectal examination revealed slightly tender but normal-sized prostate as well as second-degree hemorrhoids. Findings on physical, laboratory, and radiologic examinations were normal. Cystourethroscopy showed congested bladder neck and posterior urethra,
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/ AUGUST1981
/ VOLUMEXVIII,NUMBERZ
Since medical treatment of the hemorrhoids gave temporary improvement, they were injected. Patient, two and one-half years after injection, is rid of symptoms. It was noted that during a period of five weeks after injection, discharge and urinary symptoms increased, after which time they vanished entirely. Case 7 A thirty-two-year-old male patient complained of urethral discharge at defecation of six years’ duration. He was infertile for four years. He had chronic constipation and anal pain at defecation. There was a little difficulty at voiding together with urgency and frequency. The patient had been under continuous medical treatment for assumed chronic prostatitis but without improvement. Results of physical, laboratory, and radiologic examinations were normal. Rectal examination revealed slightly enlarged and tender prostate, as well as third-degree hemorrhoids. Cystourethroscopy showed congested bladder neck and posterior urethra. Repeated semen examination showed high semen volume, oligospermia, and diminished sperm motility with sperm morphology within normal range. The last semen report before presentation was: volume 5.3 ml., sperm count 26.8 million/ml., motile sperms 58 per cent, and abnormal forms 15 per cent. Hemorrhoidectomy was performed one and one-half years ago. Urethral discharge and urinary symptoms disappeared. Normal semen quality was achieved at the ninth postoperative month and thereafter. Comment These 7 cases have common clinical features: urethral discharge at defecation, constipation, and hemorrhoids. In all patients, the discharge occurred at defecation, either separately or at Neither was there urinary end of voiding. trouble apart from slight difficulty and, in some cases, urgency and frequency, nor did a history of venereal disease or acute prostatitis exist. Physical, laboratory, and radiologic examination results were normal. Hemorrhoids, encountered in all patients, were of the first degree in 1 patient, second degree in 2 patients, and third degree in 4 patients. The prostate was slightly tender and turgid but of normal size in 5 patients and slightly enlarged in 2. Cystourethroscopy showed mild bladder neck congestion in all cases with extension to the posterior urethra in 3 patients and to the trigone in 1.
157
prostatic plexus extends on the lateral surface of the prostate and the bladder. The laterovesical and lateroprostatic veins tend to converge and unite posteriorly. They receive, at the posterior prostatic surface, the vesiculo-deferential and rectal veins. Accordingly, rectal venous congestion could lead to prostatic and vesiculodeferential congestion. The encroachment of the congested prostate on bladder neck and posterior urethra would explain the difficulty at micturition in such patients. The congested bladder neck resulting from prostatic congestion could cause the frequency and urgency of urination. The urethral discharge occurring at defecation with hard stools seems to be the result of “milking” down the congested prostate by both the fecal column and the urinary stream if voiding occurs at defecation.
FIGURE 1. Fecal and urinary “milking” of prostate. Force of fecal descent in lower rectum directed downward and forward toward base of prostate, seminal vesicles, and vasal ampullae, and leads to fecal “milking” of these structures. Urinary stream in posterior urethra causes urinary “milking” of prostate.
Three patients were infertile. Semen showed high volume, diminished sperm motility, but normal sperm morphology. In 2 of the 3 patients, the sperm count was persistently oligospermic, whereas in 1 it showed fluctuations between the normal and oligospermia. All patients had been treated previously for chronic prostatitis for periods varying between two and twelve years, yet with no permanent cure. Syndrome
of prostatorrhea,
constipation,
Fecal
and
The constancy of urethral discharge with constipation and hemorrhoids in all cases points to a relation between these conditions. It is known that chronic constipation predisposes to hemorrhoids. The latter seems to promote the development of venous congestion not only in the lower rectum and anal canal but also in the Drostate. seminal vesicles, and vasal amDullae. This is due to the fact that the rectal, Gesical, plexuses anastomose and prostatic venous to Farabeuf, lo the vesicofreely. 8,g According
Normal Prostitic
of prostate
At defecation, the hard fecal column repeatedly “milks” down the congested prostate by which action its secretions are expressed into the urethra to appear as urethral discharge at the end of defecation. The factors predisposing the prostate to be affected by fecal “milking” need to be discussed. Anatomically, most of the prostate lies behind the posterior urethra in direct relation to the lower anterior rectal wall and anorectal junction.g The seminal vesicles and vasal ampullae lie between the bladder base and the lower rectum (Fig. 1). At defecation, the force of descending stools in the lower rectum is directed downward and forward toward the prostatic base, seminal vesicles, and vasal ampullae (Fig. 1). At the anorectal junction, the fecal column changes its direction downward and backward to
hemorrhoids
Congested
“milking”
Prostate
Prostate \’
secietions-3 -5c
/
,
ConFIGURE 2. Congested prostate and seminal vesicles encroach on lower rectum and anorectal junction. gested prostate encroaches on bladder neck and posterior urethra. (Dotted line represents congested prostate and seminal vesicle.)
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Rectum
FIGURE 3. Full urinary bladder pushes both seminal vesicles and vasal ampullae back toward lower rectum and anorectal junction. (Dotted line represents full bladder and displaced seminal vesicles. )
FIGURE 4. Rectal angle brings lower rectum and prostate, seminal vesicles, ted line represents rectum
straightening at defecation anwectal junction close to and vasal ampullae. (Dotat defecation.)
C
A
FIGURE 5. Mechanism of urinary “milking” of congested prostate. (A) Normal prostate and posterior urethra. (B) Congested prostate encroaches on bladder neck and posterior urethra with resulting narrowing which increases force of urinary stream that rubs prostate. (Dotted line represents congested prostate, posterior urethra, and bladder neck.) (C) Urine passing through constricted bladder neck sets up turbulence within posterior urethra which results in sufficient lateral pressure to cause prostatic “milking” (arrows represent urine rubbing inner aspect of prostate).
the anal canal. Since the anorectal junction represents a kink and the site of change offecal direction, it and the related posterior prostatic surface sustain the maximal force of fecal descent. This would result in repeated “milking” down of the prostate and perhaps the seminal vesicles and vasal ampullae, especially if (1) these structures are congested to encroach on the anorectal junction (Fig. Z), (2) th e urinary bladder is full as to push these structures backward toward the lower rectum and anorectal junction (Fig. 3), and (3) the fecal column is hard (constipated). Moreover, lower rectum straightening at defecation1’*12 would bring the fecal column closer to the prostate, seminal vesicles, and vasal ampullae thus augmenting fecal “milking” of these congested structures (Fig. 4).
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Urinary
“milking”
of prostate
It seems that during voiding at defecation, the current of urine passing through the posterior urethra effects prostatic “milking,” especially when a resulting narrowing of the bladder neck and the posterior urethral lumen from the encroachment of the congested prostate would increase the urinary stream mechanical force that rubs the inner aspect of the congested prostate (Fig. 5). In addition, the urine passing through the narrowed bladder neck would set up turbulence within the posterior urethra which results in sufficient lateral pressure to cause prostatic “milking” (Fig. 5C), a condition similar to the poststenotic turbulence occurring in arteries and leading to aneurysmal dilatation.
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Meanwhile, straining at urination, the result of the congested narrowed bladder neck and posterior urethra, would augment not only the pelvic and in turn the prostatic congestion but also the urinary stream force that massages the prostate. The congested prostate is thus “milked” down both externally by the hard fecal column and on its inner aspect by the constricted forcible turbulent urinary stream. Sandwiched between the fecal and urinary currents, it would express its secretions into the urethral lumen to appear as urethral discharge (Fig. 1). infertility
and congested
prostate
The disordered semen quality and infertility encountered in 3 patients require special mention. The characteristic high semen volume could be the sequel of the congestion of prostate, seminal vesicles, and vasal ampullae, especially since these patients had no endocrinal or clinical defects, notably varicocele, to explain the high semen volume. The varying degrees of oligospermia as well as the diminished sperm motility could be the result of the toxic effect of metabolic accumulation in the secretions of the congested prostate. It seems likely that the congested prostate, seminal vesicles, and vasal ampullae act on the spermatogenic process in a way similar to that of the congested testicle in varicocele. The only difference probably lies in the sites and times of action of these metabolites. In varicocele, they act in the testicle at the time of spermatogenesis with a resulting sperm maturation arrest, l3 whereas in the congested prostate, the metabolites seem to act on the mature sperms. Both varicocele and the prostatic congestion syndrome are identical as to high semen voland diminished sperm ume, oligospermia, motility. They differ in the abnormal sperm forms which are increased in varicocele and are within normal in prostatic congestion. Presumably this is because the sperm maturation is arrested early in the former and completed in the latter. Improvement of semen quality after prostatic decongestion could be due to the same factors leading to improved semen quality after testicular decongestion by a varicocele operation. Pelvic decongestion Permanent disappearance of the symptoms and the urethral discharge with improvement of semen quality in infertile patients was achieved
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in all cases after pelvic decongestion by medical treatment, hemorrhoid injection, or hemorrhoidectomy. This could be further evidence of a relationship between the urogenital manifestations and hemorrhoids. The temporary increase in urethral discharge following hemorrhoid injection in Cases 3 and 6 is probably the result of the temporarily increased anoprostatic congestion induced by the irritant sclerosant. This also indicates a relationship between anoprostatic congestion and urethral discharge. In Case 3, the fact that the patient was free of urethral discharge after hemorrhoid injection despite the remaining constipation points to prostatic congestion as a prerequisite for the urethral discharge to be expressed by the hard stools. On the other hand, the absence of the urethral discharge in the constipation-free periods, despite prostatic congestion, indicates the necessity of hard stools to effect prostatic “milking” and discharge expression. To conclude, urethral discharge at defecation, constipation, and hemorrhoids constitute a syndrome that should be considered in patients with idiopathic urethral discharge as well as infertile patients. 2, Talaat Harb Street Cairo, Egypt References 1. Meares EM: Bacterial prostatitis vs “prostatosis,” a clinical and bacteriological study, JAMA 224: 1372 (1973). 2. Holmes KK, and Kiviat MD: Urethritis, in Harrison JH, et al. (Eds): Campbell’s Urology, -. ed. 4, Philadelphia, W. B. Saunders Co., 1978, vol. 1, pp. 538-556. 3. Dubin L, and Amelar RD: Etioloeic factors in 1.294 consecutive cases of male infertility, Fertil. Sreril. 22: 469 (I971). 4. Shafik A: Absent dartos, Br. J. Urol. 50: 354 (1978). 5. Shafik A, and Olfat S: Aligamentous testicle. New clinicopathological entity in genesis of male infertility and its treatment by orchiopexy, Urology 13: 54 (1979). 6. Shafik A: Constrictive albuginitis: report of 3 cases, J. Ural. 122: 269 (1979). 7. Shafik A, and Olfat S: Scrotal lipomatosis, a new clinicopathological entity in the genesis of male infertility, Br. J. Ural. 53: 50 (1981). 8. Cunningham D: Cunningham’s Manual of Practical Anatomy, ed. 12, London, Oxford University Press. 1960, vol. 2, p. 429. 9. Last RJ: Anatomy, Regional and Applied, ed. 5, The English Language Book Society, and Churchill-Livingstone, Edinburgh and London, 1973, pp. 512, 524. 10. Farabeuf LH: The Blood Vessels of the Genitourinary Organs of the Perineum and the Pelvis, Paris, Masson, 1995, p. 212. 11. Shafik A: A new concept of the anatomy of the anal sphincter mechanism and the physiology of defaecation. II. Anatomy of the levator ani muscle with special reference to puborectalis, Invest. Urol. 13: 175 (1975). 12. IDEM: A new concept of the anatomy of the anal sphincter mechanism and the physiology of defaecation. VIII. Levator hiatus and tunnel. Anatomy and function, Dis. Colon Rectum 22: 539 (1979). 13. IDEM: Venous tension patterns in cord veins. I. In normal and varicocele individuals, J. Urol. 123: 383 (1980).
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