‘Prostatorrhea’ is a term used to describe a unique complaint of urethral discharge that is frequently seen by sexual health professionals practicing in conservative societies. Interestingly, a literature search on this topic does not yield any publications explaining the etiology and characteristics of this complaint. A small amount of clear or mucoid urethral discharge before sexual intercourse is probably the result of sexual stimulation and is referred to as prosemen. In the absence of sexual arousal, the discharge may be because of prostatorrhea (spermatorrhea), both of which may be noticed at urination or defecation 1. It was generally assumed that young men who abstain from sex and masturbation for cultural or religious reasons may accumulate secretions in their accessory sex glands that spontaneously pass out during increased pelvic pressure. However, this assumption has not been confirmed through scientific studies.
Prosemen is a clear or mucoid fluid produced by accessory sex glands and expressed on sexual stimulation into the urethra. The organs that produce this fluid are Cowper’s glands, the glands of Littre, and possibly the glands of Morgagni. Prosemen volume may range in normal men from a few drops to more than 5 ml. Pre-ejaculate functions as a chemical neutralizer to the urine residual acidity in the urethra and thus provides the basic pH of the semen, allowing for safe passage of sperm 2.
A urethral discharge is the most common presenting symptom of a sexually transmitted disease in men. A few discharges may be physiological but most of those seen by the general practitioners and specialists are pathological 1.
Sexually transmitted urethritis is classified as either gonococcal urethritis following infection with Neisseria gonorrhoeae or nongonococcal urethritis from organisms such as Chlamydia trachomatis, Ureaplasma parvum, Ureaplasma urealyticum, Mycoplasma hominis, Mycoplasma genitalium, Trichomonas vaginalis, and Gardnerella vaginalis3–5.
However, idiopathic urethritis is defined as urethritis in the absence of nucleic acid amplification testing evidence for the most common infectious causes (N. gonorrhoeae, C. trachomatis, M. genitalium, and T. vaginalis), and may be considered by some authors as the most frequently encountered 6.
Less commonly, infectious causes of urethritis may include herpes genitalis, syphilis, mycobacterium, adenovirus, cytomegalovirus as well as typical bacteria (usually gram-negative rods) associated with cystitis in the presence of urethral stricture or following anal sex.
This study aimed to assess the assumption that the complaint of prostatorrhea is characteristically associated with sexual abstinence, and is thus composed of accumulated seminal vesicular and prostatic secretions.
Materials and methods
Patients were recruited after obtaining approval from the ethical committee of the Department of Andrology, Faculty of Medicine, Cairo University. Fifty male patients ranging in age from 18 to 30 years who attended the Andrology outpatient clinic in Kasr El Aini Hospital with complaints of urethral discharge were included in the study. The discharge was observed only after straining upon urination or defecation. Patients with a history of chronic urinary tract infection or chronic prostatitis were excluded. Another 50 patients of the same age group attending the same clinic for any complaint other than urethral discharge were included as a control group.
Both married and single patients were included and patients of both groups were subjected to a detailed assessment of history including personal history such as age, work, marital status, and habits of medical importance, sexual history [morning erection, visual sexual response, manual sexual response, frequency of intercourse (if any), libido, and erection], and a questionnaire was used to aid assessment of sexual history (Appendix 1).
All participants underwent a general examination for secondary sexual characteristics and a local examination for the pubic area for hair distribution, scars of operations, penile examination, and testicular examination.
Also, laboratory investigations were performed including urine analysis on two glasses, expressed prostatic secretions analysis, and serum total testosterone (morning sample).
Data were described in terms of range, mean±SD, frequencies (number of cases), and percentages when appropriate. The t-test was used to analyze parametric data and compare means. For comparison of categorical data, the χ2-test was used. P values less than 0.05 were considered statistically significant. All statistical calculations were carried out using computer programs Microsoft Excel 2007 (Microsoft Corporation, New York, New York, USA) and the statistical package for the social science (SPSS Inc., Chicago, Illinois, USA) version 12 for Microsoft Windows.
Fifty men (18–30 years old), mean age 26.19±3.2 years, with complaints of urethral discharge were matched with another 50 patients, mean age 28.17±4.3 years, who were attending the clinic for any other complaint as an age-matched control group.
The percentage of men with a complaint of prostatorrhea who were sexually abstinent (neither masturbation nor sexual intercourse) was 80% (n=40), whereas among those who had no complaint of any physiological discharge, 2% (n=1) were sexually abstinent; therefore, there was a significant difference between the sexual activity of both groups (Table 1).
Also, there was a significant difference in the frequency of sexual activity between men with a complaint of prostatorrhea and those without discharge, as 50% men with a complaint of prostatorrhea, who were sexually active, had infrequent sexual activity (<1/week), whereas 93.9% (n=46) of men with no complaint of prostatorrhea had frequent sexual activity (≥2/week) (Table 2).
However, there was nonsignificant difference between men complaining of prostatorrhea and those without physiological discharge in terms of the frequency of sexual exposure and urinary tract infection, which means that they have a minimal effect on this complaint (Tables 3 and 4).
Serum total testosterone level did not seem to be statistically significant in patients complaining of prostatorrhea as all patients (100%) had a normal total testosterone level compared with 96% of the men in the control group (Table 5).
It is surprising that prostatorrhea, a very common complaint in our conservative religious societies, is almost unheard of in the international medical literature. A literature search for ‘spermatorrhea or prostatorrhea’ yielded only one 30-year-old reference. The so-called ‘Dhat syndrome’ assumes that these patients have a psychological disorder and that there is no real discharge. It was described in India by Behere et al.7 as ‘a symptom complex most commonly seen in younger group of patients in between 16 and 25 years of age. These patients present with whitish discharge with urine (patients believe it to be semen). This is associated most commonly with impotency, marked anxiety, general weakness, premature ejaculations, and hypochondriasis’.
However, there is no proof that Dhat syndrome is psychological and that the patients are delusional; in particular, there might be some other complaints sharing the same etiology (unrelieved sexual tension) with prostatorrhea, for example, testicular pain, leading to the impression that the patient may have ‘Dhat syndrome’. In fact, this complaint is common in the Middle East and has been assumed to be related to male accessory gland secretions in young men with no sexual activity (masturbation or intercourse) because of religious or social factors. In this study, we aimed to assess this assumption.
Our study investigated patients who sought medical advice because of a complaint of urethral discharge with no frank history of urethritis (dysuria, frequency, or pathological discharge). We conclude that young men with regular sexual activity either in the form of sexual intercourse or masturbation rarely complain of prostatorrhea, whereas others who are sexually abstinent have a higher frequency of presentation with this complaint and seek medical help.
We also found that prostatorrhea in young men is neither associated with nor related to urinary tract infection or prostatitis.
The frequency of exposure to sexual stimulation either in daily life (e.g. during work) or by pornography does not affect the frequency of presentation with physiological urethral discharge in the form of prostatorrhea.
Also, we found that patients complaining of prostatorrhea as well the control group did not have any abnormal serum total testosterone level.
Finally, for prostatorrhea, we can assume that the only variable that was statistically significantly different between men with a complaint of prostatorrhea and others who did not have urethral discharge was sexual activity and its frequency, that is, absence of any sexual activity (sexual intercourse or masturbation).
Anxiety associated with prostatorrhea might explain some cases of Dhat syndrome, a condition found in the cultures of the Indian subcontinent in which male patients report that they suffer from premature ejaculation or impotence, and believe that they are passing semen in their urine 8.
Our findings are in line with the assumption that men complaining of prostatorrhea rarely ejaculate through coitus or masturbation and that an overflow of seminal vesicular and prostatic secretions that is rarely ejaculated normally explains the condition. Healthcare providers attending to patients from conservative societies presenting with a complaint of urethral discharge need to be aware of the possibility of prostatorrhea. Assessment of sexual history focusing on the frequency of masturbation and intercourse should be performed in men with this complaint and patients presenting with prostatorrhea need to be reassured and educated about the nature of their complaints. Further studies in this area are required to establish a clear distinction between prostatorrhea and Dhat syndrome and whether they are actually identical.
Conflicts of interest
There are no conflicts of interest.
Questionnaire used in the study
- What is your social status?
- In a relationship
- What is the frequency of your sexual intercourse, if so?
- No intercourse
- Do you masturbate?
- If yes, what is the frequency?
- More than one time/day
- Do you watch porn movies or photos?
- Do you get sexually excited at the place of your work/study?
- If yes, how often?
- Very rare
- Is the discharge related to sexual excitation?
- Yes, all the time
- No, not related
- Is the discharge related to straining (defecation or micturition)?
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prostatorrhea; sexual activity; urethral discharge; young aged males