Urology - Oncology, Laparoscopy, General Urology Mischel Neill - BHB MBCHB FRACS - Urology - Oncology, Laparoscopy, General Urology Urology - Oncology, Laparoscopy, General Urology
 
 
Patient Info

Women's Health

Men's health :: Female Urology :: Paediatric Urology

Infections :: Urethral Diverticulum :: Pelvic Prolapse :: Urinary Tract Injuries
Pregnancy & Urinary Tract :: Urinary Incontinence :: Haematuria :: Cancer

Haematuria

Haematuria (blood in urine) is a common condition and one which must be taken seriously. Although in the majority of cases no sinister cause is found it must be investigated to exclude treatable disorders.

Haematuria is usually divided into macroscopic (visible) and microscopic (where the blood is found only on dipstick or microscopic examination). Further clinically relevant distinctions can be made between painful and painless haematuria, and haematuria of renal (medical) and post-renal (urological) origin.

Routine haematuria investigation usually involves flexible cystoscopy, to look at the bladder and a scan to look at the kidneys and ureters.

Investigations for Haematuria

General Physical Examination which includes blood pressure, pulse and an internal pelvic examination.

Urinanalysis A mid stream specimen of urine for microscopy of red, white blood cells and bacteria. The presence of any crystals and the level of protein in the urine will be assessed. Urine may sometimes be inspected for the presence of cancerous cells as well.

Blood tests Routine blood tests may be required to assess kidney function, bleeding problems, anaemia or other related conditions.

Ultrasound Scan This test involved using a probe placed on the body surface to generate sound waves whose reflection off tissues is then converted into an image. It is painless, non-invasive and does not use radiation. As such it is the initial scan of choice for patients under 40 years of age.

CT Scan Computed Tomography scans are highly detailed x-rays that show the internal organs of the body. Dyes may be injected to help see the area more clearly. CT imaging is preferred for patients over 40 years of age and if abnormalities are detected at ultrasound.

Flexible cystoscopy In cystoscopy, a long, thin, flexible optical scope is inserted through the urethra and into the bladder. Visual examination of the urethra, bladder, and kidneys is undertaken to locate the site of bleeding. This is a 5 minute outpatient procedure that is performed under local anaesthetic and does not require an incision.

If either the imaging or flexible cystoscopy suggest a bladder lesion this will lead to examination under anaesthetic and operative removal of the lesion for both treatment and diagnosis. Other conditions may lead to other forms of investigation and treatment.

Points to consider about Haematuria

  • Haematuria may not always be due to a problem that needs treatment
  • Haematuria can be detected in the urine during a menstrual period
  • It can occur due to urine infection
  • Some medicines and foods can colour the urine red. This is not the same as passing blood
  • It can occur following strenuous exercise
  • Patients on anticoagulants whose control is in the normal therapeutic range and who have haematuria must be fully investigated as above, since haematuria is not a normal consequence of anticoagulation

Haematuria can originate from the kidney itself (eg glomerulonephritis) due to inflammation affecting the filtering units (glomeruli). When this is the cause of haematuria there are often other signs of kidney disease such as protein in urine, elevated blood pressure or abnormal renal function tests. This group of conditions is usually managed by a nephrologist (renal physician) and may be referred to as medical renal disease.

There are many conditions that may be associated with haematuria and some of the more notable are detailed below.

Renal Tumours

The commonest tumour arising in the kidney is renal cell carcinoma. It may present with haematuria, abdominal/flank pain or a mass however the majority are now detected coincidentally on scans performed for other reasons. Diagnosis is made by CT scanning and treatment is by surgical excision. Small tumours may now be treated by local excision with preservation of kidney function.

Renal Stones

Stone disease is very common, with concretions forming in the renal collecting system. Renal stones tend to be asymptomatic but may cause haematuria by either infection or direct irritation of the lining. They may also cause renal pain if large enough or obstructing. Diagnosis is by imaging, usually CT scan. A number of treatment options are available for stone disease and the choice is influenced by patient and stone related factors.

Glomerulonephritis

Glomerulonephritis tends to present with microscopic haematuria. While pain may be associated, most cases will have either no symptoms or may show signs of renal failure. Investigation is as outlined above.

Pyelonephritis (kidney infection)

Pyelonephritis results from bacteria infecting the kidney. Painless haematuria may occur but the symptom complex usually includes loin pain, fever and possibly septicaemia (generalized unwellness due to infection). Standard treatment of pyelonephritis is with antibiotics, pain relief and fluids. Surgery is reserved for complications of the infection (e.g. abscess formation, infection stones) or underlying problems that have led to infection.

Ureteric Stones

Stones that form in the kidney may migrate into the ureter (the drainage funnel connecting the kidney to the bladder). They usually present with pain but may have haematuria as the only symptom. The presence or absence of obstruction, kidney function impairment, associated infection and the size of the stone will dictate management. Most ureteric stones will pass on their own but sometimes require one of several interventions.

Cystitis

Cystitis is inflammation of the bladder. It is typically painful and associated with a change in urinary symptoms such as frequency and urgency of urination. It may be related to inadequate bladder emptying due to outflow obstruction. Bacterial infection is the most common cause of cystitis. Diagnosis is by urine microscopy and culture (growing for bugs), other tests of urine flow or cystoscopic examination are occasionally required.

Bladder Tumours

Most of the interest in painless haematuria stems from the desire to diagnose bladder tumours at an early stage.

Most bladder tumours are limited to the inner lining layers of the bladder at presentation and are managed by endoscopic (by scope without the need for an incision) surgery with or without the use of intravesical therapy (chemicals placed in the bladder to reduce the risk of cancer recurrence). For invasive tumours the choice generally lies between radical cystectomy or radiotherapy. Metastatic disease may respond to platinum based chemotherapy.

Rare Causes of Haematuria

Arteriovenous malformations, trauma, tuberculosis and arteritis may all cause haematuria.

Urinary Tract Infection (UTI)

Urinary tract infection (UTI) is a common and usually occurs when bacteria enter the opening of the urethra and multiply in the urinary tract. The urinary tract includes the kidneys, ureters (tubes that carry urine from the kidneys to the bladder), bladder, and urethra (the tube that carries urine from the bladder).

Under normal circumstances, bacteria in the urinary system are rapidly cleared, partly through the flushing and dilutional effects of voiding but also as a result of the antibacterial properties of urine and the bladder mucosa.

Types

Urinary tract infections usually develop first in the lower urinary tract (urethra, bladder) and, if not treated, progress to the upper urinary tract (ureters, kidneys). Bladder infection (cystitis) is by far the most common UTI. Infection of the urethra is called urethritis. Kidney infection (pyelonephritis) may require hospital admission for urgent treatment due to general unwellness.

The causes of urinary tract infection and why some are affected more than others are explained below.

Gender and Sexual activity

The female urethra appears to be particularly prone to colonization with colonic (bowel inhabiting) bugs, gram-negative bacilli, because of its closeness to the anus, its short length (about 4 cm), and it’s opening beneath the labia. Sexual intercourse causes the introduction of bacteria into the bladder and is associated with the onset of cystitis (“honeymoon cystitis”); it appears to be important in the causation of UTIs in younger women. Voiding after intercourse reduces the risk of cystitis, probably because it improves the clearance of bacteria introduced during intercourse.

Pregnancy

UTIs are detected in 2 to 8% of pregnant women. Upper tract infections, in particular, are unusually common during pregnancy. Pyelonephritis may be associated with the onset of premature labour if left untreated.

Obstruction

Any impediment to the free flow of urine (such as stricture, stone, or tumor) can result in an increased frequency of UTI. Infection superimposed on urinary tract obstruction in the kidney may lead to rapid destruction of renal tissue and sepsis. It is therefore important to bypass obstruction and drain infected urine if present.

Neurogenic Bladder Dysfunction

Interference with the nerve supply to the bladder, (as may be seen in spinal cord injury, multiple sclerosis, diabetes, and other diseases) may be associated with UTI. The infection may be initiated by the use of catheters for bladder drainage and is favoured by the prolonged stasis of urine in the bladder. An additional factor that can contribute in this situation is kidney/bladder stone formation which acts as a reservoir for infection because antibiotics penetrate them poorly and therefore fail to clear all the bacteria.

Vesicoureteral Reflux

Defined as reflux of urine from the bladder up into the ureters and sometimes to the kidneys, vesicoureteral reflux occurs during voiding or with elevation of pressure in the bladder.

Vesicoureteral reflux is common among children with anatomic abnormalities of the urinary tract as well as among children with anatomically normal but infected urinary tracts. In the latter group, reflux disappears with advancing age. Vesicoureteral reflux is important in children as it may result in long term loss of functional renal tissue. It does not appear to be significant for adults whose kidneys are mature, with the possible exception of pregnant women in whom pyelonephritis may contribute to premature labour.

Bacterial Virulence Factors

Bacterial virulence factors are like personality traits for a bacterial infection. They have a strong influence on the likelihood that a given strain, once introduced into the bladder, will cause cystitis.

Genetic Factors

Increasing evidence suggests that host genetic factors influence susceptibility to UTI. Other medical problems (e.g. Diabetes) and impaired immunity in hosts may also make infection more likely.

Diagnoses

The first step in diagnosis involves testing a sample of urine for signs of infection then incubation to grow any bacteria. This is collected as a "midstream" sample in a sterile container. (The method of collecting urine helps prevent bacteria around the genital area from getting into the sample and confusing the test results). The bacteria grown are tested against different antibiotics for antibiotic sensitivity, to see which drugs kill them most effectively.

Further investigation is likely to involve physical examination, a urinary flow test and bladder scan for post void residual. If you have frequent infections, cystoscopy (visual inspection of the bladder, prostate and urethra with an optical scope) or imaging of the kidneys (often using ultrasound) may be necessary.

Management

Management of recurrent UTIs for women focuses on prevention. As it is so common (a third of women will have at least 1 UTI in their lifetime) investigations are not initially recommended.

Simple measures to try and prevent UTIs include

  • Drinking plenty of fluids (1.5-2L/day to flush bacteria from the system regularly)

  • Cranberry fruit drink (at least 25% cranberry juice)

  • Don’t let your bladder become overfull, try and empty to completion

  • Drink water and void preferably before but certainly after sex to remove bacteria from the bladder

  • Replace tight clothing and nylon pantyhose with cotton underwear to reduce skin irritation, heat and bacterial growth

  • After urinating, wipe from front to back to reduce spreading bacteria from the back passage

Other strategies to reduce the frequency of UTIs include

  • Intravaginal oestrogen therapy especially in post-menopausal women (increases blood flow and suppleness to vaginal tissues while reducing vaginal bacterial numbers)

  • Intermittent antibiotics at trigger times (e.g. after sex)

  • Short course antibiotic treatment at the onset of UTI symptoms

  • Prophylactic antibiotics (daily low dose antibiotic UTI prevention)

Yeast Infections

The term "yeast" is often used to describe infections caused by fungi which are microorganisms that appear most frequently in nature as moulds, mildews, mushrooms and yeast. As organisms they are more complex than viruses or bacteria. In most healthy individuals, yeast infections are an annoyance rather than a significant health problem although they affect millions of individuals.

Yeast infections feature redness and raised spots, itching, vaginal discharge and inflammation. Luckily, most yeast infections can be eliminated or controlled by good hygiene and over-the-counter topical antifungal medications. Frequent bathing and the routine changing of undergarments especially during hot weather or after intense physical activity are advised.

In most individuals, control of superficial infections can be achieved by the use of topical antifungal creams that are readily available as over-the-counter medications. They can be found under different names such as butoconazole, clotrimazole, miconazole and terconazole. Persistent fungal infections require stronger medication such as nystatin or oral medications such as fluconazole or lamisil.

Most vaginal infections can be treated with vaginal suppositories or creams. In cases of persistent infection, the use of oral medications such as fluconazole or ketoconazole may be helpful. Chronic and recurring vaginal infections may require a change in birth control methods.

Urethral Diverticulum

A urethral diverticulum is an abnormal pouch in the wall of the urethra that may lead to infections, urinary incontinence or discomfort during intercourse. Urethral diverticula are a relatively common finding among women with chronic genitourinary conditions, such as recurrent infections, post void dribbling, and dyspareunia (difficulty or painful intercourse).

About 10% of them may have a small stone in them, and rarely a cancer may develop within the diverticulum. Most cases in women are secondary to urethral infections or obstetric urethral injury.

Treatment Small, asymptomatic diverticula found on routine x-rays may not require surgical removal.

Surgical correction (Urethral Diverticulectomy) involves vaginal surgery to excise the diverticulum. A lightly packed vaginal tampon can be left for 24 hours. The Urinary (Foley) catheter can be left indwelling for 14 days or so prior to considering a voiding trial. Antibiotics and bladder antispasmodics are administered and intercourse discouraged for 6 weeks to allow healing.

Complications of this surgery (urethral diverticulectomy) may include stress urinary incontinence, urethrovaginal fistulae (abnormal connection between the urethra and vagina), recurrent diverticula or urinary tract infections.

Urinary Incontinence

Urinary incontinence is the inability to control the flow of urine.

Normal bladder filling depends on the elasticity of the bladder wall which allows it to increase in volume at a pressure lower than that of the control mechanism – the bladder neck and urethra (otherwise incontinence would occur). Despite provocative manoeuvers such as coughing, bladder contractions and leakage do not occur. Emptying requires a lack of outflow obstruction, adequate bladder power and coordination of the emptying mechanism (relaxation of the control mechanism before bladder muscle contraction). With normal, sustained detrusor (bladder muscle) contraction, the bladder empties completely.

The Types of Urinary Incontinence

  • Stress Leakage of urine during physical movement (coughing, sneezing, exercising) due to increased abdominal pressure being transmitted to the bladder

  • Urge Leakage of urine at unexpected times, including during sleep, due to the bladder contracting despite not being told to do so

  • Functional Untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet

  • Overflow Unexpected leakage of urine because of an abnormally overfull bladder

  • Mixed Usually the occurrence of stress and urge incontinence together

Women experience incontinence twice as often as men. Pregnancy and childbirth, menopause, and the structure of the female urinary tract account for this difference. But both women and men can become incontinent from neurologic injury, birth defects, strokes, multiple sclerosis, and physical problems associated with aging.

The level of incontinence differs for each person and depends upon the treatments that they have had, however for some people the phenomena may be short lived while for a few it may be permanent.

There has however been a lot of progress in dealing with continence issues and there are a wide variety of aids and equipment for collecting urine, preventing infection and protecting the skin and surrounding area. There are also a number of exercises that can be done to strengthen the urinary sphincter muscle that controls the opening and closing of the bladder.

Treatment

Exercising the Pelvic Floor

Pelvic floor exercises are an important and relatively easy way to improve your bladder control. When done correctly they can build up and strengthen the muscles that help you hold urine. The pelvic floor is made up of muscles stretched like a hammock from the pubic bone in the front through to the bottom of the backbone. These firm supportive muscles help to hold the bladder, womb and bowel in place and also function to close the bladder outlet and the back passage. Pelvic floor exercises strengthen the muscles that support the pelvic contents and prevent the escape of wind, faeces or urine.

Bladder Retraining

The aim of bladder retraining is to overcome urgency and stretch out the intervals between trips to the toilet. It is recommended when the underlying cause of urinary urgency and frequency is thought to be bladder sensation of fullness at an abnormally small volume without other abnormalities. The focus is to postpone the initial urge to void so that the bladder becomes used to holding larger volumes.

Medical Treatment

Different treatments will be appropriate depending on the type of incontinence present.

Urodynamic assessment

If the cause of incontinence is not immediately clear or simple treatment options have failed and surgery is being contemplated, urodynamic assessment may be recommended.

Urodynamics involve placement of pressure monitors and filling tubes into the bladder as a catheter, and into the bowel. The bladder is filled and pressure is measured during the process. This confirms the suspected diagnosis (or disproves it) but provides additional information to help tailor the right surgical procedure to the right situation.

Surgical Treatment for Urge Incontinence

Surgical intervention for overactive bladder leading to urge incontinence is not usually required. Occasionally if oral medications fail, cystoscopy with injection of BOTOX into the bladder muscle is used to paralyse some of the fibres. This is performed under anaesthetic as a day case. The effects last on average 6-12 months and therefore may require repeated procedures over time. The main risks of the operation are blood in the urine, infection and the possibility of temporary complete bladder paralysis with urinary retention. If the last of these occurs either placement of an indwelling urinary catheter or regular intermittent self catheterization will be necessary until the drug effect wears off.

More advanced reconstructive bladder operations (such as clam cystoplasty) exist but are rarely required and should be discussed only once less involved treatment options have failed.

Surgical Treatment for Stress Incontinence

Several options exist for the treatment of stress incontinence and each may be more indicated under certain circumstances. These range from simple measures (including catheterisation or use of pads) to more invasive surgical options such as placement of a supportive sling under the urethra or a balloon cuff around the urethra which may be inflated and deflated as required.

Today surgery for stress incontinence has become quite minimally invasive and can often be performed either as a day stay or overnight procedure. The most common procedure involves placement of a nylon mesh tape via a couple of 5mm incisions in the lower abdomen and a 1cm vaginal incision. This tape replaces previously damaged “scaffolding” tissue that holds the urethra in place allowing the muscle mechanism to work more effectively.

Urinary stress incontinence is sometimes associated with pelvic organ prolapse. This means that the uterus and/or the vagina have fallen down from their normal position in the pelvis. This prolapse is probably caused by injuries sustaining during childbirth, aging, a woman's tissue composition or chronic coughing and heavy lifting. More than one procedure may be required to address both these issues at the same time.

Pelvic Floor Exercise (PFEs)

For urine to be stored without leakage, the bladder muscle should be relaxed and the muscles around the urethra (the tube that urine passes through) called the pelvic floor muscles should be tight. Exercises that strengthen the pelvic floor muscles can help hold urine inside the bladder, preventing leakage. These pelvic floor muscle exercises are commonly called "Kegel" named after the doctor who developed them.

There are several ways to find your pelvic floor muscle. Women will feel a slight pulling in the rectum and vagina. When contracting the muscle, men will feel a pulling in of the anus and movement of the penis. Every person is unique, and different techniques work for different people. One of the easiest approaches is to interrupt the flow of urine midstream. The muscle that does this is the one that needs to be exercised.

  • Technique #1 - Everyone, at one time or another has been in a crowded room and felt as if he or she were going to pass gas or "wind." Imagine that this is happening to you. Most of us will try to squeeze the muscles of our anus to prevent the passing of gas. The muscles being squeezed are the pelvic floor muscles. If you feel a "pulling" sensation at the anus, you are using the right muscles. In most of our patients, we have found this to be the most successful technique

  • Technique #2 - For women, lie down and insert a finger into your vagina. Try to squeeze around your finger with your vaginal muscles. You should be able to feel the sensation in your vagina, and you may also be able to feel the pressure on your finger. If you can, you are using the right muscles. If you cannot detect any movement with one finger, try two fingers

  • Technique #3- For men, stand in front of a mirror and watch your penis. Try to make your penis move up and down without moving the rest of your body. If you can, you are using the right muscles

You may not find your pelvic floor muscles immediately. Many people have to take their time with this

Don't Exercise the Wrong Muscles!

One of the most common mistakes made is exercising the wrong muscle(s). When trying to find a new muscle, especially a weak one, most people tighten other muscles too. Some people clench their fists or teeth, hold their breath, or make a face. None of these help. It is very tempting to use other muscles, especially stronger ones, to support smaller, weaker muscles such as the pelvic floor muscles. However, using other muscles interferes with learning how to use the right ones. It is best just to relax your body as much as possible and concentrate on your pelvic floor muscles.

To avoid using your stomach muscles, rest your hand lightly on your belly as you are squeezing your pelvic floor muscles. Do you feel your belly tightening? If you do, relax and try again. Be sure that you do not feel any movement of your stomach.

If you find yourself holding your breath then you are probably using your chest muscles. First, relax completely and notice how you are breathing for a few moments. Then, squeeze your pelvic floor muscles while you continue to breathe normally. This will help to assure that you are not using your chest muscles because chest muscles are usually relaxed when you breathe.

The other set of "wrong muscles" are the muscles of the buttocks (bottom). To test whether you are also tightening your buttock muscles by mistake, squeeze your pelvic floor muscles while sitting in front of a mirror. If you see that your body is moving up and down slightly, you are also using your buttock muscles.

Another set of muscles used are the thigh muscles. If you see your upper legs moving which will cause your entire body to lift, you are contracting the wrong muscles. When done properly, no one should be able to tell that you are squeezing your pelvic floor muscles-except for you.

Strengthening your Pelvic Floor Muscles

Once you have located your pelvic floor muscles and you are able to squeeze them without using your abdominal or buttock muscles, you are ready to begin your daily exercise program.

The reason for daily exercise is two fold. First, exercise increases the strength of your pelvic floor muscles, so that they will be strong enough to prevent urine leakage. Second, through repeated practice you gain control over these muscles. Then you can use them quickly to prevent urine loss or to decrease the urge feeling. These exercises are the mainstay of your program.

Each exercise consists of squeezing and then relaxing your pelvic floor muscles. Squeeze the muscles for three seconds and then relax the muscles for three seconds. It is common for most people not to take the time to relax between squeezes. You must allow the muscles to relax between squeezes so that your muscles can rest before squeezing again.

Doing Your Exercise Program

It is recommended that you complete at least two exercise sessions a day. Generally, do one set in the morning when you get up and one at night. Do sixty pelvic floor muscles every day, divided into two sessions of thirty exercises each. Remember, each squeeze and relaxation counts as one exercise. Do the exercises in each position every day; ten exercises lying, ten sitting, and ten standing. The exact time of day is not crucial. What is crucial is that you develop the habit of doing the exercises every day.

In the beginning, you will need to set aside time to concentrate while you do the exercises. Each time should be associated with a cue that will remind you to practice. For example, you may want to exercise just before you get up in the morning and before you fall asleep at night. Any activity that you perform regularly on a daily basis can be used as a cue.

Here is an exercise schedule to follow:

  • Lying down squeeze for 5 seconds and relax for 5 seconds, fifteen times
  • Sitting down squeeze for 5 seconds and relax for 5 seconds, fifteen times
  • Standing up squeeze for 5 seconds and relax for 5 seconds, fifteen times

You should build to 10 second contractions. Remember to squeeze and count slowly "1-2-3-4-5-6-7-8-9-10" and relax the muscle and count "1-2-3-4-5-6-7-8-9-10." Continue with forty-five exercises twice a day.

Bladder retraining - Using Your Pelvic Muscle to Control the "Urge"

Many people think that the only way to relieve the uncomfortable sudden feeling of urgency is to empty the bladder, but this is not so. Urges can come and go without you emptying the bladder; they are simply messages telling you that eventually you will need to urinate. In someone with overactive bladder, the urges are often false messages that you need to go now. Urges, however, should not be commands. They should function as an early warning system, getting you ready to find a place to urinate-after you have relaxed and suppressed the urge.

To reduce or eliminate the urge to urinate, you will use your pelvic floor muscles. Remember to squeeze your pelvic floor muscles quickly several times when you get the urge feeling. To do this, tighten/squeeze and relax the pelvic muscle as rapidly as possible. Do not relax fully in between squeezes. Try this now. Squeezing your pelvic floor muscles in this way sends a message to your nervous system and back to your bladder to stop contracting. As your bladder stops contracting and starts relaxing, the urge feeling subsides. Then, once the urge to urinate has subsided, you have a safe period when the bladder is calm. This "calm period" is the best time to go the bathroom.

These Exercises Cannot Harm You

These exercises are not harmful. You should find them easy and relaxing. If you get back pain or stomach pain after you exercise, you are probably trying too hard and using your stomach muscles. If you experience headaches, then you are also tensing your chest muscles and probably holding your breath. We do not recommend that you practice these exercises during urination by starting and stopping the flow of urine.

Pelvic floor muscle support usually improves within six weeks after starting the exercises, and three months should bring significant changes. However, symptoms improve slowly, so tracking symptom improvement is essential.

Making These Exercises Part of Your Life

Make the exercises part of your daily lifestyle so that exercising becomes a habit, almost like a reflex action! After six weeks of practice, the exercises will require less effort, and you will no longer need to set aside special times to concentrate on them. Tighten the muscle when you walk, before you cough, as you stand up, and on the way to the bathroom. Try to always tighten your muscle when you get a strong urge that you cannot control. Do your exercises when:

  • Standing at the sink and brushing your teeth
  • You get up in the morning
  • You are washing dishes
  • Putting on your make-up
  • Sitting in the car at a stop light
  • Sitting and having dinner
  • Reading a book in bed
  • Watching TV - during each commercial
  • Going for a walk
  • Talking on the phone
  • Having sex

Do your exercises during your daily activities or routines. You do not have to keep a formal count of the number of times you do each exercise—just do it several times in a row. Do them often enough to make them a habit.

Overactive Bladder

Urgency is a sudden and severe sense of needing to urinate. This is usually associated with daytime and nighttime frequency of urination. Urge incontinence can occur in those instances when there is uncontrollable urgency leading to loss of control and leakage. As an ongoing problem this leads to a significant impact on a person’s quality of life. Treatment options include lifestyle modification, dietary changes, medications as well as various surgical procedures.

OAB occurs when smooth muscle of the detrusor muscle of the bladder squeezes or contracts more often than normal and at inappropriate times. Instead of staying at rest as urine fills the bladder, the detrusor contracts while the bladder is filling. Underlying causes can include: drug side effects, neurological disease (e.g., multiple sclerosis, Parkinson's disease, etc.) or stroke. There are also conditions that are associated with urgency and frequency - including bladder cancer, urinary tract infections and benign prostatic hyperplasia (BPH) - that must be excluded during an examination.

Diagnosis of overactive bladder

OAB is usually diagnosed after a number of tests to exclude alternative problems. Urine testing is performed to look for infection, blood and glucose as a screening tool. Further urine tests (urine cytology) may be sent to look for the presence of cancer cells. Abnormalities on these tests may lead to cystoscopy of the bladder (internal inspection with an optical scope) or imaging with ultrasound or computed tomography of the urinary system. They are otherwise rarely required. Urodynamic assessment of bladder function may be recommended, particularly before consideration of surgical intervention.

Urodynamics involve placement of pressure monitors and filling tubes into the bladder as a catheter, and into the bowel. The bladder is filled and pressure is measured during the process. This confirms the suspected diagnosis (or disproves it) but provides additional information to help tailor the right surgical procedure to the right situation.

Medical treatment

Anticholinergics such as ditropan (oxybutynin), detrusitol (tolterodine) and vesicare (solifenacin) inhibit the smooth muscle of the bladder causing it to become more relaxed. These agents may be useful in reducing the overactivity of the bladder and therefore improve some of the symptoms such as urinary frequency and urgency. Anticholinergics are not always well tolerated and may need to be stopped due to side effects. The most common of these are increasing retention of urine, dry mouth, blurring of the vision and constipation.

Behavioral Therapies

In addition to drug therapies for OAB and urinary incontinence, behavioral regimens have been shown to reduce incontinence and urinary frequency. These regimens range from simple manoeuvers such as timed voiding (by the clock), fluid management and bladder retraining. Pelvic muscle exercises (Kegel exercises) are beneficial in reducing urge incontinence, and can be done alone or in combination with antimuscarinic drugs. Also, patients may want to change certain aspects of their diets (e.g., decreasing caffeine or alcohol intake), lose weight and stop smoking.

Surgical Treatment

Surgical intervention for overactive bladder leading to urge incontinence is not usually required. Occasionally if oral medications fail, cystoscopy with injection of BOTOX into the bladder muscle is used to paralyse some of the fibres. This is performed under anaesthetic as a day case. The effects last on average 6-12 months and therefore may require repeated procedures over time. The main risks of the operation are blood in the urine, infection and the possibility of temporary complete bladder paralysis with urinary retention. If the last of these occurs either placement of an indwelling urinary catheter or regular intermittent self catheterisation will be necessary until the drug effect wears off.

In some women with OAB and urinary incontinence who also exhibit vaginal prolapse (e.g., cystocele, enterocele) and stress urinary incontinence, correction of these conditions can improve the overactive bladder.

More advanced reconstructive bladder operations (such as clam cystoplasty) exist but are rarely required and should be discussed only once less involved treatment options have failed.

Painful bladder syndrome (PBS)

Painful bladder syndrome or bladder pain syndrome was previously known as Interstitial Cystitis (IC) and is a chronic pain syndrome. Its symptoms are pain, pressure, or discomfort that seems to be coming from the bladder and is associated with urinary frequency and/or an urge to urinate. The symptoms range from mild to severe, and intermittent to constant. It can be associated with irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and other pain syndromes. The more severe cases can have a devastating effect on both sufferers and their loved ones however many cases are of mild to moderate severity and can be palliated effectively.

Painful Bladder syndrome is incompletely understood and knowledge of causation as well as effective treatment is therefore incomplete. There are no specific behaviors or exposures (such as smoking) known to increase a person's risk for getting PBS. The tendency to get PBS may be influenced by a person's genes, and so having a blood relative with PBS may increase the risk of getting PBS yourself. About 80 percent of people diagnosed with painful bladder syndrome are women. However, the difference in rates of PBS for men vs. women may not really be as high as we think, because some men diagnosed with "prostatitis" or similar conditions with different labels may really have PBS.

What causes Painful Bladder Syndrome?

The bladder and urethra have a specialized lining called the epithelium. The epithelium forms a barrier between the urine and the bladder muscle. The epithelium also helps to keep bacteria from sticking to the bladder, so it helps to prevent bladder infections.

Many researchers believe that PBS is caused by one or more of the following:

  1. A defect in the bladder epithelium that allows irritating substances in the urine to penetrate into the bladder

  2. A specific type of inflammatory cell (mast cell) releasing histamine and other chemicals that cause inflammation and pain

  3. There is something in the urine that damages the bladder

  4. The nerves that carry bladder sensations are changed, so pain is now caused by events that are not normally painful (such as bladder filling); and/or

  5. The body's immune system attacks the bladder, similar to other autoimmune conditions

It is likely that different processes occur in different groups of patients. It also is likely that these different processes may affect each other (for example, a defect in the bladder epithelium may promote inflammation and stimulate mast cells). Some people may be predisposed to get PBS after an injury to the bladder such as an infection.

What are the symptoms of Painful bladder syndrome?

Symptoms vary for different patients. You may have urinary frequency/urgency or pain, pressure, discomfort perceived to be from the bladder or all of these symptoms.

Frequency is the need to urinate more often than normal. Normally, the average person urinates up to seven times a day, and does not have to get up at night to use the bathroom. A person with painful bladder syndrome often has to urinate frequently both day and night. Urgency to urinate is a common symptom. Some patients feel a constant urge that never goes away, even right after urinating, while others urinate often, but do not feel the urge to go all the time.

PBS patients may have bladder pain that gets worse as the bladder fills. Some feel the pain in other areas in addition to the bladder. A person may also feel pain in the urethra, lower abdomen, lower back, or the pelvic or perineal area. Women may experience pain in the vulva or the vagina and men may feel the pain in the scrotum, testicles, or penis. The pain may be constant or intermittent.

Many people can identify certain things that make their symptoms worse. For example, sometimes symptoms are made worse by certain foods or drinks. Many patients find that symptoms are worse if they have stress (either physical or mental stress). The symptoms may vary with the menstrual cycle. Both men and women with this condition can experience sexual difficulties due to this condition; women may have pain during intercourse because the bladder is right in front of the vagina, and men may have painful orgasm or pain the next day.

How is Painful Bladder Syndrome diagnosed?

There is no specific test that establishes a diagnosis of painful bladder syndrome. Any tests done are usually to rule out other important treatable conditions. These may include urine analysis, cystoscopy and imaging such as ultrasound of internal organs in some circumstances.

Investigation often involves a basic cystoscopic examination followed by a stretching or distention of the bladder by instilling fluid under pressure. Following this some patients will have small areas of bleeding, or actual ulcers, which can be seen through the cystoscope. If a person has symptoms of Painful Bladder Syndrome and the cystoscopy shows bleeding or ulcers, the diagnosis is fairly certain. Most people without PBS symptoms do not have these bleeding areas, It also helps to exclude other conditions and may be therapeutic as well as patients may experience relief of symptoms afterwards.

Urodynamic evaluation is another test that was once considered to be part of the standard Painful Bladder Syndrome evaluation, but is no longer believed to be necessary in all cases. This test involves filling the bladder with water through a small catheter, and measuring bladder pressures as the bladder fills and empties. The usual results with PBS are that the bladder has a small capacity and perhaps pain with filling.

Some doctors use a test called the potassium sensitivity test, in which potassium solution and water are placed into the bladder one at a time, and pain/urgency scores are compared. This test is not diagnostic for painful bladder syndrome, can be painful, and is not a routine part of the evaluation.

How is Painful Bladder Syndrome treated?

There are probably several different causes and as such, no single treatment works for everyone, and no treatment is "the best." Treatment must be chosen individually for each patient, based on his or her symptoms. The usual course is to try different treatments (or combinations of treatments) until good symptom relief occurs.

Non-medical management plays an important part in control of Painful Bladder Syndrome. This focuses on stress management, dietary modification and exercise.

Most (but not all) people with PBS find that certain foods make their symptoms worse. There are four foods that patients most often find irritating to their bladders: citrus fruits, tomatoes, chocolate and coffee. All four of these foods are rich in potassium. Other foods that bother the bladder in many patients are alcoholic beverages, caffeinated beverages, spicy foods and some carbonated beverages. The list of foods that have been reported to affect PBS is quite long, but not all foods affect all patients the same way. For this reason, each patient must find out how foods affect their own bladder.

The simplest way to find out whether any foods bother your bladder is to try an "elimination diet" for one to two weeks. On an elimination diet, you stop eating all of the foods that could irritate your bladder. PBS or IC food lists are available from many sources (www.ichelp.org or www.ic-network.com). If your bladder symptoms improve while you are on the elimination diet, this means that at least one of the foods was irritating your bladder.

The next step is to find out exactly which foods cause bladder problems for you. After one to two weeks on the elimination diet, try eating one food from the food list. If this food does not bother your bladder within 24 hours, this food is probably safe and can be added back into your regular diet. The next day, try eating a second food from the list, and so on. In this way, you will add the foods back into your diet one at a time, and your bladder symptoms will tell you if any food causes problems for you. Be sure to add only one new food to your diet each day. If a person eats a banana, strawberries and tomatoes all in the same day, and the symptoms get bad that evening, he/she will not know which of the three foods caused the symptom to flare up.

A reasonable fluid intake (aim at 1 -1.5L/day) is also important. A natural response to urinary frequency is to drink less water however this may in fact worsen symptoms as the urine becomes more concentrated and therefore potentially more irritative. General measures such as stress management, optimizing treatment of other medical problems and regular exercise may help both to moderate symptoms but also make them easier to deal with from a generally healthier disposition.

Oral medications include anticholinergics (Oxybutynin, Tolterodine, Solifenacin), H2 antagonists and antihistamines (Cimetidine), antidepressants with other effects (Amitryptilline), anti-inflammatories and tramadol. Intravesical (instilled into the bladder through a catheter) treatments with heparin, local anaesthetics, steroids and dimethyl sulfoxide (DMSO) follow inadequate control with oral medications.

Many other treatments are also used, but less frequently than the ones described. Some patients do not respond to any therapy but can still have significant improvement in their quality of life with adequate pain management. Pain management can include non-steroidal anti-inflammatory drugs, moderate strength opiates and stronger long-acting opiates in addition to nerve blocks, acupuncture and other non-drug therapies. Professional pain management may often be helpful in more severe cases.

What can be expected after Painful Bladder Syndrome treatment?

The most important thing to remember is that none of the PBS treatments works immediately. It usually takes weeks to months before symptoms improve. Even with successful treatment, the condition may not be "cured;" it is simply "in remission."

Most patients need to continue treatment indefinitely, or else the symptoms return. Some patients have flare-ups of symptoms even on treatment. In some patients the symptoms gradually improve and even disappear.

Although most patients will find that their symptoms improve as they are treated for PBS, not all patients will become completely symptom-free. Many patients still have to urinate more frequently than normal, or have some degree of persistent discomfort and/or have to avoid certain foods or activities that make symptoms worse.

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© Mr Mischel Neill BHB MBCHB FRACS Urology Oncology, Laparoscopy, General Urology Auckland New Zealand Your Practice Online
Urology - Oncology, Laparoscopy, General Urology Mischel Neill - BHB MBCHB FRACS Royal Australasian College of Surgeons Urological Society of Australia and New Zealand