Q 29. 1 How is urine produced?

There are normally a pair of kidneys at the back of the abdomen in the area of the loins. Within the kidneys part of the blood plasma is filtered from the capillaries into fine tubules. Much of the fluid is selectively reabsorbed as it passes through these tubules.

When the body is short of fluid almost all the fluid is reabsorbed and when there is an excess of fluid the urine volume is increased. The tubules connect to the ureters – there is one from each kidney which pass the urine down to be collected in the bladder.

The bladder is a bag of muscle (detrusor muscle) that can stretch without contracting as urine is collected. There are sensors in the bladder wall that tell the nervous system how far the bladder is being stretched as it fills.

A normal bladder can hold about half a litre (1 pint). The bladder can empty the urine through the outlet tube called the urethra (Figure 2.2). The urethra is surrounded by muscle which contracts to keep the bladder exit closed but can relax at the appropriate times.

The pelvic floor is composed of muscle and ligaments strung across the pelvis a little like a hammock. The urethra, vagina and rectum pass through the pelvic floor. Muscles are considered to be involuntary (smooth) or voluntary (striped)). Smooth muscle contracts slowly and we cannot influence when it works.

The muscle of the bowel is smooth – you cannot stop it rumbling. Striped muscles can usually be controlled voluntarily and they contract quickly – muscles in the limbs are examples. Both smooth and striped muscle play a part in bladder function. Most of the time, the smooth muscle of the bladder remains relaxed whilst the muscles around the urethra keep it closed.

These muscles have a voluntary element so that it is possible to stop the flow in mid-stream. Additional closure pressure can be exerted by the pelvic floor muscle. Most of the time, you will not be aware of the bladder and its control, which is largely achieved by reflex action.

When the bladder becomes distended, the messages from the bladder sensors reach the higher centres of the brain. During micturition (voiding of urine), the reverse occurs. The abdominal wall muscles can be used to speed voiding or initiate the flow.

During a cough or sneeze there is an automatic reflex which results in the pelvic floor muscles contracting. As the muscles contract the pelvic floor rises and this helps to squeeze the urethra keeping it closed.

Q 29. 1 How is urine produced?
Q 29. 2 What is cystitis?

Q 29. 3 How common is cystitis?

Q 29. 4 What is honeymoon cystitis?

Q 29. 5 What are frequency and nocturia?

Q 29. 6 How common are frequency and nocturia?

Q 29. 7 What is urinary incontinence?

Q 29. 8 What is stress incontinence of urine?

Q 29. 9 What is urgency, urge incontinence and the urge syndrome?

Q 29. 10 What causes stress and urge incontinence?

Q 29. 11 What is dribbling incontinence?

Q 29. 12 How common is urinary incontinence?

Q 29. 13 What is the urethral syndrome?

Q 29. 14 How can I record my bladder problems and monitor the effects of treatment?

Q 29. 15 What simple measures are available to

Q 29. 2 What is cystitis?

Cystitis means inflammation of the bladder. It is usually caused by bacteria. Cystitis is more common in women than men probably because the tube leading out of the bladder, the urethra, is relatively short in women. The inflammation causes dysuria, pain during micturition (emptying of the bladder) and frequency or shortened intervals between micturition. Haematuria, blood in the urine, may occur with severe cystitis but there are other causes and early, careful medical assessment is always essential.

At one time we thought that infection was confined to a single organ but we now believe that it usually involves other parts of the system. Thus infection is unlikely to be confined to the bladder but may involve the urethra and kidneys: we therefore now call these episodes ‘urinary tract infections’. On occasion the infection may reach the kidneys (pyelonephritis) resulting in severe loin pain and fever. Recurrent episodes of pyelonephritis can lead to renal (kidney) damage.

When urinary tract infection is suspected, a mid-stream sample of urine is usually sent to the laboratory to confirm the diagnosis, determine the type of bacteria and check the sensitivity of the organism to the more common antibiotics. Cystitis usually responds quickly to an appropriate antibiotic.

Q 29. 3 How common is cystitis?

Cystitis is a common problem in women. A study in Sweden found that 40% of women aged between 21 and 70 years had received treatment within the previous two years. More than one half the women treated for urinary tract infection have a further attack within the next two years.

Q 29. 4 What is honeymoon cystitis?

This is usually the result of frequent intercourse. There may not be true infection but just inflammation at the base of the bladder, which is situated close to the front wall of the vagina. Antibiotics may help if there is infection but a few days abstention may be required.

Q 29. 5 What are urinary frequency and nocturia?

It is normal for you to empty your bladder between four and six times during waking hours representing three to four hour intervals. Frequency means that there is a need to empty your bladder seven or more times each day.

Nocturia means a requirement to empty the bladder during the night. We generally accept one episode during the night to be reasonable but two or more episodes during the night will severely disrupt sleep and medical assessment and treatment are required. A distinction needs to be made between a bladder problem disturbing sleep and a primary sleep problem when the opportunity is taken to empty the bladder.

Frequency of micturition can be due to pressure on the bladder. The commonest cause is pregnancy but fibroids (Q23.14) or an ovarian cyst can be responsible.

Q 29. 6 How common are frequency and nocturia?

One study found that more than 50% of women emptied their bladders more frequently than three hourly and 11% more frequently than every two hours. Fourteen percent of women emptied their bladders more than once during the night.

Q 29. 7 What is urinary incontinence?

Urinary incontinence (involuntary leaking), unlike premenstrual syndrome or the menopause and HRT, is not a subject that is readily discussed socially. A young woman with this problem runs the risk of shocking her friends or family at the least mention of the subject. Many women with incontinence shy away from discussing it even with their doctor, often for many years, hoping that it will disappear.

This is particularly sad, not only because there may be loss of self-esteem and avoidance of socialising, but also because there are invariably treatments that may provide either a complete cure or, at the very least, significant improvement. Often the family doctor may be able to provide initial advice although referral to a specialist physiotherapist may be the best approach.

When specialist advice is required either a urologist, a specialist in urinary problems, or a gynaecologist should be consulted; the two specialities overlap in this area.

Q 29. 8 What is stress incontinence of urine?

The incontinence occurs in association with physical exertion. This may happen when the pressure within the abdomen is increased during coughing, sneezing or laughing. The “stress” is physical and not emotional. Jolting movements such as jumping or running may similarly result in embarrassing leaks.

In the worst situations, less strenuous movement including walking or moving in bed may be enough. Typically, there is no warning or feeling of need to empty the bladder. Sphincter incompetence means that the muscle that squeezes around the outlet from the bladder is too weak to prevent leakage in “stress” situations.

Q 29. 9 What are urgency, urge incontinence and the urge syndrome?

Urgency means that you have a sudden and urgent need to empty your bladder. With urge incontinence there is a knowledge that if a toilet is not readily available, there will be an inevitable leakage. Women with urgency incontinence of urine typically know the location of every public convenience in the localities where they shop.

The urge syndrome is a combination of frequency, nocturia, urgency and urge incontinence.

Q 29. 10 What causes stress and urge incontinence?

An anatomical (structural) cause is the most common reason for stress incontinence whereas urge incontinence suggests that the bladder muscle is contracting excessively (detrusor instability) at an inappropriate time .

This is also called an unstable bladder. These causes and effects are by no means mutually exclusive: A woman presenting with symptoms of stress incontinence may prove to have detrusor instability and urge incontinence could be related to inadequate support to the bladder outlet.

References:

The effect of oestrogen supplementation on post-menopausal urinary stress incontinence: A double-blind placebo-controlled trial. (1999 – 2714)

Q 29. 11 What is dribbling incontinence of urine?

A steady uncontrollable loss of urine always requires medical assessment. Sometimes it may be a sign that the bladder is overfull and the leak occurs as the bladder can hold no more. The other cause of dribbling incontinence is that there is a fistula (hole) in the system; this may be termed “true incontinence”.

Q 29. 12 How common is urinary incontinence?

Several studies have looked at the incidence of this distressing and common problem. The results show a surprisingly high incidence with at least one woman in twenty aged 15 to 34 years leaking urine at least twice each month and a further 16% having an accident of some degree once a month. For women aged 35 to 64 years, 10% will have two or more accidents monthly and a further 14% will have one accidental loss.

In a study in Leicestershire, 41% had some degree of incontinence, 6% reported the problem occurred regularly and 15% required protection during exercise. Studies also show the reluctance of patients to seek medical advice. At least 50% of women with incontinence restricting their lives have not been to their doctor and half the patients seeking medical advice for the first time have had problems for more than four years. Stress incontinence occurs two or three times more often than urge incontinence.

Q 29. 13 What is the urethral syndrome?

The urethra is the tube leading out from the bladder. Urethral syndrome is an ill defined condition with a variety of symptoms including pain during micturition, urinary frequency, feeling of pressure behind the pubic bone, and pain during intercourse. The latest suggested cause for this syndrome is infection in the tiny glands that secrete into the urethra.

These glands may become infected without there being evidence of infection in the urine when tested. Antibiotics may work particularly when taken for prolonged courses – usually small doses over several months. When the problem keeps recurring many urologists will dilate (stretch) the urethra.

Q 29. 14 How can I record my bladder problems and monitor the effects of treatment?

If you have a urinary incontinence problem, it is essential that you seek medical advice early to rule out infection or some other medical reason for your symptom. Bladder–training and pelvic floor exercises can provide a cure or valuable improvement for many women. To begin with it is helpful if you can keep a record of how your bladder is functioning before treatment commences. Make a note of the times that you are emptying your bladder and whether the volume is small, average or large.

Your particular problem(s) will indicate to you what else needs to be recorded. If, for example, it is incontinence, you need to note every time there is an accident and how much is lost. A daily summary for a week or two on a chart will provide a basis for comparison once treatment begins. Choose a day when you will be at home and measure the volume you void each time you empty your bladder. You will need an ordinary kitchen measuring jug.

Q 29. 15 What simple measures are available to reduce urinary incontinence?

The average fluid intake in a day is four pints; this is equivalent to about 10 cups. Drinking less puts a strain on the kidneys and drinking more may unnecessarily increase the risks of incontinence. In warmer or hotter climates than the United Kingdom, your fluid intake should be increased.

Excess weight with a large abdominal girth will stretch and damage the pelvic floor. Calorie control and increasing exercise should help. Lifting heavy objects should be avoided. Tight clothes and support girdles should be discarded.

Straining associated with increasing the abdominal muscle activity pushes the abdominal contents firmly down against the pelvic floor muscles. Stretching these muscles decreases their function and the nerve supply to them may also be damaged.

A chronic cough is to be avoided. For smokers, the advice is obvious – stop. Similarly, constipation requiring straining to empty the bowel should be avoided. Increasing the fibre content of your diet may be all that is necessary. Vegetables, fruit and wholemeal bread may be enough, but cereals particularly with bran in the morning may also be considered.

For postmenopausal women, hormone replacement therapy HRT (Q28.3) may provide benefit. Some women already taking HRT find that when they also introduce oestrogen locally into the vagina, there is further improvement in bladder symptoms.

Q 29. 16 What are pelvic floor exercises?

Pelvic floor exercises were first developed in the late 1940s. They are designed to strengthen the pelvic floor muscles and reduce stress incontinence. Stronger pelvic floor muscles will help the urethra to stay closed and prevent leakage.

On the next occasion that you go to empty your bladder, prevent the flow starting for a minute or so: you will become aware that you are lifting the pelvic floor.

Next, allow the bladder to become really full and practise tensing the pelvic floor muscles to prevent leaks. When you do empty your bladder, ensure that it really is empty: otherwise there is a risk of infection.

Try stopping your urine flow in mid-stream and you will be aware of that lifting sensation within the lower pelvis caused by the pelvic floor muscles. If the muscles are weak, you may have difficulty initially stopping the flow.

It is probably easier to stop the stream at the beginning or end of the flow. As the muscles become stronger it should become possible to stop the flow at any stage. To begin, you will have to learn to become conscious of your ability to contract the pelvic floor muscles. You may find that if you place a finger in the vagina, you will be able to feel the muscles contracting.

Once you have learned to contract the pelvic floor muscles, keep them contracting for five seconds squeezing them as much as possible. Relax the muscles for five seconds and repeat this cycle six times in a minute. You may find the exercises easier whilst sitting or lying down at least to begin with. Keep a record of how many minutes you do the exercises each day.

Gradually build up until you can do them for three to five minutes three times daily. The exercises can be undertaken at any time. The important thing is to keep doing these exercises. The daily record should help you to keep going. Some physiotherapists use a ‘perineometer’ which measures the pressure that you are able to exert. This ‘biofeedback’ can provide encouragement, as you are able to measure progress.

Electrotherapy is conducted by physiotherapists using electrical stimulation to make the pelvic floor muscles contract. This may be particularly beneficial if you are having difficulty starting the exercises.

As with any exercise, muscles take a while to become stronger so perseverance and patience are essential. If you were planning to swim the channel you would not prepare by trying to swim across from Dover on the first day. You would start with just a few hundred yards and gradually build up over months rather than days.

The same is true for pelvic floor exercises. You have to be patient, gradually building up the muscle strength over a few months and then keeping the muscles strong. The aim is to build up gradually to five minutes three times each day. Hopefully you will begin to see progress after a couple of weeks and this should provide any encouragement you may need.

It may, however, take two or three months so do not give up too quickly. Once improvement has been achieved, it is important to keep the exercises going although the amount of time spent may be reduced to perhaps two minutes daily.

Q 29. 17 How successful are pelvic floor exercises?

The originator of pelvic floor exercises, Kegel, found that patients with pure stress incontinence were often much improved within eight weeks. If you have severe problems it could take longer so patience and perseverance may be worthwhile. More recent studies suggest success in about 70% of patients with 40% being cured. Failures occur mostly with those patients who do not comply with the treatment regimen.

Almost everything we undertake in life involves risks as well as benefits. There is an element of risk even when going on holiday. There is no medicine or surgical procedure that is without an element of risk. Pelvic floor exercises are absolutely safe. With perseverance, there is likely to be benefit. Pelvic floor excercises commenced after childbirth may reduce problems in later life and there is advantage in seeking advice from a physiotherapist specialising in women’s health around this time.

The physiotherapist can ensure that you are contracting your pelvic floor correctly by checking with an internal examination. If your are a new mother, pelvic floor excercises can be recommended every time you are feeding or changing your baby. Others may find it useful to have a prompt such as every time they speak on the telephone.

Q 29. 18 How effective is bladder training?

Q 29. 19 How effective is bladder training?

A number of studies show success rates in the order of 80% by three months. Usually, within two to three weeks you are likely to have some encouraging benefit. It is important to keep practising bladder training over the years, otherwise your bladder will go back to its old bad habits: it is a matter of mind over bladder.

Q 29. 20 Are there any alternatives to bladder training for urgency symptoms?

Sometimes bladder symptoms occurring around the time of the menopause or beyond will respond to hormone replacement therapy or local (vaginal) oestrogen pessaries or cream even if there is no obvious sign of vaginal oestrogen deficiency (Q26.11). Oestrogen introduced directly into the vagina may be particularly effective. It is an empirical observation that some women who are taking HRT may still present with bladder symptoms that will improve when local oestrogen is added.

A thirty-six year old lady came to hysterectomy for very heavy periods that had not responded to medical treatment. She elected to have both ovaries removed and subsequently had regular oestradiol hormone implants. She was extremely happy with the outcome as she was free to enjoy life without the worry of her heavy periods.

Four years later she was referred to me again as she had developed urge and stress incontinence. There was excellent vaginal support under the bladder and certainly no suggestion of prolapse. Although the vaginal epithelium (lining) appeared healthy, oestradiol vaginal 25 microgram tablets, once each night for ten nights and then weekly were prescribed. At review three months later she was delighted with the result as her bladder was no longer causing any problem. She was advised to reduce the vaginal tablets to every two weeks and adjust the frequency so that she introduced them according to the response.

There are medications, which may reduce the detrusor (bladder) muscle activity e.g. oxybutinin (Cystrin – Pharmacia & Upjohn; Ditropan – Lorex).

Q 29. 21 What else is available for the treatment of urinary stress incontinence, if simple measures do not suffice?

If the incontinence is thought to be related to prolapse, vaginal repair surgery (Q30.6) will improve the problem in about 80% of patients. Some surgeons, particularly bladder specialists, may operate through the abdomen rather than the vagina. Stitches are introduced to either side of the urethra and attached to the ligaments or bone at the front of the pelvis (colposuspension).

Injections of inert substances can be introduced under the bladder neck. Although with training they are said to be simple to introduce, they are not quite so simple to remove should there be problems. If there is true incontinence associated with a hole in the system (fistula) a urologist (bladder specialist) is likely to be able to close this defect.

There are a variety of mechanical aids that put additional pressure on the bladder neck. They are designed to be easy to introduce and remove.

References:

The effect of oestrogen supplementation on post-menopausal urinary stress incontinence: A double-blind placebo-controlled trial. (1999 – 2714)

Comparison of treatment outcomes of imipramine for female genuine stress incontinence. (1999 – 2853)

Q 29. 1 How is urine produced?

Q 29. 2 What is cystitis?

Q 29. 3 How common is cystitis?

Q 29. 4 What is honeymoon cystitis?

Q 29. 5 What are frequency and nocturia?

Q 29. 6 How common are frequency and nocturia?

Q 29. 7 What is urinary incontinence?

Q 29. 8 What is stress incontinence of urine?

Q 29. 9 What is urgency, urge incontinence and the urge syndrome?

Q 29. 10 What causes stress and urge incontinence?

Q 29. 11 What is dribbling incontinence?

Q 29. 12 How common is urinary incontinence?

Q 29. 13 What is the urethral syndrome?

Q 29. 14 How can I record my bladder problems and monitor the effects of treatment?

Q 29. 15 What simple measures are available to reduce urinary incontinence?

Q 29. 16 What are pelvic floor exercises?

Q 29. 17 How successful are pelvic floor exercises?

Q 29. 18 What is bladder

Q 29. 22 What are urodynamic studies?

If simple treatments are not proving effective and there is doubt as to whether your symptoms are related to detrusor instability or weakness of the pelvic floor, urodynamic studies may indicate the most appropriate mode of treatment. A fine pressure transducer and catheter are introduced through the urethra and into the bladder. The transducer will measure the pressure in the bladder which is also influenced by the pressures within the abdomen.

A second balloon and pressure transducer are introduced into the rectum to reflect the abdominal pressure. The associated recording instrument will subtract the rectal pressure from that obtained from the bladder transducer and the result is a true indication of the pressures generated by the bladder.

The bladder is slowly filled and a note made when there is the first feeling of needing to void. If there is detrusor instability, inappropriate increases in bladder pressure will be observed. The pressure transducer is then slowly withdrawn through the urethra and a record of the pressure there is made. This urethral pressure will be low if the bladder symptoms are due to an anatomical weakness.

Q 29. 23 Where can I obtain further information about bladder problems?

https://2womenshealth.com/

Q 29. 24 Could I have some useful Web sites?

Evaluation of the quality of Web sites is discussed in Q4.27. You may find that several general women’s health sites may help you (Q4.28). The following are more specialised Web sites on topics found in this chapter: https://2womenshealth.com/

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