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Urinary incontinence and other bladder problems.
This page contains a wealth of patient-friendly information about bladder problems. Click on any of the following links or scroll down to find out more.
Common bladder symptoms
Frequency - the passage of urine 8 or more per day.
Urgency - a sudden strong desire to pass urine.
Urge incontinence - the leakage of urine with urgency.
Nocturia - waking due to the desire to pass urine more than once per night.
Stress incontinence - the leakage of urine with some form of exertion eg. coughing, sneezing, laughing, bending, running, jumping.
Dysuria - pain or burning on passing urine, felt where the urine comes out.
Haematuria - the presence of blood in the urine. This can be macroscopic where the blood is visible to the eye, or microscopic where its presence can only be detected by dipstix or a microscope.
Hesitency - A delay in starting to pass urine after sitting on the toilet.
Double voiding - Returning to the toilet to pass more urine shortly just after going.
Stress Urinary Incontinence
This is the leakage of urine with some form of exertion eg. coughing, sneezing, laughing, bending, running, jumping. Usually caused by pregnancy / childbirth, it often worsens with time.
Treatment for most women should begin with pelvic floor exercises, which ideally should be commenced during a woman's first pregnancy. Not everyone finds it easy to contract these muscles, especially when they have been weakened by vaginal births. You can read my information leaflet about pelvic floor exercises. I strongly advise that you have a simple examination by a doctor / nurse / physiotherapist to check that you are performing these exercises correctly. Women whose pelvic floor strength is very poor are likely to benefit from the help of a physiotherapist. Various devices exist that can help a woman perform the exercises correctly. Exercises will benefit around 50% of women.
A drug, Duloxetine (Yentreve) was introduced in 2004 for the treatment of stress incontinence. Approximately 50% of women will derive some benefit from Duloxetine, although for most of these the benefit will only be mild. Side-effects (which include nausea and sleep disturbance) can be troublesome for some women. The benefit only lasts as long as the drug is taken and its main uses are in women who cannot have (or do not want surgery) and as a short-term help combined with exercises.
Despite performing exercises, many women with troublesome stress incontinence will eventually consider having an operation. Nowadays, the most commonly performed operation is the Tension-free Vaginal Tape (TVT) procedure. This minimally invasive operation has revolutionised the treatment of stress incontinence over the past 10 years. This operation is often performed as a day case procedure and most women can return to work after 2 weeks.
Stress incontinence can also be treated with Urethral bulking injections. This can be performed under local anaesthesia and is suited to women for whom a TVT carries increased risks eg. Those who have not completed their family, have poor bladder emptying or previous failed surgery. The success rate is 50-60% and often needs to be repeated to achieve a good and durable outcome.
Overactive bladder syndrome (OAB)
This common condition becomes more common with advancing age but can also affect children. Sufferers usually have a varying combination of frequency, nocturia, urgency and urge incontinence. Frequency is the passage of urine 8 or more per day. Nocturia is waking due to the desire to pass urine more than once per night. Urgency is the sudden strong desire to pass urine. Leakage, often heavy, accompanied by urgency is called urge incontinence. It is important to exclude cystitis in women with these symptoms. Treatment involves a sensible control of fluid intake, avoidance of caffeine and other fluids which can irritate the bladder, bladder retraining and drug therapy.
The simplest way to treat OAB is by retraining your bladder to accept larger amounts of urine. This can be done by resisting the urge to pass urine when it arises - easier said than done! The trick is to remain still - sit down if possible, and contact your pelvic floor 5-10 times. This should enable your bladder to relax so that you can carry on with what you were doing.
In the early stages of bladder retraining, it is best to go the toilet to pass urine at this stage. As you gain confidence in resisting the urge you can use this technique several times before passing urine. You will gradually increase the amount that your bladder can hold before urgency occurs. This takes a lot of willpower but the results can be very good, allowing you to gain more control over your life and avoid drug therapy.
Drug therapy for overactive bladder syndrome
There are a number of drugs that can be used to treat the symptoms of the overactive bladder syndrome. They all have subtle differences and women will often respond better to one drug than another. They will also usually tolerate some drugs better than others. Side-effects are fairly common but usually not too troublesome - dry mouth is common, constipation can occur, some women feel generally unwell on this type of drug. However, do not despair if the first one you try does not help or is not well tolerated. A good doctor can often find a drug that both works and is tolerated.
This is a simple outpatient test that is used to diagnose the cause of symptoms such as incontinence, frequency, urgency and difficulty passing urine. Click here to view patient information leaflet.
Difficulty passing urine
This may be experienced as difficulty starting the flow of urine, a slow stream, a sensation of incomplete bladder emptying or a desire to return to the toilet soon after passing urine. Women in whom the bladder does not empty completely may develop cystitis frequently. Incontinence can also result. Causes include prolapse of the bladder (cystocele), previous surgery for stress incontinence or prolapse and an underactive bladder (detrusor hypotonia). A cystocele can be treated either by surgery or a pessary device. Women with an underactive bladder may need to consider performing intermittent self-catheterisation. For many women this technique is easy to learn and perform two or three times per day.
The symptoms of cystitis include dysuria, frequency, urgency, bladder pain, haematuria and fever. In severe cases, the infection can spread to the kidneys causing loin pain and a high fever. A significant number of women will develop cystitis during their lifetime but frequent infections warrant investigation. Cystitis occurs more frequently in women, during pregnancy, in diabetics and in women who have a catheter inserted into their bladder. Recurrent infections may be due to abnormalities of the kidneys / bladder but are often due to inadequate treatment of the original infection. Women with recurrent infections should have a urine sample sent to identify the responsible bacteria and its antibiotic sensitivities. Many women will benefit from a prolonged course of low dose antibiotics. Link to NKUDIC website for more information.
Getting up at night to pass urine has several causes. Most people pass less than a third of their total 24 hour output of urine during the night (the urine sample produced on waking in the morning must be included with the night time volume). People who produce excessive urine overnight usually do so because of ankle oedema (swelling). This fluid come out of the ankles when lying down, returns to the bloodstream and is excreted by the kidneys/bladder. The treatment of nocturia in this situation is the treatment of the ankle oedema.
Women who produce small volumes of urine when they wake may have an overactive bladder, urinary infection or chronic urinary retention. Women who sleep poorly will often go to the toilet when they wake out of habit - this is different from being woken by the need to pass urine.
Painful Bladder Syndrome
This is a poorly understood condition where women complain of pain in the region of their bladder, which worsens as their bladder fills up. Affected women pass urine frequently, their bladder only holding small volumes, typically around 100ml. Diagnosis is made on the basis of symptoms and cystoscopy findings. It can be treated with tablets and / or bladder instillations, but such treatments are often not effective in this very troublesome condition.