Bladder Trouble

Patients describe various urinary symptoms as bladder trouble. Usually this is due to inability to control the bladder which results in symptoms like increased frequency of urinating (going to urinate a greater number of times then normal), urgency (difficulty in postponing urination or an urgent desire to pass urine), leakage of urine which could be associated with unconformable urge or it could be associated with cough, effort and exertion. When the leakage is associated with an uncontrollable urge it is referred to as urge incontinence. The leakage that is associated with effort, exertion and coughing or sneezing is referred to as stress urinary incontinence. The bladder trouble can also be used to describe the pain in the bladder area that may come on with a full bladder. This condition is called painful bladder. Painful bladder can be due to urinary tract infections affecting the bladder (cystitis) and it could also be due to recurrent episodes of such infections (a condition called chronic cystitis) which can result in painful bladder. Previously a severe type of chronic cystitis was called interstitial cystitis and currently it is referred to as painful bladder syndrome. In extreme cases it could also be referred to as interstitial cystitis. The following clinical conditions may cause symptoms that could be described as bladder trouble.

  • Over Active Bladder (OAB) & Urge Urinary Incontinence
  • Stess Urinary Incontinence
  • Painful Bladder
  • Recurrent Cystitis

Over Active Bladder (OAB) & Urge Urinary Incontinence

Overview

What is overactive bladder?

Overactive bladder is a term used to describe a condition that is associated with uncontrollable urgency to pass urine which could be associated with leakages (incontinence). This leads to increased frequency of urination during the day time as well as at night time (nocturia which means getting up from sleep more than once in the night to pass urine).

Overactive bladder is a common condition that affects one in six individuals in the United Kingdom.

When can I say I am suffering from overactive bladder?

Normally people pass urine five to six times during the day time and could comfortably hold up to 400ml before they have the urge to pass urine. When people suffer from overactive bladder they feel the necessity to go more than normal, for example more then seven to eight times during the day time. This is a result of the bladder’s inability to hold a normal volume of urine. This may also cause the need to wake up during the night time to pass urine.

What are the causes of overactive bladder?

By definition, to diagnose overactive bladder other diseases/conditions in the bladder should be ruled out particularly conditions like infections, inflammations, stones, bladder tumours or any other neurological diseases which could result in bladder over activity. When these conditions are ruled out and the individual has the symptoms of overactive bladder then it called “overactive bladder” (idiopathic, which means the cause is unknown). Before a clinician diagnoses overactive bladder, they would need to rule out the conditions which would cause overactive bladder symptoms as mentioned above.

How is overactive bladder diagnosed?

After ruling out the underlying disease conditions which could affect the bladder, the over active bladder can be diagnosed by using a simple tool called a “Bladder diary”(Hyperlink) or “frequency/volume chart”. In these diaries one has to record the timing of urination during the day time and night time over a three day period and then need to measure the volume of urine that they have passed and record it against the time the urine was passed in the chart. They would also need to record the volume and type of beverages they drink throughout the day, during the three day period. This will help to diagnose if the frequency is related to the inability of the bladder to hold normal volumes or if it is due to over production of urine which may be due to excessive drinking of beverages or certain other disease conditions.

How is overactive bladder treated?
Overactive bladder is treated by a variety of treatment methods. These methods start with conservative treatment which includes medications and lifestyle changes and also by moderating the beverage intake. The essential part of the treatment is bladder retraining.

Treatment

Conservative Treatment

Life style Modification
Conservative treatment includes lifestyle changes and changes to beverage intake. It is important to cut down on caffeinated drinks (coffee, tea, colas). Some cough remedies and prescription medications may also have caffeine. Another common bladder irritant is alcohol. It is essential to keep moderately normal quantities of fluids which do not contain any irritative substances. It would be recommended to drink 1½ to 2 litres of water or juice per day. People who suffer from overactive bladder do develop habit patterns of visiting the toilet as a precaution even before they need to go. When someone embarks on the treatment of overactive bladder, they need to make up their mind to defer going to the toilet unless it is absolutely necessary to do so.
Bladder Retraining
Bladder retraining means to retrain the bladder to hold urine longer and longer to achieve an interval of at least three to four hours between the times of visiting the toilet. Once someone completes a bladder diary they will have a full idea of how frequently they are going to the toilet to urinate. From that interval, for example if they are going to the toilet every two hours, they need to increase the interval by one-half hour increments to achieve a maximum of three to four hours. This needs to be done in increments of one-half hour, setting goals to increase by one-half hour and once that goal is reached then move on to the next goal.
Pelvic Floor Exercises
Pelvic floor exercises are helpful to strengthen the pelvic floor which supports the bladder. This could be helpful to improve any associated stress leaks which could be presenting as a leakage that may occur during effort, exertion or coughing. Moreover mastering the pelvic floor exercises may also be helpful to deter the urge sensation which is a common symptom of overactive bladder. (HDML: Pelvic Floor Muscle Rehabilitation)

Medical Treatment

Antimuscarinics
A group of medications called antimuscarinics are useful to treat the overactive bladder. This group of medications include different preparations: Oxybutynin, Tolterodine, Fesoterodine, Solifenacin, Darifenacin and Trospium chloride. These medications work by slowing down the bladder by relaxing the bladder muscle thus making the urge sensation less prominent so that it will reduce the frequency and increase the capacity of the bladder to hold larger amounts of urine. This group of medications does have a common profile of side effects which include: dry mouth, dryness of the eyes, occasional sedation and drowsiness, indigestion and constipation. Very occasionally this group of medications may cause palpitation and blurred vision. Therefore patients should be warned about these side effects when started on these medications and if these side effects are intolerable please see your general practitioner or you urologist and stop the medication. This group of medications will aid in trying to retrain your bladder and increase of intervals between times you go to urinate.
Oestrogen
In women going through menopause, the lack of oestrogens predisposes them to various types of bladder problems. This includes bladder infections and overactive bladder. Therefore using topical oestrogen preparations in the vaginal lining by means of pessaries or cream may be helpful. These are particularly helpful to improve the integrity or robustness of the vaginal lining which could also provide some protection against urinary infections.

Invasive Treatment

Bladder Injections of Botox

Botox injection of the bladder is useful to treat overactive bladder (both idiopathic overactive bladder and overactive bladder secondary to other neurological diseases). Botox is a highly potent toxin known to man and is produced by a bacterium called Closteridium Botulinum. This is a very potent muscle relaxant and injecting this toxin in very minute quantities in the bladder muscle helps to relax to bladder muscle and increases the capacity to hold urine. When patients are diagnosed with bladder over activity, Botox injections do help and result a substantial improvement of their symptoms. The use of Botox for other conditions in cosmetic surgery and as well as in muscle spasms in the other parts of the body is well established. Botox works by blocking the nerve fibres in the muscle thereby preventing the muscle contractions in the part where the Botox is injected. Botox injection into the bladder is a fairly recent method of treatment and it has been in practice just over ten years. However when over activity of the bladder is treated with Botox injections the results are about 70-80% improvement in incontinence and reduction in the frequency. The improvement after the Botox injection lasts for about six months. After this the Botox effects do wear off and it is necessary to repeat the injections of Botox.

How is Botox injected into the bladder? The Botox is a powder preparation which is reconstituted with by adding in fluid which is used as an injection. It is injected through a special needle which is passed down an instrument called a cystoscope. This can be done under either local anaesthetic or general anaesthetic. The entire procedure can take from 15 to 20 minutes.

What are the long term effects of Botox? Since the Botox treatment has been in practice for only the past ten years, it is difficult to predict the long term consequences of injecting Botox into the bladder. Therefore urologists are cautious about using this method of treatment for very young patients with a long life expectancy. Since Botox treatments need to be repeated on regular interval to achieve the ongoing control of the symptoms, it is a concern for urologists and patients alike with regard to long term effect on the bladder function. (HTML: Botox information sheet)

Posterior Tibial Nerve Stimulation
Posterior tibial nerve stimulation is a non-invasive method of achieving better bladder control. The nerve endings in the leg are stimulated by using the nerve stimulator which is a small gadget attached to very tiny needle electrodes that are inserted in the skin of the lower leg and in the hind foot. Stimulating the sensitive nerves in this area does give better control of the bladder by its action at the spinal root level. After placing the needle electrode through two pads which are applied just above the ankle and near the hind foot which is connected to the small gadget device (called a pulse generator), the entire treatment takes about 30 minutes. This treatment is repeated on a weekly basis for twelve weeks. PTNS does not have any significant side effects. It is a fairly less risky procedure. The minor side effects are irritation from the pads or from the needles. This may include minor skin irritation. There are a few studies which effectiveness of this treatment. Overall the results are broadly similar with 70-80% of patients showing some improvement in their overactive bladder symptoms.
Sacral Neuro-modulation

What is Sacral Neuro-modulation? This is a special type of treatment which is useful to re-establish the normal bladder function. This is done by applying electrical stimulation to the nerves of the sacral spinal cord level that controls the bladder.

What conditions are treatable with Sacral Neuro-modulation? Sacral Neuro-modulation is used to treat the following: Non-obstructive urinary retention (female urinary retention). This is a condition where women find it impossible to pass urine due to blockage at the level of the urethra without any obvious blockage. Overactive bladder in men and women with the typical symptoms of urgency and frequency with a bit of urge incontinence.

What is involved in this treatment? The Sacral Neuro-modulation is done by a device called Intestim which generates a pulse. This is done in two phases. In the first phase, which is called test phase, a temporary electrode is inserted into the sacral spine touching the S2/S3 nerves. Then the electrodes are connected to a temporary nerve stimulator device. Patients will be assessed for a few weeks with this device to see if this enables them to better control their bladder or improves their urinary retention. If the temporary device is effective, then they would move onto the second phase of implanting the permanent device which would be implanted in the buttocks and connected to the electrodes. Recently the electrodes which are used for the test phase are permanent electrodes though they are connected to the temporary device. This avoids the insertion of the second electrode into the spinal canal.

How effective is this treatment? This treatment is effective in the range of 70-80% of those treated for retention. More than 70% of the patients can be rendered catheter free or they can be made free of having to use self catheterisation. With regard to overactive bladder symptoms, the success rates are about 70%. This treatment is uniquely different from Botox or other treatment because this neural modulation treatment helps to re-establish the bladder function. This is an appropriate treatment method for a group of patients who respond favourably to the test phase treatment.