Bladder Issues

This section focuses on common issues associated with the bladder.

Pelvic Floor Muscle Exercises (AKA Kegels)

Pelvic muscle exercises, also known as kegels, are an essential part of improving incontinence and preventing it from worsening. They also can be used to help you suppress the urge to urinate.

The exercises strengthen and tone the muscles that support the pelvic organs. These muscles contract and relax under your command to control the opening and closing of the bladder. When these muscles are weak, urine leakage or loss may result.

To achieve the best results when performing these exercises, imagine yourself as an athlete in training. You need to build strength and endurance of your muscles. This requires commitment and regular exercise. Correct technique is also very important.

How to Locate the Pelvic Floor Muscles

  • Squeeze the area of the rectum to tighten the anus as if trying not to pass gas. Feel the sensation of the muscles pulling inward and upward.

OR

  • Insert a finger in your vagina and contract the vaginal muscles. The squeeze you feel will confirm that you are exercising the correct muscles. Remember not to tense your stomach, buttock or thigh muscles. Using other muscles will defeat the purpose of the exercise and slow your progress.

How to Do Pelvic Floor Muscle Exercises

When you have located the correct muscle, set aside a short time each day for three exercise sessions. At breakfast, lunch, dinner or before bed are convenient and easy to remember times for many women. Make it a habit to exercise at regularly scheduled times each day.

Squeeze your muscle for a slow count of three. Then relax the muscle completely to a slow count of three. Do not “push out” during the relaxation of the muscle. Repeat the exercise 15 times. Fifteen exercises is one set.

Be sure to do three complete sets each day. As you feel your muscle strength growing, increase the count to five for each squeeze and each relaxation.

Other Tips

Remember that this is a muscle conditioning exercise and like any other exercise, it is important to do it correctly in order to gain the most benefit. Focus on isolating the pelvic muscle and continue to breathe normally throughout each repetition. Muscles need oxygen to grow and strengthen.

In the beginning, check yourself frequently by placing your hand on your abdomen and buttocks to ensure that you are not contracting these muscle groups. If you feel movement, continue to experiment until you have isolated just the muscles of the pelvic floor. Don’t get discouraged. This is a learning process.

It can take four to seven weeks to notice improvement. If you keep a record of leakage each day, you will begin to notice fewer accidents as you regain control.

If you have difficulty performing these exercises or fail to see any improvement in the expected time, discuss this with your health care provider. Advice, support and learning aids are available.


Overactive Bladder (OAB)

What is overactive bladder?

Overactive bladder (OAB) is a condition where a patient without a full bladder feels a strong urge, which cannot be suppressed.  One of the main causes is involuntary bladder contractions – this is called “primary” OAB.  It is important to remember that in most cases, an underlying reason for these contractions is never found.  When leakage of urine occurs with the urgency to urinate it is called “wet” OAB.

OAB caused by another condition is called “secondary” OAB.  Examples of other conditions that may cause OAB include neurologic disorders, stones, bladder infections or a bladder growth, but this last one is rare.   OAB itself is very common and affects up to 20 percent of the population over age 35.

How is overactive bladder diagnosed?

OAB is diagnosed with an evaluation that eliminates other reasons as being the cause of the symptoms.  This is called a “diagnosis of exclusion”.  The evaluation can include the following:

  • Questionnaires
  • A clinical interview and examination
  • Urine and or Imaging testing
  • Cystoscopy – an internal examination of the bladder and urethra using a cystoscope
  • Urodynamics – a test of bladder function
  • Bladder diary – a take home activity where you measure and record the time and amount of urine passed over 3 days.

What treatment is there for overactive bladder?

Primary OAB is most often treated with lifestyle and behavioral changes.  If those don’t work, medication can be prescribed.  Finally, there are other options for severe cases if neither the lifestyle modification nor the medication works.   Each is discussed here:

Lifestyle and behavioral changes include pelvic floor exercises, pelvic floor physiotherapy, dietary changes and behavioral therapy for the bladder.

  • Pelvic floor exercises – Commonly known as Kegel exercises, this involves the contraction of the pelvic floor muscles, which strengthens and tightens them.
  • Pelvic floor physiotherapy – Exercises other than Kegels that are taught by specialized physiotherapists using internal examination.
  • Dietary Changes – Basically avoiding foods that irritate the bladder. Some common bladder irritants include caffeinated drinks, carbonated drinks or alcoholic drinks, spicy foods and artificial sweeteners.
  • Behavioral therapy for the bladder – regulating fluid intake, avoiding constipation and retraining the bladder to void every 3-4 hours.

Medication

When behavior changes and exercises are not successful in treating OAB, medication may be prescribed.  These medications block the involuntary actions of the muscle (detrusor). There are two types:

  • Anticholinergics (many different brands available)
  • Beta Adrenergic Agonists (recently developed)

They can cause side effects ranging from dry eyes and constipation to confusion, which your doctor will discuss with you.

Both of these medications take at least 6 weeks to work and therefore should not be judged as effective or not until that time.

Other options

In severe cases of OAB where lifestyle changes and medications are not working, other options may be tried. These include catheterization, surgery, neuromodulation techniques and Botox injections into the bladder.  Botox injections into the bladder wall are a very effective, outpatient treatment that can provide relief without the side effects of anticholinergic medications.

Introduction to OAB

Evaluating OAB

Medical treatment of OAB


Bladder Retraining

Bladder Training Guide

Bladder training is an important form of behavior therapy that can be effective in treating urinary incontinence.

The goals are to increase the amount of time between emptying your bladder and the amount of fluids your bladder can hold.

It also can diminish leakage and the sense of urgency associated with the problem.

Bladder training requires following a fixed voiding schedule, whether or not you feel the urge to urinate.

Keeping a diary of your bladder activity is very important. This helps your health care provider determine the correct place to start the training and to monitor your progress throughout your program.

Bladder Retraining Instructions

Empty your bladder as soon as you get up in the morning. This act starts your retraining schedule.

Go to the bathroom at the specific regular times. This time is chosen by you based on how long you can hold your urine without a sensation of urgency. This may be as short at 1hour at the beginning.

Wait until your next scheduled time before you urinate again. Be sure to empty your bladder even if you feel no urge to urinate.

Follow the schedule during waking hours only. When you feel the urge to urinate before the next designated time, use “urge suppression” techniques or try relaxation techniques like deep breathing (discussed below).

If you cannot suppress the urge, wait five minutes then slowly make your way to the bathroom. After urinating, re-establish the schedule.

Repeat this process every time an urge is felt.

When you have accomplished your initial goal, gradually increase the time between emptying your bladder by 15-minute intervals.

Try to increase your interval each week — however, you will be the best judge of how quickly you can advance to the next step.
Don’t be discouraged by setbacks. You may find you have good days and bad
days. As you continue bladder retraining, you will start to notice more and more good days, so keep practicing.<

Urge Suppression Techniques

The following steps can help reduce the urge to urinate and will improve bladder control.

Stop

Stop, stand very still and do not move. Sit down if possible. Breathe and stay calm. Do not panic. Anxiety only makes the urge more severe.

Squeeze

Contract pelvic floor muscles quickly and strongly 5 -10 times. This sends a signal to the bladder to stop the feeling of urgency. Try not to contract abdominal muscles at the same time. Remember that when the pelvic floor muscles contract, the bladder muscle must relax. As the bladder muscle is relaxed, it is less likely to leak urine.

Relax

Take a deep breath and let it out. Try to make the urge go away by using relaxation and visualization techniques. For example imagine a dry desert; do not visualize a flowing waterfall. Do not rush to the bathroom in the middle of a strong urge to urinate.

Finally

When the urge has gone away, walk normally to the bathroom; or wait for a while until the urge returns again. If you urinate frequently, you will develop the habit and will also feel the urge more frequently. The ultimate goal is to allow at least two to four hours between urination episodes.

At Night

If feeling the urge to urinate at night, try the stop, squeeze and relax technique to go back to sleep. Try to lie still. Perform 10 quick and strong pelvic floor muscle contractions without contracting abdominal muscles. Then try to go right back to sleep. It is normal to get up one time per night to urinate. If awakened after a few hours, you can decide to get up to urinate. The goal is no more than once per night of sleep.


Bladder Pain Syndrome aka IC

What is Bladder Pain Syndrome?

  • BPS is one of many Chronic Pelvic Pain Syndromes.
  • BPS is defined as persistent or recurrent pain perceived in the urinary bladder region, accompanied by at least one other symptom, such as pain worsening with bladder filling or day-time and/or night-time urinary frequency.
  • BPS was previously known as interstitial cystitis but this term has fallen out of favour.
  • BPS is an umbrella term with a number of “types” of bladder pain

Symptoms of BPS

  • Pain or Pressure in the lower abdomen with bladder filling
  • Pain with urination
  • Frequent and urgent need to urinate
  • The need to wake during the night to urinate.
  • Constantly having to wait for the stream to begin, no matter how urgent it feels.
  • Pain when performing basic tasks, such as driving, working, or having sexual intercourse.

What is the cause of BPS?

There is not one known cause for BPS but likely a number of different causes.  Some of the proposed mechanisms include:

  • Mast cell activation
  • Bladder wall infection
  • Autoimmune modulated
  • Neurogenic pain
  • Inflammation secondary to urinary toxins
  • Leaky bladder lining

Getting Your Evaluation

  •  A clinical interview and standardized questionnaires are the most important part of the evaluation
    • It is important to rule out more life threatening conditions
  • Physical evaluation
  • Possible Tests
    • Urine tests, blood tests
    • Voiding diary is essential to the diagnosis
    • Cystoscopy
    • Bladder Function Tests (Urodynamics)

How is BPS treated?

BPS is a condition with fluctuating exacerbation’s and remissions.  The main goal of treatment is to make the symptoms more manageable and to improve your quality of life.

  • LIFESTYLE directed treatment
    • Stress management, improved sleep, regular exercise
    • Avoid bladder irritants (a few are listed here):
      • Coffee, tea (even decaf, herbal teas are ok)
      • Alcohol
      • Carbonated drinks
      • Acidic foods and drinks
      • Spicy foods
      • Artificial sweeteners
    • Avoid constipation
  • PHYSIOTHERAPY can help to relieve trigger points that can cause a “migraine” like pain in the pelvis
  • MEDICATIONS
    • Can be instilled into the bladder on a weekly basis for 6-8 weeks
    • Other medications include:
      • Bladder relaxants: Anticholinergics, B-Agonists, Botox
      • Elmiron
      • Hydroxyzine (antihistamine)
      • Tricyclic antidepressants
      • Selective Serotonin Reuptake inhibitors
  • SURGERY
    • Has a limited role
    • Bladder hydro-distension can help with increasing the size of the bladder to make it react less when filling.
    • Urethral Dilation

Bladder Pain Syndrome / Interstitial cystitis


RECURRENT URINARY TRACT INFECTION INFORMATION

Urinary tract infections or “Bladder infections” are very common, particularly in women. About 30% of women will have a UTI  by the age of 24 and about 50% will have at least one in their lifetime. The bugs, which cause the bladder infections usually, enter the urinary tract from the surrounding genital skin and then travel up the urethra to the bladder. UTI’s are considered recurrent if you have more than three culture proven infections in one year.

Fortunately, bladder infections themselves are not dangerous, but sometimes the bugs will travel up to the kidneys and cause a kidney infection this is called pyelonephritis. If you have a bladder infection as well as a fever and or flank pain (pain high up on the back just under the ribs not the lower back), you may have a kidney infection and a physician should see you emergently.
.

Now you might be wondering ‘how do you know if you really have a bladder infection?’ Three things are needed to diagnose an infection.

How do I know if I have a UTI?

Now you might be wondering ‘how do you know if you really have a bladder infection (UTI)?’ Three things are needed to diagnose an infection.
These are:
1. Symptoms, which include burning when you urinate, urinating frequently and or urgently
2. Having inflammatory cells in your urine sample
3. And it is important to culture the urine to prove there are bacteria present
If you only have the symptoms of a bladder infection but no bacteria are found or the antibiotics are not improving your symptoms it is important to let me know that, as there are other conditions that can mimic a bladder infection. It is ok for an initial infection to be diagnosed based on symptoms and an office urine dip test alone. However, if you are having recurrent UTI’s you should have a urine sample sent to the lab to the lab to find out what bacteria you are growing and what antibiotic work best.

Why am I getting recurrent bladder infections?

A common misconception is that the infections are due to poor hygiene but this is not true. The most common causes of
recurrent bladder infections include:
1. Sexual intercourse
2. Spermicide use
3. Chronic constipation
4. Being post-menopausal or have low estrogen
5. A change to the normal vaginal flora
6. Your genetics, which can lead to bacteria, binding to the bladder easier
7. Blockage in the urinary system, catheters, stones and other sources.
The most frustrating part of managing bladder infections for the patient and for the urologist is that we often never find a cause. But even if we don’t find the cause of your bladder infections after a detailed history, physical exam and urine test we can still make a plan to try to decrease the number of infections you are having as well as put the control of treating them into your
hands so they will be less disruptive on your life. You and I will work together by giving you the knowledge and tools to prevent infections as well as treat them as soon as they occur.

How to I prevent UTI’s

1. Prevention of constipation
    a. Some over-the-counter suggestions: PEG-3350, magnesium malate, stool softeners
2. Urinating often and especially before and after intercourse
    a. Aim to urinate at least 5 times a day. This will allow you to expel the bacteria from your bladder before it binds to the wall.
3. Taking probiotics with lactobacillus rhamnosus and Lactobacacillus reuteri have been proven to fight off UTI causing bacteria from the vulvua (female genitalia)
    a. These can be taken orally or improved results have been seen with placing the probiotic into the vagina at bedtime.
4. Taking cranberry extract supplement
5. Taking D-Mannose supplement
6. Quercetin won’t prevent a UTI but it can help with the inflammation and pain that goes along with a UTI. It can be found at many health food stores
7. Estrogen cream if vaginal atrophy is present in post-menopausal women
8. Lastly is the use of prophylactic antibiotics at the time of intercourse if this is the most common time for you to get a bladder infection. This is taken as a single pill before or immediately after sex to prevent the bacteria from getting into your bladder.
If these preventative measures fail and you feel you are getting an infection we can make a plan to allow you to treat them as
soon as you feel the symptoms coming on without having to make a trip to the doctor. We call this the “self-start” regime. And
we can talk more about this approach if you are interested.