The Surrey Park Clinic
FEMALE HEALTH-GYNAECOLOGY-HORMONES01483 454 016
Stirling House, Stirling Road, Guildford, Surrey, GU2 7RF
Problems with the bladder are not unusual, can be extremely distressing and results in loss of confidence and severe lack of quality of life as it takes over and interferes with day to day activities.
Recurrent infections resulting in pain can be disabling, where as incontinence or an irritable bladder can result in a reluctance to go out due to embarrassment or lack of confidence.
It is very important that investigations and treatment are taken seriously.
Sudden involuntary loss of urine, or difficulty holding onto urine in the bladder is extremely common affecting 60-70% of all women and many more so after childbirth and additionally with advancing age. Often the treatment is very simple but because advice from the doctor is not sought often due to embarrassment the correct treatment is not given.
There are two types of incontinence.
• Stress Incontinence
This is where loss of urine occurs with straining, coughing, laughing or sudden movement. It is usually due to the change in the pelvic anatomy or weakening of the pelvic floor, so that where there is a rise in abdominal pressure, the direction of pressure does not act to close the urethra (tube leading from the bladder), but instead is largely directed on the bladder with resulting involuntary loss of urine.
Raised intra abdominal pressure such as with increased weight, pelvic masses pressing on the bladder (fibroids, ovarian cysts); and chronic cough can worsen these symptoms.
Weakened pelvic floor – causes of this…
• Childbirth, especially where with prolonged second stage of birth, large baby, repeated pregnancies at short intervals.
• Loss of oestrogen (poor quality ovulation, polycystic ovaries, perimenopause, post menopause). This leads to weakening of the ligaments and muscles in the pelvic floor, which results in descent of the bladder neck.
• Bladder instability
• Urgency to pass urine (having to dash to empty bladder).
• Frequency of emptying (small or large volumes).
• Getting up at night to pass urine.
These symptoms indicate unstable bladder, which can be due to wrong nervous impulses from the nerves supplying the bladder.
• Over-activity of the bladder muscle.
• Polyps or lesions in the bladder causing irritation.
• Infection of inflammation.
• Recurrent Urinary Tract Infection
Urine is sterile and it is produced in the kidneys, transmitted via the ureters into the bladder. Occasionally ascending infections via the urethra can result in severe pain, inflammation and frequency of urination.
• Suppressed immune system
• Poor hormones
• Altered pH in the bladder (more alkaline). Improving the pH of the bladder can prevent recurrence of infections. Alkaline urine leads to much more likelihood of overgrowth of normal organisms. Local oestrogen improves the production of lactobacillus, lactic acid and more acidic pelvic floor and fewer infections.
• Times of low oestrogen, such as premenstrually, polycystic ovaries, peri and post menopause and also during pregnancy can result therefore in recurrent infections.
Improving acidity with either local oestrogen (pessaries, cream or ring) or improved oestrogen in the circulation and improve the body’s production of lactic acid and correct the pH.
In the short-term reacidifying naturally with products such as cranberry tablets (not cranberry juice, which is sugary) can be of benefit.
Diet – high-carbohydrate or sugar diet can affect hormone production resulting in less efficient ovulation and less production of oestrogen. This therefore effects the pH of the vagina and bladder, resulting in more infections. Cutting out sugar and severely curtailing carbohydrate or eating only low-GI carbohydrate and avoiding snacking can make a massive difference to infection rate.
• Loss of acidity occurs with loss of ovarian hormones and this results in overgrowth of normally occurring organisms and recurrent infections.
History and examination will usually give the best idea in the majority of cases but it will usually need backing-up with investigations.
• Urine sample
• Culture and sensitivity (infections)
• Abnormal cells (blood or early cancer cells)
• Cystoscopy (this is a camera inspection of the bladder, which will enable view of the bladder to see whether there are polyps, over active bladder muscle, infection or early bladder cancer.
• Urodynamic Investigations
This is an outpatient test where the amount of water tolerated by the bladder is measured and the type of incontinence diagnosed. If a surgical bladder neck elevation is being considered, it is important that this test is done to exclude another cause of incontinence as unless this is done, the wrong operation may result in severe bladder problems for the future.
• Bladder/Kidney Scan
If a growth or polyp or stone is suspected, then a scan of the kidneys, urethra and bladder can be helpful.
• Treatment
Antibiotic treatment for infection and any other obvious cause, and surgery for a stone etc.
1. Stress incontinence
• Pelvic floor physiotherapy.
Skilled physiotherapy can strengthen the pelvic floor muscles enough to allow the correct direction of muscle onto the bladder neck to close off the urethra again and prevent leakage.
• Bladder retraining for an unstable bladder.
This is beneficial where somebody has got in the habit of keeping their bladder empty, often because of loss of confidence and it can be important to retrain the bladder, to become ‘used to’ having fluid it again.
This can be done with taught exercises.
• Pelvic Floor Stimulators.
These devices are inserted into the vagina and small electric currents directed at the right area of the pelvic floor can produce gradual strengthening of the muscles required to close the urethra at coughing or sneezing.
• Vaginal Cones.
These are placed by the patient in the vagina and require the patient to squeeze constantly to keep them in place. This results in effective directed full strengthening which can be beneficial.
• Vaginal Pessaries.
These are inserted by your GP or Gynaecologist and can result in elevation of the bladder neck with an artificial form of support during coughing and straining. They are more usually a short-term measure whilst surgery is awaited. They can also serve as an effective test of where there is laxity in the bladder neck and to ascertain if surgery is going to help in the long-term.
• Dietary Advice.
Weight loss reduces stress incontinence due to less pressure in the pelvic floor region. Other causes of raised intra abdominal pressure, such as fibroids or cysts and correction of the vaginal pH improves bladder instability.
2. Surgical procedures for bladder instability.
• Sometimes stretching the bladder and bladder neck can be helpful at least in the short-term especially where the muscles are overactive. This is usually done by a urologist under cystoscopy control (camera).
• Bladder Sling (for stress incontinence).
There are many different approaches now but they all work on the same principal of elevating the bladder neck and providing support on coughing or sneezing when the patient is vertical. These sling procedures are much less invasive than old-fashioned colposuspension which, was a large operation requiring an abdominal incision and elevation of the vagina to provide stretching and closure of the bladder neck.
Because the pelvic floor tissues gradually lose elasticity with age and loss of oestrogen, this procedure does not usually last much longer than 3-5 years.
Bladder Slings, however are extremely effective, and can in some circumstances be done under local anaesthetic and last a long time.
3. Medication.
• Application of topical oestrogen’s.
Loss of oestrogen with age and inadequate hormone production results in weakening of the pelvic floor strength. Replacing this with either topical oestrogen (pessaries, cream or oestrogen ring) will strengthen the pelvic floor and enhance the benefit of exercise and surgery.
Improving circulating oestrogen levels is also of benefit especially where levels are prematurely low.
• Specialist medication.
Medications known as Anticholingerics act on the nerve supplying the bladder and stop the activity of the bladder muscle. These can be associated with side effects such as drowsiness and dry mouth and are not always 100% effective.
