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Bladder Control Problems |
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In
people with an overactive bladder (OAB), the layered, smooth
muscle that surrounds the bladder (detrusor muscle) contracts
spastically, sometimes without a known cause, which results in
sustained, high bladder pressure and the urgent need to
urinate (called urgency). Normally, the detrusor muscle
contracts and relaxes in response to the volume of urine in
the bladder and the initiation of urination.
People with OAB often experience urgency at inconvenient and
unpredictable times and sometimes lose control before reaching
a toilet. Thus, overactive bladder interferes with work, daily
routine, intimacy and sexual function; causes embarrassment;
and can diminish self-esteem and quality of life.
Urination
Urination (micturition) involves processes within the urinary
tract and the brain. The slight need to urinate is sensed when
urine volume reaches about one-half of the bladder's capacity.
The brain suppresses this need until a person initiates
urination.
Once urination has been initiated, the nervous system signals
the detrusor muscle to contract into a funnel shape and expel
urine. Pressure in the bladder increases and the detrusor
muscle remains contracted until the bladder empties. Once
empty, pressure falls and the bladder relaxes and resumes its
normal shape.
Incidence and Prevalence
Overactive bladder affects men and women equally. The U.S.
Department of Health and Human Services has reported that
approximately 13 million people in the United States suffer
from OAB and other forms of incontinence.
Causes
A malfunctioning detrusor muscle causes overactive bladder.
Identifiable underlying causes include the following:
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Nerve damage
caused by abdominal trauma, pelvic trauma, or surgery
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Bladder
stones
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Drug side
effects
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Neurological
disease (e.g., multiple sclerosis, Parkinson's disease,
stroke, spinal cord lesions)
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Other conditions can produce symptoms
similar to those experienced with overactive bladder, the most
common of which is urinary tract infection (UTI) in women.
Signs and Symptoms
Three symptoms are associated with an overactive bladder:
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Frequency
(frequent urination)
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Urgency
(urgent need to urinate)
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Urge
incontinence (strong need to urinate followed by leaking
or involuntary and complete voiding)
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Diagnosis
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A complete medical history, including a
voiding diary; a physical examination; and one or more
diagnostic procedures help the physician determine an
appropriate treatment plan for overactive bladder.
Medical history
The medical history includes information about bowel habits,
patterns of urination and leakage (when, how often, how
severe), and whether there is pain, discomfort, or straining
when voiding. The patient's history of illnesses, pelvic
surgeries, pregnancies, and medications currently used also
supply the physician with information relevant to making a
diagnosis. In the elderly, a mental status evaluation and
assessment of social and environmental factors may be
performed.
Physical examination
A physical examination includes a neurologic status evaluation
and examination of the abdomen, rectum, genitals, and pelvis.
The cough stress test, in which the patient coughs forcefully
while the physician observes the urethra, allows observation
of urine loss. Instantaneous leakage with coughing indicates a
diagnosis of stress incontinence. Leakage that is delayed or
persistent after the cough indicates urge incontinence.
The physical examination also helps the physician identify
medical conditions that may be the cause of overactive
bladder. For instance, poor reflexes or sensory responses may
indicate a neurological disorder.
Urinalysis
Examination of the urine may identify medical conditions
associated with overactive bladder, such as the following:
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Bacteriuria—presence
of bacteria in urine; indicates infection
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Glycosuria—excess
glucose in urine; may indicate diabetes
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Hematuria—blood
in urine; may indicate kidney disease
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Proteinuria—excess
protein in urine; may indicate kidney disease, cardiac
disease, blood disease
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Pyuria—presence
of pus in urine; indicates infection
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Specialized Testing
If overactive bladder persists after diagnosis and treatment,
additional testing may be needed. Urologists perform
urodynamic, endoscopic, and imaging tests to obtain a more
extensive evaluation of the lower urinary tract to determine a
new treatment plan.
Postvoid residual volume (PRV)
This procedure requires catheterization or pelvic ultrasound.
The patient voids just before the PRV is measured. This
initial void should be observed for hesitancy, straining, or
interrupted flow. A PRV less than 50 mL indicates adequate
bladder emptying. Repeated measurements of 100 to 200 mL or
higher represent inadequate bladder emptying. The clinical
setting and the patient's readiness to void may affect the
test result; therefore, repeated measurements may be
necessary.
Urodynamic Testing
Cystometry may be used to measure the anatomic and functional
status of the bladder and urethra. The cystometer is an
instrument that measures the pressure and capacity of the
bladder; thus evaluating the function of the detrusor muscle.
Simple cystometry detects abnormal detrusor compliance, but
abdominal pressure is not included and the results must be
evaluated with caution.
The multichannel, or subtracted, cystometrogram simultaneously
measures intra-abdominal, total bladder, and true detrusor
pressures. This allows involuntary detrusor contractions to be
distinguished from increased intra-abdominal pressure. The
voiding cystometrogram detects outlet obstruction in patients
who are able to void.
Uroflowmetry identifies abnormal voiding patterns.
Urethral pressure profilometry measures the resting and
dynamic pressures in the urethra.
Endoscopic Tests
Cystoscopy may be performed when urodynamic testing fails to
duplicate symptoms, when the patient experiences new symptoms
(e.g., cystitis, pain), or when urinalysis reveals a disease
process (e.g., menaturia, pyuria). Cystoscopy identifies the
presence of bladder lesions (e.g., cysts) and foreign bodies.
Imaging Tests
X-rays and ultrasound may be used to evaluate anatomic
conditions associated with overactive bladder. Imaging of the
lower urinary tract before, during, and after voiding is
helpful in examining the anatomy of the urinary bladder and
urethra.
Treatment
Treatment may include one or more of the following:
Bladder Training
with Timed Voiding
This treatment is used for urge and overflow incontinence. The
patient keeps a voiding diary of all episodes of urination and
leaking, and the physician analyzes the chart and identifies
the pattern of urination. The patient uses this timetable to
plan when to empty the bladder to avoid accidental leakage. In
bladder training, biofeedback and Kegel exercise help the
patient resist the sensation of urgency, postpone urination,
and urinate according to the timetable.
Medication
Drugs such as oxybutynin chloride (Ditropan XL®) and
tolterodine (Detrusitol®, Detrol LA®) are taken orally, once a
day, for overactive bladder. They can improve symptoms within
2 weeks. These drugs (antimuscarinics) affect the central
nervous system and muscarinic receptors in smooth muscle. They
relax the smooth muscle of the bladder, which reduces detrusor
contraction and subsequent wetting accidents. In a recent
study, participants taking Ditropan XL had 90% fewer
accidents, used fewer protective pads, and experienced 24-hour
relief from urgency and loss of control.
Side effects, including dry mouth, constipation, headache,
blurred vision, hypertension, drowsiness, and urinary
retention occur in approximately 50% of those who use the
drugs. People with glaucoma or certain types of kidney, liver,
stomach, and urinary problems are advised not to take Ditropan
XL. Although there is no evidence that Ditropan XL causes
birth defects, pregnant women should not take it without
consulting a physician.
Oxybutynin
Transdermal System
The oxybutynin transdermal system (Oxytrol™) is a thin,
flexible, clear patch that is applied to the skin of the
abdomen or hip, twice weekly, to treat overactive bladder.
This treatment delivers oxybutynin continuously through the
skin into the bloodstream and relieves symptoms for up to 4
days allowing twice a week dosing.
Patients who have urinary or gastric retention, uncontrolled
narrow-angle glaucoma, and those with hypersensitivity to
oxybutynin should not use the oxybutynin transdermal system.
Side effects are usually mild and include adverse reactions at
the site of application, dry mouth, and constipation.
Sacral Nerve
Stimulation
InterStim® therapy is a reversible treatment for people with
urge incontinence caused by overactive bladder who do not
respond to behavioral treatments or medication. InterStim is
an implanted neurostimulation system that sends mild
electrical pulses to the sacral nerve, the nerve near the
tailbone that influences bladder control muscles. Stimulation
of this nerve may relieve the symptoms related to urge
incontinence.
Prior to implantation, the effectiveness of the therapy is
tested on an outpatient basis with an external InterStim
device. For a period of 3 to 5 days, the patient records
voiding patterns that occur with stimulation. The record is
compared to recorded voiding patterns without stimulation. The
comparison demonstrates whether the device effectively reduces
symptoms. If the test is successful, the patient may choose to
have the device implanted.
The procedure requires general anesthesia. A lead (a special
wire with electrical contacts) is placed near the sacral nerve
and is passed under the skin to a neurostimulator, which is
about the size of a stopwatch. The neurostimulator is placed
under the skin in the upper buttock.
Adjustments can be made at the doctor’s office with a
programming device that sends a radio signal through the skin
to the neurostimulator. Another programming device is given to
the patient to further adjust the level of stimulation, if
necessary. The system can be turned off at any time.
Possible adverse effects include the following:
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Change in
bowel function
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Infection
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Lead movement
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Pain at
implant sites
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Unpleasant
stimulation or sensation
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Surgery
Surgical augmentation of the bladder is reserved for people
who do not benefit from bladder retraining or medication.
Those who cannot take medication due to medical conditions or
intolerance may find incontinence management devices helpful.
Elimination and Challenge Diet
Bladder control problems that are not the result of
neurological damage, poor muscle tone, or hormone deficiencies
may result from irritability within the bladder or urethral
tissues caused by chronic inflammation and/or food
sensitivities. An elimination and challenge diet can help
determine a food sensitivity. Symptoms that can occur on a
food challenge include the following:
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Headache (may
be brief or prolonged)
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Nausea,
stomachache, sharp abdominal pain
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Sore throat,
stuffy nose, runny nose, itchy nose or eyes
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Skin rash or
itching, facial flushing, red ears
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Sleepiness,
insomnia, fatigue, apathy
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Irritability,
depression, anxiety
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Excitability
(feeling hyper or "buzzed")
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Aching or
twitching muscles
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Symptoms associated with food challenges may
not be the same symptoms experienced before the elimination
process. For example, before the elimination and challenge
diet began, a patient's symptom was chronic sinus pain, but a
stomachache occurred during the challenge. This does not mean
that the food group being challenged was not causing the sinus
pain. It is just that the body and immune system react
differently when the offending agent is removed and then
reintroduced.
Option 1
For 2 to 6 weeks, eliminate all suspect foods and focus diet
on fresh fruits, vegetables, potatoes, yams, animal protein
(fish, poultry, lamb), and nonglutenous grains (rice,
buckwheat). Eat organic foods whenever possible.
After 2 to 6 weeks of maintaining a strict elimination diet,
there should be relief from symptoms. Weight may also be lost.
Now begin the challenge. Start with the food group that is
least problematic. Challenge a specific food group for one day
only. Eat several servings of that food group throughout the
day. Then do not eat that food again for at least 48 hours
while continuing to eat only elimination diet foods. If
symptoms do not return after 48 hours, go on to the next
suspected food group. However, feel free to wait more than 48
hours. Waiting a week between food group challenges is
optimal. This increases the accuracy of the diagnosis.
Remember to challenge only one food group at a time.
Continue this process until the problematic food group is
determined. In most cases, reactions occur within 48 hours.
Rarely do symptoms appear several days or weeks later.
Option 2
Maintain a regular diet and eliminate only the food group that
is believed to be causing the symptoms. Eliminate all items in
that food group for at least 1 month. If the symptoms
disappear before the end of the month, continue to abstain
from that food group for another week before starting the
challenge.
To do the challenge, eat several servings of the suspect food
group during a 24-hour period. Then return to the elimination
diet and do not eat the suspect food group for at least 48
hours. More often than not, immediate reactions occur if there
is a sensitivity.
Herbal Support
Anti-inflammatory Support
Homeopathic Support
Herbal Support
Soothing urinary tract tonics may help heal the bladder and
related nervous irritation. Also drink 2 - 3 quarts of water
daily.
Herbs to use as tea:
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Cleavers (Galium
aparine) - traditional urinary tonic
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Marshmallow
root (Althea officinalis) - soothing demulcent properties,
best in "cold infusion" (Soak herb in cold water several
hours; strain and drink.)
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Buchu -
soothing diuretic and antiseptic for the urinary system
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Corn silk (Zea
mays) - soothing, diuretic
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Horsetail
(Equisetum arvense) - astringent, tissue-healing
properties, mild diuretic
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Usnea lichen
- very soothing and antiseptic
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Anti-inflammatory
Support
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Flax oil: 1
tablespoon daily
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Vitamin C:
500 mg, 2 to 3 times daily with meals
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Bromelain 400
mg or Wobenzyme 5 tablets: 3 times a day away from meals
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Vitamin E:
400 IU daily
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Homeopathic Support
A trained homeopathic practitioner is needed to diagnose and
prescribe a deep acting, constitutional remedy. For acute,
symptomatic relief, the following remedies may relieve some of
the symptoms associated with incontinence.
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Causticum for
stress incontinence associated with frequent urging and
difficulty urinating.
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Natrum
muriaticum for stress incontinence associated with the
menopausal symptoms of vaginal dryness, painful
intercourse and a history of emotional grief.
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Pareira for
difficulty urinating due to prostate enlargement.
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Sepia for
stress incontinence with sudden urging, especially
associated with vaginitis or prolapsed uterus.
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Zincum for
difficulty urinating while standing up (must sit to
initiate flow), associated with prostate problems.
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Standard dosage for acute symptom relief is
12c to 30c, 3 to 5 pellets taken 3 times a day until symptoms
resolve. If you have chosen the right remedy, you should
experience improvement shortly after the first or second dose.
Warning: Most homeopathic remedies are delivered in a small
pellet form that has a lactose sugar base. If you are lactose
intolerant, be advised that a homeopathic liquid may be a
better choice.
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