Archive for March, 2013

Of Nighttime Urination, Sleep Disruption and Promiscuous Eating

March 29, 2013

Andrew Siegel, M.D.  Blog #100

Nocturia is a condition in which one awakens from sleep to urinate. Arising once or so to empty one’s bladder during sleep hours is considered normal; however, when it happens multiple times, it can be not only annoying but also sleep-disruptive. It is common in both men and women and increases in prevalence as we age.  It is primarily a kidney-driven urine production problem, as opposed to a bladder-driven urine storage issue.

As with many matters, nocturia is more complicated than it appears and is often multi-factorial.  That stated, it is important to reiterate that the most common underlying cause of nocturia is nocturnal overproduction of urine.  Although most associate the occurrence of nighttime urination with lower urinary tract conditions, in many cases the problem is actually due to the kidneys (upper urinary tract) and not the bladder and prostate (lower urinary tract).  Nighttime urine overproduction, a.k.a. nocturnal polyuria, may result from kidney issues, but also from cardiac or lung conditions. Nocturnal overproduction of urine at night has been implicated as a causal factor in over 80% of cases of nighttime urination.

Nocturia can certainly occur on the basis of lower urinary tract conditions, particularly with benign prostate enlargement or overactive bladder. Under these circumstances, the nocturnal urinary frequency is often on the basis of decreased bladder capacity (in which the bladder is incapable of storing normal volumes) or sometimes because of failure to empty the bladder (in which the bladder is always left partially full).  Additionally, any source of bladder irritation such as an infection, stone, cancer, etc., can irritate the lining of the bladder and cause nighttime urination.   Nocturia can be induced by extrinsic pressure on the bladder, seen with fibroids of the uterus and rectal fullness due to either gas or constipation, although it can be caused by the presence of any pelvic mass. Nocturia can also occur on a neurological basis since neurological diseases such as stroke, spinal cord injury, multiple sclerosis, Parkinson’s disease, etc., can affect urinary frequency during sleep. Even when nocturia is caused primarily by prostate enlargement, overactive bladder, bladder irritation or a neurological issue, etc., nocturnal overproduction can contribute to the process.

Why does nocturnal overproduction of urine occur?  It can result from a number of factors such as the mobilization of excess fluid stored in the lower extremities in people who have peripheral edema. Edema refers to fluid within the tissues–typically the ankles–that tends to accumulate with gravity over the course of the day. Upon assuming the lying-down position when sleeping, the legs are relatively elevated as opposed to standing and this tissue fluid returns into circulation, causing the kidneys to increase urine production.  In general, those with peripheral edema go to sleep with ankles (and perhaps legs) engorged with edema fluid and wake up with thinner legs, as the return of some of the fluid to the circulation and the subsequent increased urination rids them of this. Another underlying cause is excessive production of atrial natriuretic peptide due to sleep apnea or congestive heart failure.  Yet another possibility is an abnormality in the nocturnal secretion of anti-diuretic hormone.  This pituitary hormone functions to cause the kidneys to retain fluid; nocturia may occur because of an age associated decline in its secretion while sleeping. Other factors include excess fluid intake in the evening, especially caffeine-containing beverages, and the use of medications such as diuretics.   Systemic diseases such as diabetes mellitus, diabetes insipidus, and kidney insufficiency, can all cause nocturnal polyuria.

Sometimes nighttime urination occurs not because of any systemic illness or bladder, prostate, kidney or overproduction issue, but simply because of poor sleep. When sleeping poorly, one often gets up to urinate because the wakeful state makes one more conscious of their bladder being full, or alternatively, for an activity to occupy time during the insomnia. Any sleep disorder—insomnia, obstructive sleep apnea, restless leg syndrome, etc.—can result in poor quality sleep and often nocturia. The bladder is a convenient outlet for anxiety, which can induce urinary frequency.

The principal diagnostic tool for assessing nocturia is a voiding diary in which the time and the volume of urination are recorded for a 24-hour period.  There are 4 major findings that may occur: reduced bladder capacity; global polyuria; nocturnal polyuria; or a mixed pattern.  Typical bladder capacity is 10–12 ounces with 4–6 urinations per day. Reduced bladder capacity is a condition in which frequent urination occurs with low bladder capacities, for example, 3–4 ounces per void. Global polyuria is a condition in which bladder volumes are full and appropriate and the frequency occurs both daytime and nighttime. Nocturnal polyuria is nocturnal urinary frequency with full and appropriate volumes, with daytime voiding patterns being normal. A mixed pattern can be a more complex picture involving elements of the other patterns.

If fluid intake is found to be excessive, simple moderation of intake will be helpful, particularly with respect to caffeinated beverages and high fluid content foods such as melons and other fruits. Restricting liquid intake after dinner is often advisable. Minimizing high salt content foods and table salt can help prevent fluid retention. If edema is the issue, compression stockings worn during the day as well as elevating the legs during the day can be of value in getting some of the interstitial fluid out of the system. Diuretics taken during the late afternoon may decrease fluid accumulation.

Medications may be helpful, depending upon the cause of the nocturia.   Synthetic  antidiuretic hormone, aka DDAVP which is useful for childhood bedwetting, can be useful for adults with nocturia associated with nocturnal polyuria. Bladder relaxing medications as well as behavioral techniques and pelvic floor exercises can be beneficial for overactive bladder. Prostate relaxing and shrinking medications or surgical treatment can be helpful if an enlarged prostate is the cause.

Nighttime urination is one of the most annoying and bothersome of urinary symptoms given how sleep-disruptive it often proves to be.  Chronically disturbed sleep can negatively affect one’s quality of life and health.  It can result in daytime fatigue, increased risk of traffic accidents, increased incidents of fall-related nighttime injuries, and weight gain because of altered eating patterns. Insufficient sleep alters our internal biochemical environment and can profoundly disrupt our eating drives leading to patterns of “promiscuous eating.” Clearly, there appears to be a physiological basis for this fatigue-driven eating. Sleep deprivation or the need for sleep results in decreased levels of leptin, our chemical appetite suppressant, and increased levels of ghrelin, our appetite stimulant, in addition to increased levels of cortisol, one of the stress hormones. This sleep-deprived change of our internal chemical milieu can drive our eating. Therein lies the link between urology and nutrition/health/wellness that I am so fond of establishing.

Bottom Line: Nocturnal urinary frequency should be investigated to determine its cause, which may in fact be related to conditions other than urinary tract issues.  Nighttime urination is not only bothersome, but may also pose real health risks. Chronically disturbed sleep can lead to a host of collateral wellness issues.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

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Pavlov, the Munchies, and the Bladder

March 23, 2013

Andrew Siegel, MD   Blog #99

Ivan Petrovich Pavlov (1849-1936) was a Russian physician, physiologist and psychologist who won the 1904 Nobel Prize in medicine.  Pavlov is best known for describing classical conditioning, summarized as follows: Pavlov recognized that meat causes dogs to salivate, an instinctual reaction called an unconditioned response. He used a metronome to call his dogs to their meaty meal and, after a few cycles of repetition, the dogs began to salivate just on the basis of the sound of the metronome. The reaction to the metronome is called a conditioned response, since it is a learned behavior.

Humans are little different from Pavlov’s dogs. Many foods literally elicit a “mouth watering” unconditioned response and certain specific contexts can exact a conditioned response in the absence of the specific food item. This can help explain the foraging for food that many of us undertake when the television gets turned on, or alternatively, the desire for snacks when we go out to the movies—I refer to this as the “media munchies.”  Similarly, when we enter our homes and head into the kitchen, many food-associated context clues—the refrigerator, pantry, kitchen table, cookie jar, etc.—trigger our desire to eat via the classical conditioning pathway. The importance of classical conditioning with respect to eating is that food-associated context cues can elicit a conditioned response that can trigger eating and drive overeating, weight gain and obesity.

Let’s now shift gears to the bladder—I must admit that this is a strange segue!  Many develop a conditioned response to cues that we associate with the act of emptying our bladders.  Any source of running water—the kitchen sink, bathroom fixture, shower, etc.—can elicit a conditioned response in which exposure to such a trigger causes urinary urgency, defined as the sudden desire to urinate and need to get to the bathroom in a hurry.  At times, it can even cause incontinence, leakage occurring before arrival to the bathroom.

When I was a wee lad (no pun intended!), I noticed that I consistently experienced the sudden need to urinate when I brushed my teeth.  For years, I was perplexed about this, thinking it had something to do with the act of brushing of my teeth, only to realize years later that it had nothing to do with the toothbrush, toothpaste or act of brushing, but with the water running from the faucet!

For ages, parents have been trying to get their infants to learn to urinate on command by sitting them on the toilet and turning the bathroom sink on, creating and reinforcing an association between running water and urinating.  It is truly a helpful tool in the effort to achieve toilet training; however, this conditioned response can come back to haunt us later in life, when exposure to running water triggers an involuntary bladder contraction (the bladder squeezing without our permission) and hence urgency and perhaps even urgency incontinence!  Other common Pavlov-type conditioned responses that can elicit an involuntary bladder contraction are putting the key in the door to one’s home, arising out of a car, and getting closer to the bathroom.  “Latchkey” incontinence is a very common condition in which simply placing the key in the lock is enough to cause intense urgency and the need to literally scramble to get to the bathroom on a timely basis.  Any cue that reminds us of the act of voiding is enough to trigger this response.

What can we do about these maladaptive and annoying conditioned responses?  If our bladders are truly full, nothing will help short of emptying them.  However, if our bladders are not full, but are simply contracting involuntarily in response to the trigger, there is a simple and effective means of countering it.  The answer is to deploy our pelvic floor muscles to counteract/prevent the involuntary bladder contraction.  Whether female or male, by doing a few rhythmic contractions of the pelvic floor muscles (Kegel exercises), either after the urgency is triggered or preferably before exposure to the trigger, the involuntary bladder contraction can be terminated/obviated.

In fact, pelvic floor muscle exercises have a number of very helpful uses and benefits and will be the subject matter of my forthcoming book entitled “Male Pelvic Fitness: Optimizing Sexual and Urinary Health.”  The female version will follow.  In the meantime, if you would like information on the pelvic floor muscles, take a look at my YouTube video, which can be accessed at: http://www.youtube.com/watch?v=5IbliBiRzOw

Bottom Line: The mind-body connection is powerful beyond our understanding.  Contextual cues can provoke responses and actions in the absence of the original stimulus.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

I Was a Cancer Caregiver

March 16, 2013

Blog #98

The following essay was written by Cameron Von St James, who sent me this inspirational story with a very happy ending.  I was delighted to honor his request to post his essay on my weekly blog.

My wife Heather and I will always remember November 21, 2005. On that day, she was diagnosed with mesothelioma, and I became her caregiver. Just three months before, we had rejoiced over the birth of Lily, our only child.  We had been blissfully enjoying the thrills of new parenthood, but all of that came to a halt when we heard the terrible news. Heather’s cancer diagnosis pulled the rug out from under us, and we began down a long and difficult road to save her life. The next few months would be utter chaos for our family.

As we began our new lifestyle of treatments and caregiving, it was hard to stay positive. Heather couldn’t work, and I needed to clear my days to take care of her. We went from two full-time jobs to one part-time job. The comfortable routine we had was replaced by a hectic schedule of doctors, traveling and caring for Lily on my own. I kept thinking that we would lose everything as we battled this disease. I was worried that Heather could die and that Lily would lose her mother at the end of the fight. I admit to breaking down in tears a few times, but Heather never knew. She didn’t have the energy to fret over me. She had her own battle to wage. I needed to stay strong for her.

Luckily, our friends, family and even total strangers helped Heather and me deal with our situation. We were bombarded with kind words and even much needed financial help to get us through the tough times. There’s no way to adequately show our appreciation to those who gave us support. If I had to give one piece of advice to other caregivers out there, it would be to accept every offer of help that comes your way.  I had to learn that pride is something you can’t afford as a caregiver.  Each offer of help that I accepted was a weight off my shoulders, and reminded me that I was not alone in caring for my wife.

Heather endured surgery, radiation and chemotherapy in the attempt to destroy her cancer over the following months. Despite the odds against her, she was able to do just that. It’s now been seven years since her mesothelioma diagnosis, and she remains cancer free to this day. We learned that when you fight such a tough foe, you need to make the most of every resource at your disposal. You’ll have good days and bad days, but you need to stay focused and confident.  The most important thing is to never give up hope.

Being a cancer caregiver taught me how to better manage my time and how to deal with stress. Two years after her diagnosis, I decided to return to school.  Being a caregiver had given me the courage I needed to pursue that dream of mine. Five years after our ordeal, I graduated at the top of my class, even being granted the opportunity to speak at my graduation. In my speech, I told my fellow graduates all that I had learned as my wife’s caregiver.  I said that within each of us is the strength to accomplish incredible, even impossible things, as long as we never give up hope and always keep fighting for the ones we love.

Cameron Von St James

For more info on mesothelioma:

http://www.mesothelioma.com/

http://www.mesothelioma.com/mesothelioma/diagnosis/

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Exercise Vs. Diet To Lose Weight?

March 9, 2013

Andrew Siegel, M.D.   Blog # 97

An article in the International Journal of Obesity (Katz DL: Unfattening our children: forks over feet: Int J Obesity 2011; 35: 33-37) concluded that when it comes to weight loss, diet plays a more important role than exercise.

To quote Dr. Katz’s conclusion:  “Feet and forks are master levers of medical destiny. Diet and physical activity patterns exert powerful influences on weight and health. There can be no choosing between them when it comes to overall health: physical activity is the vital, conditioning work of the human machine, diet is its fuel. But forced to choose a side of the energy balance equation to favor in weight control, it is forks over feet for fundamental reasons of modern living. One may readily out-eat even somewhat extraordinary levels of physical activity, but most will find it very difficult to out-exercise even fairly ordinary levels of dietary intake.”

If you would like to read the full article, which is quite worthwhile:

http://www.nature.com/ijo/journal/v35/n1/full/ijo2010218a.html

Dr. Katz’s article confirmed what I reported in Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food.  The following is a verbatim excerpt from pages 117-118 from the chapter entitled “Raw Facts and Truths”:

As important as exercise is, calorie restriction is the most efficient means of achieving weight loss: exercising restraint over eating trumps exercising our bodies in terms of weight loss.

This is not to denigrate exercise in any way, as getting moving andactive is a fundamental part of any weight loss regimen. Exercise is incredibly important to our health, fitness and well being and can aid the process of weight loss. There are a host of compelling reasons to exercise, including the following: augmented caloric expenditure; aerobic and cardiovascular fitness; improved strength, physical conditioning and self-image; and a productive means of dealing with many of the emotions that drive eating. Ironically, though, burning calories via exercise will leave many of us with a vigorous appetite that can be potentially detrimental to a weight loss program. As important as exercise is, it is not very efficient in terms of weight loss. It takes a great deal of effort to burn a lot of calories and the resultant increased hunger can often negate the effort. For example, I can run for 30 minutes at a good clip and burn 300 calories. By the same token, I could consume 300 calories in two minutes by eating a few cookies. When it comes down to degrees of ease, it is a lot easier to take calories in by eating than it is to expend calories by exercising. Therefore, as important as exercise is, with respect to weight loss, a reduction in caloric intake is of paramount importance and is more efficient than exercise.

Bottom Line:  If you want to drop the pounds, drop the fork…and the most efficient exercise with respect to weight loss is to exercise restraint in terms of eating!  It is simply very difficult to “out-exercise” dietary intake.  Another perspective is that eating less will help you to look better clothed, but exercise will help you look better naked.  In terms of overall health, there is no substitute for the synergy of healthy eating and exercise.  If you commit to one, you will have a better chance of staying on track for the other.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Stroke of Unluck

March 2, 2013

Andrew Siegel, MD   Blog #96

The medical term cerebrovascular accident (CVA) is more commonly referred to as a stroke because many years ago it was felt that it occurred when God “struck a person down.” Essentially, a CVA arises when there is a sudden cessation of blood supply to the brain, or alternatively, a rupture of a blood vessel within the brain. Strokes are a major cause of disability and death in Western nations and, in fact, are the number 4 cause of death in the United States.  A stroke occurs every 40 seconds in the USA and a death from a stroke occurs every 4 minutes.

The brain, as with all tissues in the body, requires arterial blood flow to supply oxygen and vital nutrients in order to sustain function. When there is a blockage of blood flow to the brain or bleeding into brain tissue, there is insufficient oxygen supply to the area of concern, and within a short period of time, infarction, or tissue death, occurs. This is not unlike a heart attack (myocardial infarction), in which a region of the heart muscle dies because of insufficient blood flow; therefore, a  stroke can be referred to as a “brain attack.”

There are two major kinds of strokes, ischemic and hemorrhagic.  An ischemic stroke occurs when there is insufficient blood flow to the brain.   This generally occurs from either a ruptured fatty plaque (thrombosis) of one of the arteries in the neck or alternatively, a clot that forms in the heart and is pumped into the brain, acutely blocking the arterial supply (embolism). Ischemic strokes account for 87% of strokes.  A hemorrhagic stroke occurs when a blood vessel in the brain ruptures. Thirteen (13)% of all strokes are hemorrhagic, but the morbidity and mortality of a hemorrhagic stroke is much greater than an ischemic stroke, with hemorrhagic strokes accounting for approximately 30% of deaths from strokes.

A transient ischemic attack (TIA) is a temporary neurologic dysfunction caused by insufficient blood flow, and is the greatest predictor of stroke.  TIAs do not cause permanent brain tissue damage, as do strokes.  The symptoms of a TIA or stroke are very much dependent upon the location and extent of the brain tissue that is affected.   Classic symptoms are the following: sudden weakness or numbness on one side of face or limb; sudden trouble speaking or comprehending; confusion; sudden visual problems; sudden difficulty walking; dizziness/balance problems; and sudden headache.   Sometimes a stroke will cause no overt symptoms whatsoever; such silent strokes have been correlated with the occurrence of dementia.

The greatest risk factor for TIA and CVA is high blood pressure (hypertension). The high pressure within the arterial wall promotes dislodgement of a fatty plaque, or alternatively can stress the arterial wall to the point where the blood vessel itself ruptures.  Other risk factors include the use of tobacco, excessive alcohol intake, obesity, a poor diet, and a sedentary lifestyle with insufficient exercise. Promiscuous eating is certainly a risk factor for TIA and CVA.  A big risk factor for an embolic ischemic stroke is atrial fibrillation, a not uncommon cardiac arrhythmia that promotes clot formation within the heart.

To avoid or mitigate hypertension, lifestyle improvement measures are imperative.  These include weight loss; the DASH (Dietary Approaches to Stop Hypertension) diet; decrease in salt intake; increase in potassium intake, which works to lower blood pressure; exercise on a regular basis; and moderate consumption of alcohol.

So what to do if you experience symptoms suggestive of a TIA or stroke?   The first thing to do is to get to the Emergency Room ASAP or call 911 so that you be transported to an ER as expeditiously as possible, since time is of the essence in the management of a CVA. Many emergency rooms, in fact, have a “stroke protocol” in order to expedite the process, which requires evaluation, imaging (with computerized tomography or magnetic resonance imaging), and rapid management.

The emergency room will schedule the appropriate tests to make the distinction between an ischemic and hemorrhagic stroke.  This is of fundamental importance, insofar as they are treated differently. With ischemic strokes, the expeditious use of a clot-busting medication such as tissue plasminogen activator (tPA) can make a major difference in terms of the presence or extent of the disability sustained after an ischemic cerebral infarction.

A hemorrhagic stroke (intra-cerebral hemorrhage) results in bleeding within the brain, a highly compact organ located within the closed space of the skull that has little margin for the swelling that occurs as a result of the ruptured vessel.  Treatment of a hemorrhagic stroke aims to save the life of the stroke victim, alleviate symptoms, fix the bleeding and prevent complications.  Blood pressure needs to be controlled, the brain swelling minimized, and supportive care administered.  On occasion, a collection of blood known as a hematoma, will need to be evacuated surgically in order to take the pressure off the brain.  Long-term treatment aims to help the stroke victim recover as much function as possible and prevent future strokes.

BOTTOM LINE: Maintain a healthy, active lifestyle in order to minimize the risk factors for stroke. Should you experience TIA symptoms or an actual stroke, time is of the essence: get to an ER immediately in order to maximize your chances of survival and reduced debilitating aftereffects. 

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.