Posts Tagged ‘bladder’

Female Bladder Works

February 11, 2017

Andrew Siegel MD   2/11/17

This entry is a brief overview of bladder anatomy and function to help you better understand the two most common forms of urinary leakage—stress urinary incontinence and overactive bladder— topics for entries that will follow for the next few weeks.  Having a working knowledge of the properties of the bladder will serve you well in being able to understand when things go awry. 

                          6. bladder

                             Drawing of the bladder and urethra by Ashley Halsey from “The Kegel Fix:                           Recharging Female Pelvic, Sexual and Urinary Health”

The bladder is a muscular balloon that has two functions—storage and emptying of urine. The stem of the bladder balloon is the urethra, the tube that conducts urine from the bladder during urination and helps store urine at all other times. The urethra runs from the bladder neck (where the urinary bladder and urethra join) to the urethral meatus, the external opening located just above the vagina.

Bladder Control Issues—More Than Just a Physical Problem

Urinary incontinence is an involuntary leakage of urine. Although not life threatening, it can be life altering and life disrupting. Many resort to absorbent pads to help deal with this debilitating, yet manageable problem. It is more than just a medical problem, often affecting emotional, psychological, social and financial wellbeing (the cumulative cost of pads can be significant). Many are reluctant to participate in activities that provoke the incontinence, resulting in social isolation, loss of self-esteem and, at times, depression. Since exercise is a common trigger, many avoid it, which can lead to weight gain and a decline in fitness. Sufferers often feel “imprisoned” by their bladders, which have taken control over their lives, impacting not only activities, but also clothing choices, travel plans and relationships.

Bladder Function 101

Healthy bladder functioning depends upon properties of the bladder and urethra. Bladder control issues arise when one or more of these go awry:

Capacity

The average adult has a bladder that holds about 12 ounces before a significant urge to urinate occurs. Problem: The most common capacity issue is when the capacity is too small, causing urinary frequency.

Elasticity

The bladder is stretchy like a balloon and as it fills up there is a minimal increase in bladder pressure because of this expansion. Low-pressure storage is desirable, as the less pressure in the bladder, the less likelihood for leakage issues. Problem: The bladder is inelastic or less elastic and stores urine at high pressures, a setup for urinary leakage.

Sensation

There is an increasing feeling of urgency as the urine volume in the bladder increases. Problem: The most common sensation issue is heightened sensation creating a sense of urgency before the bladder is full, giving rise to the frequent need to urinate. Less commonly there exists a situation in which there is little to no sensation even when the bladder is quite full (and little warning that the bladder is full), sometimes causing the bladder to overflow.

Contractility

After the bladder fills and the desire to urinate is sensed, a voluntary bladder contraction occurs, which increases the pressure within the bladder in order to generate the power to urinate. Problem: The bladder is “under-active” and cannot generate enough pressure to empty effectively, which may cause it to overflow when large volumes of urine remain in the bladder.

Timing

A bladder contraction should only occur after the bladder is reasonably full and the “owner” of the bladder makes a conscious decision to empty the bladder. Problem: The bladder is “overactive” and squeezes prematurely (involuntary bladder contraction) causing sudden urgency with the possibility of urinary leakage occurring en route to the bathroom.

Anatomical Position

The bladder and urethra are maintained in proper anatomical position in the pelvis because of the pelvic floor muscles and connective tissue support. Problem: A weakened support system can cause urinary leakage with sudden increases in abdominal pressure, such as occurs with sneezing, coughing and/or exercising.

Urethra

In cross-section, the urethra has infoldings of its inner layer that give it a “snowflake” appearance. This inner layer is surrounded by rich spongy tissue containing an abundance of blood vessels, creating a cushion around the urethra that permits a watertight seal similar to a washer in a sink. The female hormone estrogen nourishes the urethra and helps maintain the seal. Problem: With declining levels of estrogen at the time of menopause, the urethra loses tone and suppleness, analogous to a washer in a sink becoming brittle, potentially causing leakage issues.

Sphincters

The urinary sphincters, located at the bladder neck and mid-urethra, are specialized muscles that provide urinary control by pinching the urethra closed during storage and allowing the urethra to open during emptying. The main sphincter (a.k.a. the internal sphincter) is located at the bladder neck and is composed of smooth muscle designed for involuntary, sustained control. The auxiliary sphincter (a.k.a. the external sphincter), located further downstream and comprised of skeletal muscle contributed to by the pelvic floor muscles, is designed for voluntary, emergency control. Problem: Damage to or weakness of the sphincters adversely affects urinary control.

The main sphincter is similar to the brakes of a car—frequently used, efficient and effective. The auxiliary sphincter is similar to the emergency brake—much less frequently used, less efficient, but effective in a pinch. The pelvic floor muscles are intimately involved with the function of the “emergency brake.”

Nerves

The seemingly “simple” act of urination is actually a highly complex event requiring a functional nervous system providing sensation of filling, contraction of the bladder muscle and the coordinated relaxation of the sphincters. Problem: Any neurological problem can adversely affect urination, causing bladder control issues.

Bladder Reflexes

A reflex is an automatic response to a stimulus, an action that occurs without conscious thought. There are three reflexes that are vital to bladder control:

Guarding Reflex: During bladder filling, the “guarding” (against leakage) pelvic floor muscles contract in increasing magnitude in proportion to the volume of urine in the bladder; this provides resistance that helps prevent leakage as the bladder becomes fuller.

Cough Reflex: With a cough, there is a reflex contraction of the pelvic floor muscles, which helps prevent leakage with sudden increases in abdominal pressure.

Pelvic Floor Muscle-Bladder Reflex: When the pelvic floor muscles are voluntarily contracted, there is a reflex relaxation of the bladder. This powerful reflex can be tapped into for those who have involuntary bladder contractions that cause urgency and urgency leakage.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.wordpress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery. Much of the content of this entry was excerpted from his recently published book The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health: http://www.TheKegelFix.com

He is also the author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Uterine Fibroids And The Bladder

January 9, 2016

Andrew Siegel MD   1/9/16

shutterstock_femalebluepelvic

 

Fibroids are muscular growths that develop within the womb that can put direct pressure on the next door neighbor of the uterus–the urinary bladder.  This compression can give rise to a host of annoying urinary symptoms including urinary urgency, frequency, urinary leakage and difficulty urinating.  

Although fibroids usually grow within the uterine wall, at times they do so internally into the uterine cavity or, alternatively, externally on the outside of the uterus. They are virtually always benign and much of the time they do not cause symptoms. When symptomatic they may cause the following: heavy uterine bleeding; pelvic pressure; a swollen and distended lower abdomen; urinary and bowel issues; pelvic and lower back pain; pain with sexual intercourse; as well as fertility problems, reproductive issues and complications of pregnancy (breech births, failure of labor to progress, the need for C-section, preterm delivery, and bleeding following delivery).

The most common presenting symptom of uterine fibroids is uterine bleeding, which often begins as prolonged menstruation and can be severe enough to cause a low blood count.  Fibroids are problems of the reproductive years, prevalent in women in their 30s, 40s and 50s. They can be solitary or multiple, range in size from tiny to huge and vary in location within the uterus. The largest fibroids can outgrow their blood supply and undergo degenerative changes. When extremely large, they can distort the lower abdomen, simulating pregnancy. Fibroids are “tumors”–-although benign–- that microscopically consist of interlacing bundles of smooth muscle surrounded by condensed uterine tissue. There is a genetic basis for fibroids with an increased prevalence in women with a family history. Obesity increases one’s risk for fibroids.

The growth of uterine fibroids is largely controlled by estrogen, the key female sex hormone. Fibroids tend to grow rapidly during pregnancy and regress after menopause when estrogen production ceases.

The presence of fibroids may significantly impair one’s quality of life. Because of the pressure they apply against the typically balloon-thin female urinary bladder, they often cause urinary symptoms, much as in pregnancy when an enlarged uterus compresses the bladder. Urinary symptoms most often occur when the fibroids are located closest to the bladder and/or urethra. Typical symptoms include urinary urgency, frequency and stress urinary incontinence (leakage of urine with sneezing, coughing, and exertion). Symptoms are proportionate to the size of the fibroid, with larger fibroids causing more significant symptoms. On occasion, a fibroid can cause an obstruction of the urinary tract, impairing one’s ability to empty their bladder, sometimes requiring the placement of a urinary catheter to alleviate the obstruction.

On pelvic examination, fibroids can often be recognized as pelvic masses. Thye can be further evaluated with imaging studies, including ultrasound, computerized tomography and magnetic resonance imaging. They characteristically cause a “popcorn” appearing calcification on abdominal radiographs.

Those fibroids that do not cause symptoms or bleeding do not require treatment. There are numerous pharmacological options for symptomatic fibroids including medications that lower estrogen levels that cause suppression and shrinkage of the fibroids. Surgery may be required when there is an inadequate response to conservative measures. Surgical options include removing or destroying the uterine lining to control heavy bleeding, deliberately blocking the blood supply to the fibroid, surgical removal of one or more of the fibroids and, at times, removing the entire uterus (hysterectomy).

Bottom Line: As a urologist, I not uncommonly see women with urinary urgency, frequency, incontinence or urinary obstruction caused by one or more uterine fibroids pushing and compressing the bladder or urethra. It is usually very obvious on pelvic ultrasound or cystoscopy (visual inspection of the bladder), where the fibroid can be seen to cause extrinsic compression. The good news is that such fibroids are eminently manageable, which most often resolves the urinary issues.    

Wishing you the best of health and a very happy New Year,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

Getting Up At Night Gets Me Down: Nighttime Urinating

May 24, 2014

Blog #155

Getting up once to relieve your bladder during sleep hours is usually not particularly troublesome. However, when it happens two or more times, it can negatively impact one’s quality of life because of sleep disruption, daytime fatigue, an increased risk of fatigue-related accidents and an increased risk of fall-related nighttime injuries. Fatigue has a negative effect on just about everything, even influencing us to mindlessly eat.

Nocturia is the medical term for the need to awaken from sleep to urinate. One’s natural response is to think urinary bladder problem and seek a consultation with a urologist, the type of doctor who specializes in the urinary system. Although nocturia manifests itself via the bladder and much of the time is a urological issue, it is often not a bladderproblem. Rather, the kidneys are frequently culprits in contributing to the condition.

The kidneys are remarkable organs that can multitask like no other. They not only filter blood to remove waste products, but are also responsible for other vital body functions: They are in charge of maintaining the proper fluid volume within our blood stream. They regulate the levels of our electrolytes including sodium, potassium, chloride, etc. They keep our blood pH (indicator of acidity) at a precise level to maintain optimal function. They are key players in the regulation of blood pressure. Furthermore—and unbeknownst to many—they are responsible for the production of several important hormones: calcitrol (calcium regulation), erythropoietin (red blood cell production), and renin (blood pressure regulation). The kidneys regulate our blood volume by concentrating or diluting our urine depending on our state of hydration. When we are over-hydrated, the kidneys dilute the urine to rid our bodies of excess fluid, resulting in virtually clear urine. When we are dehydrated, the kidneys concentrate urine to preserve our fluid volume, resulting in very concentrated urine that can look as dark as apple cider.

Nocturia correlates with aging and the associated decline in kidney function and decreased ability to concentrate urine. Although having an enlarged prostate may certainly contribute to nocturia, it is obviously much more complicated than this since women do not have prostates and nocturia is equally prevalent in men and women. As simple as getting up at night to urinate sounds, it is actually a complex condition often based upon multiple factors that require careful evaluation in order to sort out and treat appropriately. When a urology consultation is sought, our goal is to distinguish between urological and non-urological causes for nighttime urinating. It often comes down to one of three factors: nighttime urine production by the kidneys; capacity of the urinary bladder; and sleep status. In the elderly population, excessive nighttime urine production is a factor almost 90% of the time.

Nocturia can ultimately be classified into one or more of 5 categories: global polyuria (making too much urine, day and night); nocturnal polyuria (making too much urine at night); reduced bladder capacity; sleep disorders; and circadian clock disorders (problems with our bio-rhythms). Global polyuria can result from excessive fluid intake from overenthusiastic drinking or from dehydration from poorly controlled diabetes mellitus (sugar diabetes). The pituitary gland within our brain manufactures an important hormone responsible for water regulation. This hormone is ADH—anti-diuretic hormone—and it works by giving the message to the kidneys to concentrate urine. Diabetes insipidus is a disease of either kidney origin—in which the kidneys do not respond to ADH—or pituitary origin—in which there is deficient secretion of ADH. In either case, lots of urine will be made, resulting in frequent urination, both daytime and nighttime. Medications including diuretics, SSRIs (selective serotonin reuptake inhibitors), calcium blockers, tetracycline and lithium may induce global polyuria.

Nocturnal polyuria may be on the basis of excessive fluid intake, especially diuretic beverages including caffeine and alcohol, a nocturnal defect in the secretion of ADH, and unresponsiveness of the kidneys to the action of ADH. Congestive heart failure, sleep apnea and kidney insufficiency may also play a role. Certain conditions result in accumulation of fluids in tissues of the body such as the legs (peripheral edema); when lying down to sleep, the fluid is no longer under the same pressures as determined by gravity, and returns to the intravascular (within the blood vessels) compartment. It is then subject to being released from the kidneys as urine. Such conditions include heart, kidney and liver impairment, nephrotic syndrome, malnutrition and venous stasis. Circadian clock disorders cause reduced ADH secretion or activity, resulting in dilute urine that causes nocturia.

Nocturia may also be caused by primary sleep disorders including insomnia, restless leg syndrome, narcolepsy, and arousal disorders (sleepwalking, nightmares, etc.)

There are numerous urological causes of reduced bladder capacity. Any abnormal process that occurs within the bladder can irritate its delicate lining, causing a reduced capacity: bladder infections, bladder stones, bladder cancer, bacterial cystitits, radiation cystitis, and interstitial cystitis. An overactive bladder—a bladder that “squeezes without its owner’s permission”—can cause nocturia. Some people have small bladder capacities on the basis of scarring, radiation, or other forms of damage. Prostate enlargement commonly gives rise to nocturia, as can many neurological diseases that often have profound effects on bladder function. Incomplete bladder emptying can give rise to frequent urination since the bladder is already starting out on a bias of being partially filled. This problem can occur with prostate enlargement, scar tissue in the urethra, neurologic issues, and bladder prolapse.

The principal diagnostic tool for nocturia is the frequency-volume chart (FVC), a simple test that can effectively guide diagnosis and treatment. This is a 24-hour record of the time of urination and volume of urination, requiring a clock, pencil, paper and measuring cup. 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.

Lifestyle modifications to improve nocturia include the following: preemptive voiding before bedtime, intentional nocturnal and late afternoon dehydration, salt restriction, dietary restriction of caffeine and alcohol, adjustment of medication timing, use of compression stockings with afternoon and evening leg elevation, and use of sleep medications as necessary.

Urological issues may need to be managed with medications that relax or shrink the prostate when the issue is prostate obstruction, and bladder relaxants for overactive bladder. For nocturnal polyuria, synthetic ADH (an orally disintegrating sublingual tablet) in dosages of 50-100 micrograms for men and 25 micrograms for women can be highly effective.

Bottom Line: Nocturia should be investigated to determine its cause, which may often 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, MD

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health; available in e-book (Kindle, iBooks, Nook) and coming soon in paperback.

www.MalePelvicFitness.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

www.healthdoc13.wordpress.com