Posts Tagged ‘kidneys’

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

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When Our Kidneys Go South

October 26, 2013

Andrew Siegel MD Blog #125

Our kidneys are paired, bean-shaped, fist-sized organs that work diligently and silently behind the scenes 24/7/365, filtering our blood free of toxins and waste products so that we can maintain a healthy existence. When they are working well, they are often taken for granted.  The renal arteries bring blood to the kidneys, the kidneys do their magic, and the cleansed and purified blood is returned into the renal veins, with the liquid waste—urine—excreted into the ureters that drain into the urinary bladder.

If the kidneys stop working properly, excessive fluid and toxic wastes build up rapidly, resulting in death within a matter of days to weeks. Death by kidney failure is described as “euphoric” because of the very abnormal blood chemistries and electrolyte disturbances that occur…not that death is something to be “giddy” about, but kidney failure just happens to be an easier, more peaceful way to exit the planet than many others.

Because of their critical importance to our healthy existence, it behooves us to take great care of these prized possessions, which nature gave us in duplicate. This “spare tire” is capable of sustaining life in the event of trauma, cancer requiring surgical removal, donating a kidney or other issues resulting in loss of one kidney.

The kidneys are multifunctional, not only filtering our blood to remove waste products, but also responsible for regulating fluid, electrolyte, acid-base balance and blood pressure.  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).

Kidney disease is a very common cause of serious illness with a prevalence of more than 25 million Americans. Each year approximately 110,000 new patients start dialysis treatments in the USA.  Kidney disease is responsible for nearly 100,000 American deaths annually. When the kidneys fail (end stage renal disease), the options are peritoneal dialysis, hemodialysis, kidney transplantation, or death. Peritoneal dialysis uses the peritoneal membrane that lines the abdomen as a filter to clear wastes and extra fluid from the body. Hemodialysis involves being hooked up to a machine that mimics the function of the kidneys; it requires three sessions weekly that take about 3-4 hours per session.

The unfortunate thing about kidney disease is that it typically causes few symptoms until it is advanced; however, simple tests are capable of detecting it.   Symptoms of kidney disease are non-specific and may include the following: fatigue; decreased energy; poor appetite; difficulty concentrating; insomnia; swollen ankles and feet; nighttime muscle cramping; puffiness around one’s eyes; dry and itchy skin; and the need for frequent urination, particularly at night

A definitive sign of kidney disease is the presence of protein in the urine, which is easily detectable on a urinalysis. Additionally, uncontrolled high blood pressure is highly suggestive of kidney disease, as is an elevated serum creatinine, detectable by a simple blood test.  Early detection is critical as it can help prevent kidney disease from progressing to kidney failure. The bottom line is that three simple tests can detect kidney disease:  blood pressure; serum creatinine; urine albumin (protein).

Under normal circumstances, the kidneys filter the blood, removing waste products and excessive fluid, returning into circulation the body’s important chemicals and constituents. When the filtration system is not working properly, one’s system is not cleared of the bad (waste products), resulting in electrolyte disturbances and proteinuria, a condition in which what is good for the body (protein) ends up being filtered out into the urine.

Risk factors for kidney disease are the following: African-American race; diabetes; high blood pressure; and family history of kidney disease.  The two leading causes of chronic kidney disease are hypertension and diabetes, responsible for about two thirds of cases.

Urologists are the specialists who deal with surgical kidney issues whereas nephrologists are the specialists who deal with medical kidney tissues including hypertension and impaired kidney function. If kidney disease is diagnosed, one will typically be referred to a nephrologist for further evaluation and management.  Nephrologists will typically measure the serum creatinine, and do blood and urine tests to assess the glomerular filtration rate, a quantitative test of kidney function.  Often a renal ultrasound is performed and in some cases it is necessary to do a renal biopsy to find the root cause of the kidney dysfunction

Treatment for progressive kidney disease includes interventions such as blood pressure control, often with the use of ACE inhibitors and angiotensin receptor blockers, and control of diabetes.   Nutritional interventions include dietary protein restriction that may slow the progression of chronic kidney disease.   High-protein intake can worsen the proteinuria and result in the accumulation of various protein breakdown products as a result of decreasing kidney function, which can cause toxic effects.

A truly unfortunate fact of life is that many of us are not responsible caretakers of our kidneys (or any of our other “precious physical valuables”); many seem to take better care of their automobiles than they do of their own health.  How many of us change our oil every 3000 miles, bring our cars in for regular service and proudly maintain shiny exteriors while at the same time neglecting our own health by living a harmful lifestyle.  This includes a sedentary existence, excessive stress, insufficient sleep and substance abuse—of alcohol, tobacco and food—with diets high in red and processed meats, sodium and fat laden concoctions, sugar-sweetened drinks, etc., and low in fruits, vegetables, legumes, nuts, whole grains, and low-fat dairy.  The result: obesity, high blood pressure, and elevated cholesterol, which oftentimes leads to diabetes, heart attack, stroke, cancer, and premature death. Sadly, the diabetic situation in our nation—often referred to as “diabesity”—has become epidemic and, as mentioned, is one of the leading causes of chronic kidney disease in the United States.

So how do we care for our kidneys?  The prescription for healthy kidneys is to maintain a healthy lifestyle and, if you have been neglectful in this department, to do a lifestyle remake through the following: good eating habits; maintaining a healthy weight; engaging in exercise; obtaining adequate sleep; consuming alcohol in moderation; avoiding tobacco; and stress reduction.  Additionally, being proactive by seeing a physician on a regular basis for “scheduled maintenance” is of paramount importance in order to detect kidney disease—or any other malady—as early as possible, no matter what the ivory tower pundits say about the ineffectiveness of annual physicals.

Bottom Line: Kidney disease is a debilitating—oftentimes deadly—condition, the risk for which can be greatly reduced by adopting a healthy lifestyle. Never neglect your health, for it is your greatest wealth. 

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

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

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

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What The Heck is Urology?

August 24, 2013

Andrew Siegel, MD  Blog #116

“Urology” (uro—urinary tract and logos—study of) is a medical specialty concerned with the study, diagnosis, and treatment of diseases of the urinary tract in females and of the genitourinary tract in males. The organs under the “domain” of urology include the adrenal glands, kidneys, the ureters (tubes connecting the kidneys to the urinary bladder), the urinary bladder and the urethra (the channel that conducts urine from the bladder to the outside).  The male reproductive organs include the testes (i.e., testicles), epididymis (structures above and behind the testicle where sperm mature and are stored), vas deferens (sperm duct), seminal vesicles (the structure that produces the bulk of semen), prostate gland and, of course, the scrotum and penis.  The reproductive and urinary tracts are closely connected, and disorders of one oftentimes affect the other…thus urologists are referred to as  “genitourinary” specialists. Urology involves both medical and surgical strategies to approach a variety of conditions.

Urology has always been on the cutting edge of surgical advancements (no pun intended) and urologists employ minimally invasive technologies including fiber-optic scopes to be able to view the entire inside aspect of the urinary tract, as well as ultrasound, lasers, laparoscopy and robotics.  There is a great deal of overlap in what urologists do with other medical and surgical disciplines, including nephrology (doctors who specialize in medical diseases of the kidney); oncology (cancer specialists); radiation oncologists (radiation cancer specialists); radiology (imaging); gynecology (female specialists); and endocrinology (hormone specialists).

Urologists are the male counterparts to gynecologists and the go-to physicians when it comes to expertise in male pelvic health.  Urologists, in addition to being physicians, are also surgeons who care for serious and potentially life-threatening illnesses, particularly cancers of the genital and urinary tracts.  In terms of new cancer cases per year in American men, prostate cancer is number one accounting for almost 30% of cases; bladder cancer is number four accounting for 6% of cases; and cancer of the kidney and renal pelvis (the inner part of the kidney that collects the urine) are number six accounting for 5% of cases.  Urologists are also the specialists who treat testicular cancer.  Urologists also treat women with kidney and bladder cancer, although the prevalence of these cancers is much less so than in males. 

Very common reasons for a referral to a urologist are the following: blood in the urine, whether it is visible or picked up on a urinalysis done as part of an annual physical; an elevated PSA (Prostate Specific Antigen) or an accelerated increase of PSA over time; prostate enlargement; irregularities of the prostate on examination; urinary difficulties ranging the gamut from urinary incontinence to the inability to urinate (urinary retention).

Urologists manage a variety of non-cancer issues. Kidney stones, which can be extraordinarily painful, keep us very busy, especially in the hot summer months when dehydration (a major risk factor) is more prevalent. Infections are a large part of our practice and can involve the bladder, kidneys, prostate, or the testicles and epididymis.  Urinary infections is one problem that is much more prevalent in women than in men.  Sexual dysfunction is a very prevalent condition that occupies much of the time of the urologist—under this category are problems of erectile dysfunction, problems of ejaculation, and testosterone issues. Urologists treat not only male infertility, but create male infertility when it is desired by performing voluntary male sterilization (vasectomy).   Urologists are responsible for caring for scrotal issues including testicular pain and swelling.   Many referrals are made to urologists for blood in the semen.

Training to become a urologist involves attending 4 years of medical school after college and 1–2 years of general surgery training followed by 4 years of urology residency. Thereafter, many urologists like myself pursue additional sub-specialty training in the form of a fellowship that can last anywhere from 1–3 years.  Urology board certification can be achieved if one graduates from an accredited residency and passes a written exam and an oral exam and has an appropriate log of cases that are reviewed by the board committee.  One must thereafter maintain board certification by participating in continuing medical education and passing a recertification exam every ten years.  Becoming board certified is the equivalent of a lawyer passing the bar exam.

In addition to obtaining board certification in general urology, there are 2 sub-specialties within the scope of urology in which sub-specialty board certification can be obtained—pediatric urology, which is the practice of urology limited to children and female pelvic medicine and reconstructive surgery (FPMRS), which involves female urinary incontinence, pelvic organ prolapse, and other female uro-gynecological issues.  The FPMRS boards were offered for the very first time in June 2013, and I am pleased to announce that I am now board certified in both general urology and FPMRS.  There are approximately 100 or so urologists in the entire country who are board certified in the urology subspecialty of FPMRS.

In terms of the demographics of urology, although urology is largely a male specialty, women have been entering the urological workforce with increasing frequency.  This is because female students now comprise approximately 50% of United States medical school population. There are 10,000 practicing urologists in the USA, of which about 500 are women. Urologists have a median age of 53, so we are not a particularly young specialty. The aging population will demand more urological health services and the Affordable Care Act will result in the dramatic expansion of the number of American citizens with health insurance. These factors combined with the aging of the urological workforce and the contraction due to retirement, all in the face of growing demands, does not augur well for a balance of supply and demand in the forthcoming years.  Hopefully there will be enough of us to provide urological care to those in the population that need it.

Andrew Siegel, M.D.

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

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health, in press and available in e-book and paperback formats in the Autumn 2013.

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.