Posts Tagged ‘nocturia’

6 Reasons You May Be Peeing Too Often (That Do Not Require A Urologist)

December 2, 2017

Andrew Siegel MD  12/2/2017

512px-Manneken_Pis_Brussel

Photo of Mannekin Pis in Brussels by Pbrundel (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)%5D, via Wikimedia Commons

Some Necessary Basic Science

The kidneys are the paired organs that regulate urine production. They function by  filtering waste and excess volume from the blood and excreting these as urine. The volume of excretion by the kidneys is based upon several factors: One key factor is your state of hydration—for example, if you have not consumed enough liquid (state of dehydration) there will be scant urine production that is very concentrated appearing (amber color).  On the other hand, if you have over-consumed fluid (state of over-hydration), there will be abundant urine production that is very dilute (like water).  Another important factor determining volume of excretion is the effect of two hormones that regulate kidney function: Anti-diuretic hormone (ADH) is a pituitary hormone that restricts urine production (in order to maintain blood volume and blood pressure), whereas atrial natriuretic peptide (ANP) is a heart muscle hormone that increases urine production and inhibits ADH (in order to decrease blood volume and blood pressure).

ADH Trivia:

  • It is also known as Vasopressin, since it causes arteries to contract
  • It is sometimes used for shock (with severely low blood pressures) and also to stop gastro-intestinal bleeding
  • Certain cancers and other disorders can cause a syndrome called Inappropriate Secretion of ADH in which excessive ADH is produced, resulting in the kidneys over-concentrating urine, causing fluid and electrolyte imbalance, muscle cramps, confusion and convulsions
  • There is a biorhythmic pattern to ADH production, with less ADH production while sleeping, sometimes giving rise to  frequent nocturnal urination. Some people have very suppressed ADH production while asleep and therefore do most of their urinating during sleep hours and minimal urinating during the day.  This can be treated with administration of synthetic ADH.
  • Bedwetting in children is often treated with synthetic ADH

 

6 Reasons You May Be Peeing Too Frequently

  1. Too Much Fluid Intake

As obvious as this one is, it is often overlooked by the over-zealous drinker. As mentioned above, the kidneys play a vital role in fluid regulation and blood pressure.  If you drink excessive volumes of any fluid (this goes for consuming foods high in water content, especially fruit and veggies), you will be making frequent trips to the bathroom to relieve yourself, generally full volumes of dilute-appearing urine. All too often I see patients in the office with urinary urgency and frequency who are never without their water bottle…everything in moderation!

  1. Too Much Caffeine and/or Alcohol

Caffeine (present in coffee, tea, colas, many sports and energy drinks and chocolate) is a diuretic, meaning it makes you urinate.  Similarly, alcohol has a diuretic-like effect (by inhibiting ADH). So, if you are running to the bathroom after drinking a Starbuck’s Venti or alternatively, after drinking 3 beers at the sports bar, it is not a shocker!

  1. Diuretics (water pills)

Many people are on diuretic medications, often for high blood pressure, fluid collection in the ankles and legs (edema) and congestive heart failure.  These medications (some of which are very potent), are geared to make you pee a lot to reduce fluid volumes and blood pressure. So, if you are on Hydrochlorthiazide, Lasix, etc., and are peeing up a storm, it’s not a bladder or prostate problem, but simply the medication doing its job!

  1. Diabetes Mellitus (mellitus meaning sweet)

When diabetes is poorly controlled, high levels of blood sugar cause sugar to spill in the urine, which causes a diuretic-like effect.  In fact, many undiagnosed diabetics present to the urologist with urinary frequency and a dipstick of their urine reveals the presence of glucose and makes the diagnosis of diabetes.  Once diabetic control is achieved, the frequency dramatically improves.  If you have diabetes that is not well-controlled and are peeing hourly, the first visit should be to the internist or endocrinologist to get the diabetes finely tuned.

Certain diabetic medications (SGLT-2 Inhibitors) function by eliminating excess blood sugar in the urine, causing the same diuretic effect and therefore have the side effect of inducing urinary frequency.  These medications include Jardiance, Invokana and Farxiga.

     5. Diabetes Insipidus (insipidus meaning tasteless)

This is a rare cause of frequent urination of large volumes of dilute urine caused by either the failure of production of ADH by the pituitary or alternatively, the ineffectiveness of this hormone in inducing the kidneys to restrict water excretion.

  1. Obstructive Sleep Apnea (OSA)

OSA is a chronic medical disorder that adversely affects sleep, health and quality of life. Repeated complete or partial interruptions of breathing during sleep occur due to mechanical obstruction of the upper airway passage.

Labored efforts to breathe against an obstructed airway result in negative pressures in the chest. This increases the volume of venous blood that returns to the heart, causing distension of the right heart chambers.  The heart responds to this distension as a false sign of fluid volume overload, with the hormonal response of ANP secretion. As a result of the ANP secretion, high volumes of urine are produced during sleep, resulting in sleep-disruptive nighttime urination. There may be as many as 6 or more nighttime awakenings to urinate. When OSA is treated it results in a significant improvement, if not complete resolution of the frequent nocturnal urinating.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx

 

 

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12 STEPS TO OVERCOMING “OVER-ACTIVE” BLADDER (OAB)

May 6, 2017

Andrew Siegel MD  5/6/17 (my daughter’s 18th birthday!)

For most people, the urinary bladder is a cooperative and obedient organ, behaving and adhering to its master’s will, squeezing only when appropriate. However, some people have bladders that are unruly and disobedient, acting rashly and irrationally, squeezing at inappropriate times without their master’s permission. This condition is referred to as “overactive bladder” or OAB for short. This problem can occur in both women and men, although it is more common in females.

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“Gotta go,” the urinary urgency that is the hallmark of OAB

8. UUI

Image above (artist Ashley Halsey from “The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health”) illustrates a bladder contracting involuntarily, leading to urinary leakage

OAB (http://www.njurology.com/overactive-bladder/) is a common condition often due to one’s bladder contracting (squeezing) at any time without warning.  This involuntary bladder contraction can give rise to the symptoms of urgency, frequency (daytime and nighttime) and urgency incontinence. The key symptom of OAB is urinary urgency (a.k.a. “gotta go”), the sudden and compelling desire to urinate that is difficult to postpone.

Although OAB symptoms can occur without specific provocation, they may be triggered by exposure to running water, cold or rainy weather, hand-washing, entering the shower, positional changes such as arising from sitting, and getting nearer and nearer to a bathroom, particularly at the time of placing the key in the door to one’s home.

An evaluation includes a urinalysis (dipstick exam of the urine), a urine culture (test for urinary infection) if indicated, and determination of the post-void residual volume (amount of urine left in bladder immediately after emptying). A 24-hour voiding diary (record of urination documenting time and volume) is an extremely helpful tool.  Urodynamics (test of storage and emptying bladder functions), cystoscopy (visual inspection of inside of bladder), and renal and bladder ultrasound (imaging tests using sound waves) may also prove helpful.

The management of OAB is challenging, yet rewarding, and necessitates a partnership between patient and physician. Successful treatment requires a willing, informed and engaged patient with a positive attitude. Management options for OAB range from non-invasive strategies to pills to surgery. It is sensible to start with the simplest and least invasive means of treatment and progress accordingly to more aggressive and invasive treatments if there is not a satisfactory response to conservative measures.  Behavioral treatments are first-line: fluid management, bladder training, bladder control strategies, pelvic floor muscle training and lifestyle measures.  Behavioral therapies may be combined with medication(s), which are considered second-line treatment. Third-line treatments include neuromodulation (stimulating specific nerves to improve OAB symptoms) and Botox injections into the urinary bladder.

References that will help the process include the following:

Book: THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health www.TheKegelFix.com

Book: MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health www.MalePelvicFitness.com

DVD: Easy-to-use, follow-along, FDA-registered pelvic training program that includes a detailed instruction guide, an interactive DVD and digital access to the guided training routines: www.PelvicRx.com

12 Steps To Overcoming OAB

The goal of the 12 steps that follow is to re-establish control of the urinary bladder.  Providing that the recommendations are diligently adhered to, there can be significant improvement, if not resolution, of OAB symptoms.

  1. FLUID AND CAFFEINE MODERATION/MEDICATION ASSESSMENT  Symptoms of OAB will often not occur until a “critical” urinary volume is reached, and by limiting fluid intake, it will take a longer time to achieve this volume. Try to sensibly restrict your fluid intake in order to decrease the volume of urinary output. Caffeine (present in tea, coffee, colas, some energy drinks and chocolate) and alcohol increase urinary output and are urinary irritants, so it is best to limit intake of these beverages/foods.  Additionally, many foods—particularly fruits and vegetables—have hidden water content, so moderation applies here as well.  It is important to try to consume most of your fluid intake before 7:00 PM to improve nocturnal frequency. Diuretic medications (water pills) can contribute to OAB symptoms. It is worthwhile to check with your medical doctor to see if it is possible to change to an alternative, non-diuretic medication. This will not always be feasible, but if so, may substantially improve your symptoms.
  2. URGENCY INHIBITION Reacting to the first sense of urgency by running to the bathroom needs to be substituted with urgency inhibition techniques. Stop in your tracks, sit, relax and breathe deeply. Pulse your pelvic floor muscles rhythmically (see below) to deploy your own natural reflex to resist and suppress urgency.
  3. TIMED VOIDING (for incontinence) Urinating by the “clock” and not by your own sense of urgency will keep your bladder as empty as possible. By emptying the bladder before the critical volume is reached (at which urgency incontinence occurs), the incontinence can be controlled.  Voiding on a two-hour basis is usually effective, although the specific timetable has to be tailored to the individual in accordance with the voiding diary.  Such “preemptive” or “defensive” voiding is a very useful technique since purposeful urinary frequency is more desirable than incontinence.
  4. BLADDER RETRAINING (for urgency/frequency) This is imposing a gradually increasing interval between voids to establish a more normal pattern of urination. Relying on your own sense of urgency often does not give you accurate information about the status of your bladder fullness.  Urinating by the “clock” and not by your own sense of urgency will keep your voided volumes more appropriate. Voiding on a two-hour basis is usually effective as a starting point, although the specific timetable has to be tailored to the individual, based upon the voiding diary.  A gradual and progressive increase in the interval between voiding can be achieved by consciously delaying urinating.  A goal of an increase in the voiding interval by 15-30 minutes per week is desirable.  Eventually, a return to more acceptable voiding intervals is possible.  The urgency inhibiting techniques mentioned above are helpful with this process.
  5. BOWEL REGULARITY Avoidance of constipation is an important means of helping control OAB symptoms. Because of the proximity of the rectum and bladder, a full rectum can put pressure on the bladder, resulting in worsening of urgency, frequency and incontinence.
  6. PELVIC FLOOR MUSCLE TRAINING (PFMT)  *All patients need to understand the vital role of the pelvic floor muscles (PFM) in inhibiting urgency and frequency and preventing urge leakage.  PFMT voluntarily employs the PFM to help stimulate inhibitory reflexes between the pelvic floor muscles and the bladder.  Rhythmic pulsing of the PFM can inhibit an involuntary contraction once it starts and prevent an involuntary contraction before it even begins. Initially, one must develop an awareness of the presence, location, and nature of the PFM and then train these muscles to increase their strength and tone.  These are not the muscles of the abdominal wall, thighs or buttocks.  A simple means of recognizing the PFM for a female is to insert a finger inside her vagina and squeeze the PFM until the vagina tightens around her finger.  A simple means of identifying the PFM for either gender is to start urinating and when about half completed, to abruptly stop the stream. It is the PFM that allows one to do so. It is important to recognize the specific triggers that induce urgency, frequency or incontinence and prior to exposure to a trigger or at the time of the perceived urgency, rhythmic pulsing of the PFM–“snapping” the PFM several times–can either preempt the abnormal bladder contraction before it occurs or diminish or abort the bladder contraction after it begins.  Thus, by actively squeezing the PFM just before and during these trigger activities, the urgency can be diminished and the urgency incontinence can often be avoided.

oab

Schematic diagram above illustrates the relationship of the contractile state of the bladder muscle to the contractile state of the PFM. Note that a voluntary PFM contraction can turn off an involuntary bladder contraction (+ symbol denotes contraction; – symbol denotes relaxation)

7. LIFESTYLE MEASURES: HEALTHY WEIGHT, EXERCISE, TOBACCO CESSATION   The burden of excess pounds can worsen OAB issues by putting pressure on the urinary bladder. Even a modest weight loss may improve OAB symptoms.  Pursuing physical activities can help maintain general fitness and improve urinary control. Lower impact exercises–yoga, Pilates, cycling, swimming, etc.–can best help alleviate pressure on the urinary bladder by boosting core muscle strength and tone and improving posture and alignment. The chemical constituents of tobacco constrict blood vessels, impair blood flow, decrease tissue oxygenation and promote inflammation, compromising the bladder, urethra and PFM.  By eliminating tobacco, symptoms of OAB can be improved. 

8.  BLADDER RELAXANT MEDICATIONS A variety of medications are useful to suppress OAB symptoms. It may take several trials of different medications or combinations of medications to achieve optimal results. The medications include the following: Tolterodine (Detrol LA), Oxybutynin (Ditropan XL), Transdermal Oxybutynin (Oxytrol patch), Oxybutynin gel (Gelnique), Trospium (Sanctura), Solifenacin (Vesicare), Darifenacin (Enablex) and Fesoterodine (Toviaz).  The most common side effects are dry mouth and constipation.  These medications cannot be used in the presence of urinary or gastric retention or uncontrolled narrow-angle glaucoma.  The newest medication, Mirabegron (Myrbetriq), has a different mechanism of action and fewer side effects.

9.  BIOFEEDBACK This is an adjunct to PFMT in which electronic instrumentation is used to relay feedback information about your PFM contractions.  This can enhance awareness and strength of the PFM.

10.  BOTOX TREATMENT This is a simple office procedure in which Botox is injected directly into the bladder muscle, helping reduce OAB symptoms by relaxing those areas of the bladder into which it is injected. Botox injections generally will last for six to nine months and are covered by Medicare and most insurance companies.

11.  PERCUTANEOUS TIBIAL NERVE STIMULATION (PTNS) This is a minimally invasive form of neuromodulation in which a tiny acupuncture-style needle is inserted near the tibial nerve in the ankle and a hand-held stimulator generates electrical stimulation with the intent of improving OAB symptoms. This is done once weekly for 12 weeks.

12.  INTERSTIM This is a more invasive form of neuromodulation in which electrical impulses are used to stimulate and modulate sacral nerves in an effort to relieve the OAB symptoms. A battery-powered neuro-stimulator (bladder “pacemaker”) provides the mild electrical impulses that are carried by a small lead wire to stimulate the selected sacral nerves that affect bladder function.

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.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Sleep Apnea: Bad For Your Health (General, Sexual & Urinary)

February 6, 2016

Andrew Siegel MD   2/6/16

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(Thank you Pixabay for image)

This is an important topic, an issue that the medical community is just getting wind of (pardon the pun) with respect to how common a problem it is and how significant its consequences are. Obstructive sleep apnea (OSA) negatively affects all aspects of health, including sexual and urinary function. Many patients with OSA present with urological symptoms that are not genital/urinary in origin, their root cause being the OSA.  When the OSA is treated, the urological symptoms improve dramatically. 

Obstructive sleep apnea (OSA) is a chronic medical disorder that adversely affects one’s sleep, health and quality of life. It is characterized by repeated complete or partial interruptions of breathing during sleep due to mechanical obstruction of the upper airway passage. Muscle relaxation during sleeping—including those muscles that support the tongue and throat—results in the soft tissues in the throat sagging and collapsing under the force of gravity, pulling the airway closed and causing intermittent suffocation. This reduces or halts breathing and causes below-normal levels of oxygen in the blood, giving rise to insomnia and restless sleep with frequent awakenings. OSA sufferers wake up fatigued and have excessive daytime sleepiness, which correlates with an increased chance of motor vehicle accidents, “fatigue” eating and sleep deprivation-related cognitive impairment and mood disturbances.

OSA is present in about 25% of men and 10% of women in the USA. It is more prevalent with aging and with obesity.  Snoring in a loud and exaggerated fashion is typical, and snorting and gasping for air is characteristic. Other manifestations of OSA are a dry mouth and throat and abnormal daytime breathing patterns–particularly loud, shallow mouth breathing. It is not uncommon for those with OSA to have anatomical irregularities, including a thick neck, enlarged tonsils and palate and jaw abnormalities.

Obesity and OSA share much in common, both chronic diseases that give rise to serious medical issues affecting quantity and quality of life. OSA results in hypoxia (lack of oxygen supply), an unhealthy state since every cell, tissue and organ in our body depends upon oxygen to fuel proper function. A spectrum of serious medical issues can result, including headache, impaired glucose metabolism/type 2 diabetes, depression, chronic kidney disease, peripheral neuropathy, glaucoma and cardiovascular disease. OSA is detrimental to endothelial cell function, the specialized cells that line arteries, and OSA-related cardiovascular disease includes high blood pressure, heart attack, stroke, congestive heart failure, arrhythmia and atrial fibrillation. OSA increases the risk of premature mortality.

OSA is associated with urological issues including decreased sex drive, low testosterone levels, sexual dysfunction in both men and women, overactive bladder and frequent nighttime urinating (a.k.a. nocturia).

OSA and Urination

Many with OSA have urinary symptoms because of the OSA and not because of problems with their bladder, prostate, kidneys, etc. They often end up in a urologist’s office because their primary symptoms are urinary. The two most prevalent urinary issues associated with OSA are nighttime urination and overactive bladder.

Nocturnal urine production by the kidneys is based upon many factors including fluid intake as well as the production of certain hormones. The two key hormones involved are anti-diuretic hormone (ADH) and atrial natriuretic peptide (ANP). ADH is a pituitary hormone that regulates water excretion by the kidney, restricting urine production so that humans maintain their blood volume. ANP is the opposite—a diuretic that increases water excretion by the kidney, causing abundant urine production, as well as inhibiting ADH.

Here is what happens with OSA: Vigorous efforts to breathe against an obstructed airway result in negative pressures in the chest. This increases the volume of venous blood that returns to the heart, causing distension of the right heart chambers (atrium and ventricle). The heart responds to this distension as a false sign of fluid volume overload, with a hormonal response of secreting ANP. As a result of the ANP secretion, high volumes of urine are produced during sleep, resulting in sleep-disruptive nocturia. There may be as many as 6 or more nighttime awakenings to urinate. When OSA is treated it results in a significant improvement, if not complete resolution, of the sleep disruptive nocturia.

In contrast to nocturia, overactive bladder is more of a daytime issue. Its symptoms include the sudden and urgent desire to urinate (a.k.a. “gotta go”), urinating frequently, and possibly urinary leakage (urgency urinary incontinence). The cardinal symptom of OAB is urgency, the sudden and compelling desire to urinate that is difficult to postpone. Studies have shown a direct relationship between the severity of OSA and the severity of OAB symptoms.

 OSA and Sex

Sexual issues are common among men and women with OSA. Men typically experience a loss of interest in sex, low testosterone and difficulties obtaining and maintaining erections.  Women can experience a loss in sex drive and other symptoms of female sexual dysfunction.  Neurological testing of patients with OSA-related erectile dysfunction has shown an absent or impaired bulbo-cavernosus reflex, which is a measure of pelvic floor muscle response to sexual stimulation. The extent of impairment is directly proportional to the severity of the OSA. Essentially, this is peripheral neuropathy—nerve damage that negatively affects sexual function.

 Diagnosing OSA

Despite growing awareness of OSA, 90% of those with the disorder are undiagnosed and untreated. The diagnosis is made with overnight sleep studies, performed under the care of a pulmonologist, an internist who specializes in lung problems. This study records sleep stages, heart rhythm, leg movements, breathing patterns and oxygen saturations. OSA is defined as a complete cessation of airflow lasting more than 10 seconds (apneic episodes). The degree of OSA is based upon the number of episodes per hour of breathing cessation:

  • Mild OSA: 5-15 apneic episodes per hour
  • Moderate OSA: 15-30 apneic episodes per hour
  • Severe OSA: more than 30 apneic episodes per hour

As an alternative to overnight sleep studies that require an overnight stay in a sleep lab, home sleep testing machines are now available.

Treating OSA

Since many with OSA carry the burden of extra pounds–which contributes in a major way to the problem–the first-line treatment is lifestyle improvement. This includes healthy eating, weight loss, exercise, smoking cessation, etc. Additionally, alcohol and other sedative medications (that can further interfere with breathing) should be avoided. Positional therapy–avoiding the supine position and instead sleeping upright–can be helpful as well.

Continuous positive airway pressure (CPAP) is the most common and effective treatment for OSA and is considered the gold standard. This is an apparatus that maintains the airway and airflow, preventing apnea and the negative consequences of lack of oxygen. The problem with CPAP is that it is a somewhat cumbersome device that some people tolerate poorly. Alternatively, oral appliances that are fitted by a dentist can be effective, are less cumbersome than CPAP and do not require an electrical source. A procedure under investigation is the implantation of a hypoglossus nerve stimulators, which can help prevent some of the involved muscles from sagging and causing obstruction. On occasion, surgery such as uvulo-palato-pharyngoplasty performed by an ear/nose/throat surgeon is needed to help alleviate the obstructed breathing passage.

Bottom Line: OSA causes reduced levels of oxygen in the blood and therefore diminished oxygen supply to all cells in the body. Oxygen is vital for cellular function, and similar to the mechanical choking of one’s neck from OSA, so the cells, tissues and organs of the body “choke” in response to insufficient oxygen. The symptoms of OSA are due to the collateral damage from this lack of oxygen with impaired nerve and blood vessel function being particularly detrimental. Many urological issues can develop as a result of OSA, including sleep-disruptive nighttime urination, overactive bladder and altered sexual function. Fortunately, OSA is a treatable condition.

A shout-out to my friend and dentist extraordinaire who has expertise on OSA and the use of oral appliances:  Warren Boardman, DDS, Bergen County Center for Snoring, Sleep Apnea & CPAP Intolerance, 75 Chestnut Street, Ridgewood, NJ, 07450, 201-445-4808

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

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.

Use Your Pelvic Floor To Overcome Over-Active Bladder

May 16, 2015

Andrew Siegel MD  5/16/15

shutterstock_orange gu tract closeupshutterstock_femalebluepelvic

Over-Active Bladder (OAB) is urinary urgency (the sudden and urgent desire to urinate) and frequency (urinating too often, which can be during both awake and sleep hours), with or without urgency incontinence (urinary leakage associated with the urgent desire to urinate). It is often due to involuntary contractions of the bladder in which the bladder squeezes—inappropriately so—without its “owner’s” permission. Although it can occur without provocation, it is commonly triggered by positional changes such as going from sitting to standing, exposure to running water, approaching a bathroom, and when placing the key in the door to one’s home.

The American Urological Association guidelines for OAB recommend pelvic floor muscle (PFM) training as first-line therapy for OAB because voluntary PFM contractions can effectively inhibit involuntary bladder contractions and squelch the urgency and urgency incontinence.

Bladder Physiology 101

In order to effectively tap into the powers of the pelvic floor, a basic understanding of bladder function is necessary. During urine storage, the bladder muscle is in a relaxed (non-contracting state) and the urinary sphincters (contributed to by the PFM muscles), responsible for urinary control, are engaged (contracted). During urine emptying, the bladder muscle contracts and the sphincter muscles relax synchronously. This “antagonistic” relationship between the bladder muscle and the PFMs can be used to the advantage of those suffering with OAB. Since people with OAB often have bladders that contract involuntarily causing the symptoms of urgency and frequency, a means of getting the bladder to relax is to intentionally engage the PFMs to benefit from the reflex relaxation of the bladder that occurs with voluntary contraction of the PFMs.

The PFM-Bladder Reflex

This is a very useful and practical reflex that you can easily access. This reflex is unique because it can be engaged voluntarily and because it results in the relaxation of a muscle as opposed to its contraction. Anyone who has ever experienced an urgent desire to urinate or move one’s bowels will find this reflex of great practical use. When the reflex is deployed, it will result in relaxation of both the urinary bladder and rectum and a quieting down of the urgency.

How To Use The Reflex To Your Advantage

When you feel the sudden and urgent desire to urinate, pulse the PFMs five times, briefly but intensely. When the PFM are so deployed, the bladder muscle reflexively relaxes and the feeling of intense urgency should disappear. Likewise, when the PFM are so deployed, the rectum relaxes and the feeling of intense bowel urgency should diminish. This reflex is a keeper when you are stuck in traffic and have no access to a toilet!

PFM training helps stimulate the inhibitory reflex between the PFMs and the bladder muscle. A PFM training program will stimulate your awareness of the PFM and enable you to isolate them and increase their strength, tone, and endurance. The inhibitory reflex will become more robust and you will develop an enhanced ability to counteract urgency, frequency and urgency incontinence. Urgency can often be diminished and the urgency incontinence can often be abolished.

Getting beyond inhibiting urgency after it occurs is preventing it from occurring in the first place. In order to do so, it is important to recognize the specific triggers that induce the urgency, frequency or incontinence: hand washing, key in the door, rising from sitting, running water, entering the shower, cold or rainy weather, etc. Prior to exposure to a trigger, rapid flexes of the PFM can preempt the involuntary bladder contraction before it has a chance to occur.

Bottom Line: There are many treatments available for OAB, including decreasing your fluid and caffeine intake, bladder re-training, oral medications, Botox injections into the bladder and neuro-stimulation. As a first-line approach, tap into the powers of your PFM and harness the natural reflex in which involuntary bladder contractions can be inhibited or prevented by engaging your PFM.

Wishing you the best of health,

2014-04-23 20:16:29

AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in your email in box 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:          

http://www.MalePelvicFitness.com

Co-creator of Private Gym pelvic floor muscle training program for men:

http://www.PrivateGym.com 

The Private Gym is a comprehensive, interactive, follow-along exercise program that provides the resources to strengthen the pelvic floor muscles that are vital to sexual and urinary health. The program builds upon the foundational work of Dr. Arnold Kegel, who popularized exercises for women to increase pelvic muscle strength and tone. This FDA registered program is effective, safe and easy-to-use. The “Basic Training” program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises and the “Complete Program” provides maximal opportunity for gains through its patented resistance equipment.

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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Post-Void Dribbling

May 25, 2013

Post-Void Dribbling (PVD)

Andrew Siegel, MD  Blog #108

Introduction:  Probably the two most common and annoying complaints from my male patients are sleep-disruptive nighttime urination and post-void dribbling. The following is a tiny “taste” of the content of my new book, forthcoming this summer, entitled Male Pelvic Fitness: Optimizing Sexual and Urinary Health.

The Problem: Post-void dribbling is the leakage of urine immediately or shortly after completing the act of urinating. This “after-dribble” is more annoying than serious and can be one of the first manifestations of prostate enlargement.  Although it rarely occurs before age forty, it can happen on occasion to men of any age.

Dorey et al published an article in the British Journal of Urology that demonstrated the effectiveness of pelvic floor muscle (PFM) exercises for erectile dysfunction, but also suggested an association between the occurrence of erectile dysfunction (ED) and post-void dribbling.  How fascinating—ED and PVD are linked and parallel problems, one sexual and the other urinary—both being manifestations of pelvic floor muscle weakness, and both treatable by increasing pelvic floor muscle fitness.

The Science: The urethra has an external portion within the penis, an internal portion that travels in the perineum (the area of the body between the scrotum and the anus), and an innermost portion, which traverses the prostate and enters the bladder.  After urinating, there is always some urine that remains and pools in the internal urethra.  When it drips out of the urethra aided by gravity and movement, it is referred to as PVD.

The Premise: Pelvic floor muscle contractions are the body’s natural mechanism for draining the urethra.  Improving the strength and tone of the PFM will help eject the contents of the inner, deeper portion of the urethra.  When contracted, the bulbocavernosus (BC) muscle compresses this deep portion of the urethra, displacing the urine within further downstream.  A powerful BC muscle will substantially help this process, in much the same way that it facilitates ejaculation. The BC is the body’s natural urethral “stripper”; however, the BC does not surround the entire urethra, so it is likely that a strong BC will improve the PVD, although it is possible to still have some drops remaining in the penile urethra.

The Solution: Try not to rush the act of urination.  The adage “haste makes waste” is absolutely relevant with respect to PVD. When finished urinating, vigorously contract the PFM several times to displace the inner urethra’s contents. If necessary, the urethra of the penis can be further evacuated of urine by manually compressing and stripping it.  To do so, starting where the penis meets the scrotum, compress the urethra between your thumb on top and index and middle fingers on the undersurface and draw them forth towards the penile tip, “milking” out any remaining urine.  To further improve the PVD, gently shake the penis until no more urine drips from the urethra. It is not a bad idea to apply tissue to the tip of the penis to soak up any residual urine—women have the right idea here.

 

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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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

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.