Posts Tagged ‘overactive bladder’

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.

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Applied Kegels: Functional Pelvic Fitness

November 19, 2014

Andrew Siegel MD 11/19/14

I’ll be in Miami for a few days at the SMSNA (Sexual Medical Society of North America) meeting, so will upload this blog earlier than usual.

 FUNCTIONAL PELVIC FITNESS

It’s one thing to work out your muscles in order to make them stronger, better toned and more durable, but it’s another dimension when you can put that effort to practical use over the course of your day. Since the pelvic floor muscles are muscles of function rather than form, muscles for “go” rather than “show,” they can be put into service when applied to common real life situations.

Urinary and Bowel Urgency (for both sexes)

Chances are that at one time or another you have experienced a sudden and urgent desire to use the bathroom when none was nowhere in sight. This often occurs as a result of an involuntary bladder or bowel contraction, when the bladder or bowel squeezes without your permission, sometimes on the basis of triggers that induce a conditioned response (classic triggers are hand washing, placing a key in the door to your home, rising from sitting, exposure to running water, entering the shower, cold or rainy weather, getting closer and closer to the bathroom, etc.). By recognizing the occurrence of the involuntary contraction and by actively squeezing your pelvic floor muscles using a “rapid flex” technique—rapidly pulsing the pelvic muscles 3-5 times—the urgency can be relieved (and the leakage that can sometimes occur can often be prevented). This works equally as well for bowel urgency as it does for urinary urgency.

Going a step beyond inhibiting urgency after it occurs is preventing it from occurring before it occurs. In order to do so, it is important to recognize any triggers that may induce your urgency. Immediately prior to exposure to a trigger, rapid flexes of the pelvic floor muscles can thwart the involuntary contraction before it even arises.

 

Dribbling After Urinating (for men)

An “after-dribble” of urine is more annoying than serious and is often a sign of weakening pelvic floor muscles, for which strengthening exercises have proven an effective remedy. Squeezing the pelvic floor muscles is the body’s natural way of expelling the contents of the urinary channel. When contracted, the bulbocavernosus muscle—the body’s urethral “stripper”—compresses the deep portion of the urethra, pushing the urine out. The 1909 Gray’s Anatomy aptly labeled this muscle the “ejaculator urine.”

By actively squeezing your pelvic floor muscles immediately after urinating by using a “basic flex” technique—powerfully pulsing the pelvic floor muscles 3-5 times for 1-2 seconds per contraction—the last few drops of urine will be directed into the toilet and not your pants.

 

Stress Urinary Incontinence (for both sexes)

Stress incontinence is urinary leakage provoked by sudden increases in abdominal pressure, triggered by sneezing, coughing, bending, lifting, exercising, positional change, etc. It is a common condition in women, often resulting from the pelvic trauma of childbirth, weakening the pelvic muscles and connective tissues that support the urinary channel. Although less common in men, it can occur following radical prostatectomy for prostate cancer and sometimes after prostate surgery done for benign conditions.

In order to help control stress incontinence, you need to be attentive to the triggers that provoke it. By actively squeezing the pelvic floor muscles immediately prior to the trigger exposure, the incontinence can be improved or eliminated. For example, if standing up provokes the incontinence, do a brisk pelvic floor muscle contraction using a “long, hard flex”—contracting the pelvic floor muscles powerfully for 3-5 seconds when transitioning from sitting to standing. This long, hard flex is a means of bracing the pelvic floor muscles immediately prior to an activity that incites the problem and can be a highly effective means of managing the stress incontinence. When practiced diligently, it becomes an automatic behavior.

 

Premature Ejaculation

Weak pelvic floor muscles seem to play a role in hindering your ability to delay ejaculation. Pelvic floor muscle exercises are a promising treatment option for premature ejaculation, as they will increase the strength, tone, power, and endurance of the pelvic muscles, which can help short-circuit the premature ejaculation. Numerous scientific studies have demonstrated the effectiveness of pelvic floor muscle training in the management of premature ejaculation.

To apply your pelvic muscle facility to the real life situation you need to recognize the imminent ejaculation, slow the pace of intercourse, pause the pelvic thrusting and perform a “hold”—a pelvic floor muscle contraction lasting about 10 seconds or so, until the point that the ejaculatory urgency disappears. By actively deploying your pelvic floor muscles by using this sustained contraction of the pelvic floor muscles, the ejaculation can often be forestalled and intercourse resumed.

Bottom Line: Pelvic floor muscle training has numerous practical benefits, from the bedroom to the bathroom. Learn more about the specifics of these exercises—rapid flexes, basic flexes, long hard flexes and holds, through the Private Gym pelvic floor muscle training program, a comprehensive, interactive, follow-along exercise program that strengthens the muscles that support sexual and urinary health. (www.PrivateGym.com)

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

6922

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: http://www.MalePelvicFitness.com

Private Gym: http://www.PrivateGym.com – now available on Amazon

10 Myths About Kegel Exercises: What You Need to Know

November 14, 2014

Andrew Siegel, M.D.

 

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shutterstock_femalebluepelvic

 

Myth: Kegels are just for the ladies.

Truth: Au contraire…men have essentially the same pelvic floor muscles as do women and can derive similar benefits to sexual, urinary, and bowel health.

 

Myth: The best way to do Kegels is to stop the flow of urine.

Truth: If you can stop your stream, it is indeed proof that you are contracting the proper set of muscles. However, this is just a means of feedback to reinforce that you are employing the right muscles, but the bathroom should not be your Kegel muscle gymnasium.

 

Myth: You should do Kegel exercises as often as possible.

Truth: Pelvic floor muscle exercises strengthen and tone the pelvic floor muscles and like other muscle-strengthening routines, should not be performed every day. Pelvic exercises should be done in accordance with an intelligently designed plan of progressively more difficult and challenging exercises that require rest periods in order for optimal muscle growth and response.

 

Myth: You can and should do Kegels anywhere (while stopped in your car at a red light, waiting in line at the check out, while watching television, etc.)

Truth: Exercises of the pelvic floor muscles, like any other form of exercise, demand gravitas, focus, and isolation of the muscle group at hand. Until you are able to master the exercise regimen, it is best that the exercises be performed in an appropriate venue, free of distraction, which allows single-minded focus and concentration. This is not to say that once you achieve mastery of the exercises and a fit pelvic floor that you cannot integrate the exercises into the activities of daily living.

 

Myth: Holding the pelvic floor muscles tight all the time is desirable.

Truth: Not a good idea…the pelvic floor muscles have natural tone to them and when you are not actively engaging and exercising them, they should be left to their own natural state. There exists a condition—tension myalgia of the pelvic floor muscles—in which there is spasticity, tightness and pain due to excessive tension of these muscles. Pelvic floor training in this circumstance must be done with caution in order to avoid aggravating the pain, but maximal muscle contraction can induce maximal muscle relaxation, a meditative state between muscle contractions.

 

Myth: Focusing on your core is enough to ensure pelvic floor muscle fitness.

Truth: The pelvic floor muscles do form the floor of the “core” group of muscles and get some workout whenever the core muscles are exercised. However, for maximum benefit, specific focus needs to be made on the pelvic floor muscles. In Pilates and yoga, there is an emphasis on the core group of muscles and a collateral benefit to the pelvic floor muscles, but this is not enough to achieve the full potential fitness of a regimen that focuses exclusively on the pelvic muscles.

 

Myth: Kegel exercises do not help.

Truth: Au contraire…pelvic floor muscles have proven to help a variety of pelvic maladies in each gender. In females, pelvic floor muscle training can help urinary and bowel incontinence, pelvic relaxation, and sexual dysfunction. In males, pelvic floor muscle training can help incontinence (stress incontinence that follows prostate surgery, overactive bladder, and post void dribbling), erectile dysfunction, premature ejaculation and other forms of ejaculatory dysfunction as well as help bowel incontinence and tension myalgia of the pelvic floor.

 

Myth: Kegels are only helpful after a problem surfaces.

Truth: No, no, no. As in any exercise regimen, the best option is to be proactive and not reactive in order to maintain muscle mass and strength in order to prevent problems from arising before they have an opportunity to do so. Pelvic floor muscle training done during pregnancy can help prevent pelvic issues from arising in females and pelvic muscle training in males can likewise help prevent the onset of a variety of sexual and urinary maladies. There is no better time than the present to start pelvic exercises to delay or prevent symptoms.

 

Myth: You can stop doing Kegels once your muscles strengthen.

Truth: No, “use it or lose it” applies here as it does in any muscle-training regimen. Muscles adapt positively to the stresses and resistances placed upon them and so they adapt negatively to a lack of stresses and resistances. “Disuse atrophy” is a possibility with all muscles, including the pelvic floor muscles.

 

Myth: It is easy to learn how to isolate and exercise the pelvic floor muscles.

Truth: No, not the case at all. Studies have shown that over 70% of women who think they are doing pelvic floor muscle exercises properly are actually contracting other muscles, typically the rectus, the gluteal muscles, and the adductor muscles of the thigh. One of the greatest challenges is that there have been no well-designed, easy-to-follow pelvic muscle training programs…UNTIL NOW! The Private Gym Company was established after recognizing that there was an unmet need for a means by which a pelvic floor muscle-training program could be made accessible and available in the home setting. This comprehensive, interactive, follow-along exercise program is available on DVD…PrivateGym.com.

 

Myth: Kegels can adversely affect your sex life.

Truth: Absolutely not… In both genders, pelvic floor muscle training has been found to improve sexual function. The pelvic floor muscles play a critical role in both female and male sexuality, supporting clitoral and penile erections as well as ejaculation in males and orgasm in both genders.

 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

6922

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: http://www.MalePelvicFitness.com

Private Gym: http://www.PrivateGym.com – now available on Amazon

30 Interesting Kegel Facts

November 8, 2014

Kegel Facts

Andrew Siegel MD (11/8/14)

shutterstock_femalebluepelvic

 

  • Arnold Kegel (1894-1981) was a gynecologist who taught at the University of Southern California School of Medicine. He was singularly responsible in the late 1940s for popularizing pelvic floor exercises in women in order to improve their sexual and urinary health, particularly after childbirth. His legacy is the pelvic floor exercises that bear his name, known as “Kegels.”
  • Arnold Kegel invented a resistance device called the perineometer that was placed in the vagina to measure the strength of pelvic floor muscle contractions.
  • Arnold Kegel did not invent pelvic floor exercises, but popularized them in women. Pelvic floor muscle exercises have actually been known for thousands of years, Hippocrates and Galen having described them in ancient Greece and Rome, respectively, where they were performed in the baths and gymnasiums.
  • Kegel exercises are often used in women for stress incontinence (leakage with exercise, sneezing, coughing, etc.) and pelvic relaxation (weakening of the support tissues of the vagina causing dropped bladder, dropped uterus, dropped rectum, etc.).
  • Arnold Kegel wrote four classic articles: The Non-surgical Treatment of Genital Relaxation; Progressive Resistance Exercise in the Functional Restoration of the Perineal Muscles; Sexual Functions of the Pubococcygeus Muscle; The Physiologic Treatment of Poor Tone and Function of the Genital Muscles and of Urinary Stress Incontinence.
  • Kegel wrote: “Muscles that have lost tone, texture and function can be restored to use by active exercise against progressive resistance since muscles increase in strength in direct proportion to the demands placed upon them.”
  • Kegel believed that at least thirty hours of exercise is necessary to obtain maximal development of the pelvic floor muscles.
  • Kegel believed that surgical procedures for female incontinence and pelvic relaxation are facilitated by pre-operative and post-operative pelvic floor muscle exercises.
  • Kegel believed that well-developed pelvic muscles in females are associated with few sexual complaints and that “sexual feeling in the vagina is closely related to muscle tone and can be improved through muscle education and resistive exercise.” Following restoration of pelvic floor muscle function in women with incontinence or pelvic relaxation, he noted many patients with “more sexual feeling.”
  • Kegel believed that impaired function of the genital muscles is rarely observed in tail-wagging animals, suggesting that with constant movement of the tail, the pelvic floor muscles are activated sufficiently to maintain tone or to restore function following injury.
  • The pelvic floor muscles form the floor of the all-important core group of muscles.
  • The pelvic floor muscles are involved in 3 “S” functions: support of the pelvic organs; sphincter control of the bladder and the bowel; and sexual
  • Men have virtually the same pelvic floor muscles as do women with one minor variation: in men the bulbocavernosus muscle is a single muscle vs. in women it has a left and right component as it splits around the vagina.
  • Men can derive similar benefits from Kegel exercises in terms of improving their sexual and urinary health as do women.
  • Kegel exercises can improve urinary control in men, ranging from stress urinary incontinence that follows prostate surgery, to overactive bladder, to post-void dribbling.
  • Kegel exercises can improve sexual function in men, enhancing erections and ejaculation.
  • If the pelvic floor muscles are weak and not contracting properly, incontinence and sexual dysfunction can result. If they are hyper-contractile, spastic and tense, they can cause tension myalgia of the pelvic floor muscles, a.k.a. a “headache in the pelvis,” which often negatively affects sexual, urinary and bowel function.
  • The pelvic floor muscles contract rhythmically at the time of climax in both sexes. These muscles are the motor of ejaculation, responsible for the forcible ejaculation of semen at sexual climax. Kegel exercises can optimize ejaculatory volume, force and intensity.
  • The pelvic floor muscles have an important role during erections, activating and engaging to help maintain penile rigidity and a skyward angling erection. They are responsible for the transformation from a tumescent (softly swollen) penis to a rigid (rock-hard) penis. They exert external pressure on the roots of the penis, elevating blood pressure within the penis so that it is well above systolic blood pressure, creating a “hypertensive” penis and bone-like rigidity.
  • The Kegel muscles are located in the perineum, the area between the vagina and anus in a woman and between the scrotum and anus in a man.
  • The Kegel muscles are not the thigh muscles (adductors), abdominal muscles (rectus), or buttock muscles (gluteals).
  • You know you are doing Kegel exercises properly when you see the base of the penis retract inwards towards the pubic bone and the testicles rise up as you contract your Kegel muscles.
  • You know you are doing Kegel exercises properly when you can make your erect penis lift up as you contract your Kegel muscles.
  • You know you are doing Kegel exercises properly when you can interrupt your urinary stream as you contract your Kegel muscles.
  • The 1909 Gray’s Anatomy referred to one of the male Kegel muscles as the erector penis and another as the ejaculator urine, emphasizing the important role these muscles play in erections, ejaculation, and the ability to push out urine.
  • The pelvic floor muscles are 70% slow-twitch fibers, meaning fatigue-resistant and capable of endurance to maintain constant muscle tone (e.g., sphincter function), and 30% fast-twitch fibers, capable of active contraction (e.g., for ejaculation).
  • Kegel exercises are safe and non-invasive and should be considered a first-line approach for a variety of pelvic issues, as fit muscles are critical to healthy pelvic functioning.
  • The pelvic floor muscles are hidden from view and are a far cry from the external glamour muscles of the body. However, they deserve serious respect because, although not muscles with “mirror appeal,” they are responsible for powerful and beneficial functions, particularly so when intensified by training. Although the PFM are not muscles of glamour, they are our muscles of “amour.”
  • The Kegel muscles—as with other muscles in the body—are subject to the forces of adaptation. Unused as intended, they can suffer from “disuse atrophy.” Used appropriately as designed by nature, they can remain in a healthy structural and functional state. When targeted exercise is applied to them, particularly against the forces of resistance, their structure and function, as that of any other skeletal muscle, can be enhanced. Kegel exercises are an important component of Pilates and yoga.
  • As Kegel popularized pelvic floor muscle exercises in females in the late 1940’s, so Siegel (rhymes with Kegel) popularized pelvic floor muscle exercises in males in 2014, with a review article in the Gold Journal of Urology entitled: Pelvic Floor Muscle Training in Men: Practical Applications, a book entitled: Male Pelvic Fitness: Optimizing Sexual and Urinary Health, and his work co-creating the Private Gym male pelvic floor exercise DVD and resistance program.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

6922

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: http://www.MalePelvicFitness.com

Private Gym: http://www.PrivateGym.com – now available on Amazon

RUPNOK?

September 6, 2014

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Did you figure out the title? It is not the imaginary word “Rupnok”; nor the initials of my children (I have three and not six), rather, each letter or two stands for a different word, as is the case with texting abbreviations, in this example: “Are (R) you (U) peein’ (PN) okay (OK)?” This is in fact my license plate and I would estimate that 90% of folks do not figure it out, which makes me smile as I appreciate the subtlety of my tags. I can’t think of a more concise summary of what I do for a living (voiding dysfunction)—my profession in 6 letters—not bad at all!

In urology, we are quite fond of acronyms—abbreviations formed from the initial letters of other words and pronounced as a word, like NASA.

One of the most common issues that I deal with as a urologist is LUTS (lower urinary tract symptoms). The major areas of LUTS are OAB (overactive bladder), UAB (underactive bladder), SUI (stress urinary incontinence), POP (pelvic organ prolapse), BPH (benign prostate hyperplasia) and BOO (bladder outlet obstruction).

Overactive Bladder (OAB) A condition in which “irritative” LUTS are present: the compelling urgency to urinate, urinary frequency, nighttime urinating, and at times, urgency incontinence. It is often due to involuntary contractions of the urinary bladder, in which the bladder contracts without its owner’s permission.

Underactive Bladder (UAB) A condition in which the bladder muscle does not contract with the necessary force, resulting in ineffective urinating with incomplete emptying or the presence of urinary retention.

Stress Urinary Incontinence (SUI) A condition that can be present in both men and women in which there is urinary leakage associated with a sudden increase in abdominal pressure, such as may occur with sneezing, coughing, laughing, exercising, changing one’s position, etc.

Pelvic Organ Prolapse (POP) A condition in females in which there is weakness or laxity of the pelvic support tissues that often follows childbirth, resulting in descent of the pelvic organs into the vaginal space or even outside the vagina. This can involve the bladder, cervix/uterus, small intestine, rectum, and at times, the vagina itself.

Benign Prostate Hyperplasia (BPH) A condition of benign growth of the prostate gland that often accompanies the aging process, has a strong genetic influence and requires the presence of adequate levels of the male hormone testosterone.

Bladder Outlet Obstruction (BOO) A condition in which there is obstruction of the outlet of the urinary bladder. This may be on the basis of BPH but can also be caused by scar tissue in the urethra or the presence of a dropped bladder in a female, resulting in a kink in the urethra. In any of these situations there is obstruction to the flow of urine, typically resulting in obstructive LUTS including a weak urinary stream that is hesitant and intermittent with prolonged emptying time and incomplete emptying.

Bottom Line: RUPNOK?… or do you have LUTS with OAB, UAB, SUI, POP, BPH, or BOO? If so, it may be time to see a GU MD (genital-urinary medical doctor) for a H&P (history and physical) and consider PFMT (pelvic floor muscle training).

 

Wishing you the best of health,

2014-04-23 20:16:29

Andrew Siegel, M.D.

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: http://www.MalePelvicFitness.com

Private Gym: http://www.PrivateGym.com

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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Man Kegels (Pelvic Floor Muscle Exercises for Men)-Part 2

March 15, 2014

Andrew Siegel MD, Blog# 145

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The photo above was taken by a pharmaceutical rep friend who discovered this phallic carving among the Roman ruins in Fez, Morocco.

The following is largely excerpted from my forthcoming book, Male Pelvic Fitness: Optimizing Sexual and Urinary Health, available in April 2014:

With respect to sexuality, medical publications—and more specifically the urological literature—rarely, if ever make mention of targeted exercise as a means of optimizing function or helping to treat a dysfunction. The preeminent urology textbook, Campbell’s Urology, a 4000 page, 4-volume tome, devotes precisely one paragraph to the use of pelvic floor muscle exercises in the management of male sexual dysfunction and makes no mention of its use in maximizing sexual function.

Despite numerous studies and research demonstrating the effectiveness of targeted pelvic exercises, they have been given short shrift. Part of the reason for this is simply that there has never been an easy-to-follow exercise program or well-designed means of facilitating pelvic floor muscle training in men. Instead, there is an emphasis on oral medications, urethral suppositories, penile injections, vacuum devices and penile implants. In the United States we have a pharmacology-centric medical culture—“a pill for every ill”—with aggressive prescription writing by physicians and a patient population that expects a quick fix.

It is shameful that traditionally there has been such little emphasis on lifestyle improvement—healthy diet, weight management, exercising, and avoidance of tobacco, excessive alcohol and stress—as a means of preventing and improving sexual dysfunction.

In addition to general lifestyle measures, specific exercises targeted at the pelvic floor can confer great benefits to pelvic health and fitness, an important element of overall health and fitness. The pelvic floor muscles (PFM) are critical to healthy  sexual function and achieving fitness in this domain is advantageous on many levels: to enhance sexual health; to maintain sexual health; to help prevent the occurrence of sexual dysfunction in the future; and to aid in the management of sexual dysfunction. PFM exercises should be considered first-line treatment of sexual dysfunction and a safe and natural self-improvement approach ideally suited to the male population, including the baby boomers, generation X, and generation Y.  PFM fitness can serve as an effective means to help keep the boomers “booming.”

I do not mean to downplay and disparage the role of medications and other options in managing sexual dysfunction. The availability of that magic blue pill in April 1998—Viagra—was a seminal moment in the world of male sexual dysfunction that enabled for the first time a simple and effective means of treating erectile dysfunction (ED).  On the polar opposite end of the treatment spectrum—but of no less importance—was the development and refinement of the penile implant, used in severe cases of ED unresponsive to less invasive options.

But why should we not initially try to capitalize on simpler, safer, and more natural solutions and consider, for example, using a targeted exercise program or medications in conjunction with a targeted exercise program?  Sexual function is all about blood flow to the penis and pelvis.  And what better way to enhance blood flow than to exercise?  We engage in exercise programs for virtually every other muscle group in the body.  Working out our PFM can result in a strong, robust and toned pelvic floor, capable of supporting and sustaining sexual function to the maximum.

Physical therapy is a well-accepted discipline that is commonly used for disabilities and rehabilitation after injury or surgery.  The goal of a physical therapy regimen is to promote mobility, functional restoration and quality of life. A targeted PFM exercise regimen can be considered the equivalent of genital and pelvic physical therapy with the goal of increasing the bulk, strength, power and function of the PFM.

The PFM can be thought of as a vital partner to our sexual organs, whose collaboration is an absolute necessity for optimal sexual functioning, little different than the relationship between the diaphragm muscle and the lungs. The role of the PFM in sexual function has been vastly undervalued and understated. The hard truth is that a well-conditioned pelvic floor that can be vigorously contracted and relaxed at will is often capable of improving sexual prowess and functioning as much as fitness training can enhance athletic performance and endurance.

Such targeted exercises confer advantages that go way beyond the sexual domain. These often-neglected muscles are vital to our genital-urinary health and wellness and serve an essential role in urinary function, bowel function and prostate health.  Additionally, they are important contributors to lumbar stability, spinal alignment and the prevention of back pain. Specifically, PFM exercises can be beneficial with respect to the following spectrum of issues: erectile dysfunction; orgasmic dysfunction; premature ejaculation; urinary incontinence; overactive bladder; post-void dribbling; pelvic pain due to levator muscle spasm; bowel urgency and incontinence; and in mitigating damage incurred from saddle sports including cycling, motorcycling and horseback riding.

The PFM, comprised of muscles that form a muscular shelf that spans the gap between our pelvic bones, form the base of our “core” muscles.  Our core muscles are the “barrel” of muscles in our midsection.  The top of our core is our diaphragm, the sides are our abdominal, flank, and back muscles, and the bottom of the barrel are our PFM.

The core muscles, including the PFM, are not the glitzy muscles of the body—not those muscles that are for show. Our core muscles are often ignored and do not get much respect, as opposed to the external glamour muscles of our body, including the pectorals, biceps, triceps, quadriceps, latissimus, etc.  In general, muscles that have such “mirror appeal” are not those that will help in terms of sexual and urinary function. Our core muscles are the hidden gems that work diligently behind the scenes—the muscles of major function and not so much form—muscles that have a role that goes way beyond movement, which is the cardinal task of a skeletal muscle.  On a functional basis, we would be much better off having a “chiseled” core as opposed to having “ripped” external muscles, as there is no benefit to having all “show” and no “go.”

The pelvic floor seems to be the lowest caste of the core muscles—the musculus non grata, if you will kindly accept my term. The PFM, however, do deserve serious respect because, although concealed from view, they are responsible for some very powerful and beneficial functions, particularly so when intensified by training.  Although the PFM are not muscles of glamour, they are our muscles of “amour.”

Who Knew? Having “ripped” external glamour muscles might help get your romance going, but having a chiseled core and conditioned PFM will help keep it going…and going…and going!

The female pelvic floor muscles, exercises for which were popularized by gynecologist Dr. Arnold Kegel, have long been recognized as an important structural and functional component of the female pelvis. But who has ever heard of the male pelvic floor?  The male pelvic floor has been largely unrecognized and relegated as having far less significance than the female pelvic floor.  Yet from a functional standpoint, these muscles are of vital importance, certainly as critical to male genital-urinary health as they are to female genital-urinary health.

The PFM, as with other muscles in the body, are subject to the forces of adaptation.  Unused as they are intended, they can suffer from “disuse atrophy.” Used appropriately as designed by nature, they can remain in a healthy structural and functional state. When targeted exercise is applied to them, particularly against the forces of resistance, their structure and function, as that of any other skeletal muscle, can be enhanced.

The key responsibility of most of our skeletal muscles is for joint movement and locomotion. The core muscles in general, and the PFM in particular, are exceptions to this rule.  Although the core muscles do play a role with respect to movement, of equal importance is their contribution to support, stability, and posture. Consider that the pelvic floor muscles, particularly the superficial PFM, have an essential function in the support, stability and “posture” of the penis.  They should be considered the hidden “jewels” of the pelvis.

Who Knew? If you want your penis to have “outstanding” posture and stability, you want to make sure that your PFM are kept fit and well-conditioned.

The PFM have three main functions that can be summarized by three S’s: support, sphincter, and sex. Support refers to their important role in securing our pelvic organs—the urinary, genital and intestinal tracts—in proper anatomical position. Sphincter function allows us to interrupt our urinary stream and pucker the anus and contributes in a major way to urinary and bowel control.  These vital responsibilities are generally taken for granted until something goes awry. With regard to sexual function, the PFM are active during erection and ejaculation.  They cause a surge of penile blood flow that helps maintain a rigid penile erection throughout sexual activity and at the time of orgasm, contract rhythmically, enabling ejaculation by propelling semen through the urethra.

The PFM can become atrophied, flabby and poorly functional with aging, weight gain, a sedentary lifestyle, saddle sports and other forms of injury and trauma, chronic straining, and surgery.  Sexual inactivity can lead to their loss of tone, texture, and function.  However, PFM integrity and optimum functioning can be maintained into our golden years with attention to a healthy lifestyle, an active sex life, and PFM training, particularly when such exercises are performed against progressive resistance.  The goal of such a regimen is the attainment of broader, thicker and firmer PFM and maintenance and/or restoration of function.

The PFM may physically be the bottom of the barrel of our core, but functionally they are furthermost from the bottom of the barrel.  For those who are already functioning well, an intensive PFM training program—as with any good fitness regimen—can impart better performance, increased strength (rigidity), improved endurance (ejaculatory control), and decreased recovery time (the amount of time it takes to achieve another erection).  Keeping the PFM supple and healthy can help prevent the typical decline in function that accompanies the aging process. On so many domains, diligently practiced PFM exercises will allow one to reap tangible rewards, as they are the very essence of functional fitness—training one’s body to handle real-life situations and overcome life’s daily obstacles.

Andrew Siegel, M.D.

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

www.MalePelvicFitness.com

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

Available on Amazon in Kindle edition

Author of Finding Your Own Fountain of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity  (free electronic download) www.findyourfountainofyouth.com 

Amazon page: amazon.com/author/andrewsiegel

For more info on Dr. Siegel: http://www.about.me/asiegel913

Botox: Not Just for a Pretty Face

January 11, 2014

Blog #136

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Botox is derived from a poison produced by the Clostridium bacterium, the microorganism responsible for botulism in humans and animals.  Botulism—caused by eating foods contaminated with the Clostridium bacterium—is a rare but serious illness that can result in paralysis and is considered a potentially fatal medical emergency. The highly toxic and lethal botulinum toxin was initially identified by Kerner in rancid sausages and was refined and purified by van Ermengen in the Netherlands.

It is shocking that the most poisonous substance known to humanity—Botulinum toxinwhen used in minute quantities in a derivative known as Botox, becomes a magically effective and powerful potion to treat a variety of conditions. Talk about making lemonade from lemons!

Most people are aware of the use of Botox to prevent or improve the cosmetic appearance of facial wrinkles. When injected into the frown lines it paralyzes the facial muscles involved and makes creases, furrows and grooves disappear. Facial Botox injections are among the most common cosmetic procedures performed in the United State and have fostered a billion dollar industry. It is important to know that getting beyond cosmetics, Botox can be beneficial for a variety of medical conditions that have in common some form of localized muscle over-activity.

Technically speaking, Botox is a neuromuscular blocking agent that weakens, if not paralyzes muscles. It has numerous potential uses involving the following: overactive bladder (condition causing urinary urgency, frequency and incontinence); urinary incontinence due to neurological conditions including spinal cord injury and multiple sclerosis; chronic migraine headache; upper limb spasticity; cervical dystonia (involuntary contraction of the neck muscles causing abnormal movements and an awkward posture of the head and neck); axillary hyperhidrosis (excessive underarm sweating); blepharospasm (eyelid spasm with uncontrollable blinking); strabismus (cross-eye or wall-eye); and of course, the cosmetic usage to improve the look of frown lines and wrinkles. For all of the aforementioned conditions, the effect of Botox is temporary and needs to be repeated on an indefinite basis in order to maintain the therapeutic effect.

Overactive bladder and incontinence due to neurological conditions: Botox can be useful in those who have not responded to conservative methods including behavioral methods, pelvic floor exercises and medications. Such persistent and disabling urgency, frequency and urgency incontinence can be effectively managed by injecting Botox into the urinary bladder. It works by paralyzing or weakening the bladder muscle. It is done via cystoscopy (a visual inspection of the bladder with a lighted narrow telescope) and requires injecting the Botox into about 20 sites within the bladder muscle.

Chronic migraine headache: Botox is useful for preventing migraines in adults affected more than 15 days per month with headaches lasting for more than 4 hours daily. It is accomplished by injecting the Botox into different areas of the head and neck including muscles of the following areas: forehead; temples; back of head; and the neck and upper back.

Upper limb spasticity: Botox is helpful to decrease the severity of the excessive muscle tone in the elbow, wrist and finger flexors and works by paralyzing these spastic muscles. It is injected directly into the flexor muscles as well as the biceps.

Cervical dystonia: Botox can be effective to reduce the severity of the abnormal head position and neck pain. It works by paralyzing the dystonic muscles and is injected into the sternocleidomastoid muscle.

Axillary hyperhidrosis: Botox is useful in those with severe underarm sweating that has not been managed successfully with topical agents. The Botox functions to paralyze the sweat glands and is injected in numerous sites to cover the area of hyperhidrosis.

Blepharospasm and strabismus: Botox is indicated when these conditions are associated with dystonia as well as benign essential blepharospasm and facial nerve disorders. It works by paralyzing the eyelid and eye muscles and is injected into the eyelid muscles and extraocular muscles, respectively.

Bottom line: Botox, a toxin produced by Clostridium that causes paralysis, can be beneficial when injected into virtually any muscle in the body that is in a state of hyper-contraction and spasticity and has found utility for a variety of medical conditions.

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

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Author of Finding Your Own Fountain of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity  (free electronic download)

 www.findyourfountainofyouth.com 

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 2014.

www.MalePelvicFitness.com

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Obesity and Urology

April 5, 2013

Andrew Siegel, M.D.  Blog #101

A whopping two-thirds of adults in the USA are either overweight or obese.   In 1960 the obesity rate was 13%; currently it is 36%. Our physical activities have diminished, our stress levels and our portion sizes have increased, and our derrières have expanded accordingly.  There are an increasing abundance of readily available, unhealthy, processed, cheap foods.  These factors in sum have contributed to our weight gain and to a very negative impact on our overall health.  In addition to the more obvious increased risk for high cholesterol, high blood pressure, heart disease, stroke, and diabetes, weight gain and obesity are also associated with an increased incidence of gallstones, arthritis and other joint problems, sleep apnea and other breathing problems, as well as certain cancers. There are many other less obvious effects that obesity has, negatively impacting every system in our body.

Abdominal obesity—an accumulation of fat in our midsections—not only is unattractive from a cosmetic standpoint, but can have dire metabolic consequences that can affect the quality and quantity of our lives.  It is important to understand that fat is not merely the presence of excessive padding and insulation that signifies excessive intake of energy—but a metabolically active endocrine “organ” that does way more than just protrude from our abdomens, producing hormones and other chemical mediators that can have many detrimental effects on all systems of our body.  So, fat is not just fat. Today’s blog will focus on the harmful ramifications of weight gain and obesity on urological health. As a urologist, on a daily basis I sadly bear witness to the adverse effects and ill consequences of America’s bulging waistline.

Overactive bladder (OAB) is a common condition that causes urinary urgency, frequency, the need to run to the bathroom in a hurry, and at times urinary leakage before arrival at the bathroom. There is a clear-cut association between weight gain and the presence of OAB.   Similar to the way obesity taxes the joints, particularly the knees, so it burdens and puts pressure on pelvic organs including the urinary bladder.

Stress urinary incontinence (SUI) is a frequent ailment in adult women in which there is leakage of urine associated with a sudden increase in abdominal pressure, such as with sneezing, coughing, lifting, laughing, jumping, and any kind of strenuous exercise. Although the major risk factor is pregnancy, labor, and delivery, weight gain is clearly associated with exacerbating the problem.

Pelvic organ prolapse (POP) is a prevalent issue in adult women in which one or more of the pelvic organs—including the bladder, uterus, or rectum—drop down into the space of the vagina and possibly outside the vagina.  Similar in respect to stress urinary incontinence in that the major risk factor is pregnancy, labor and delivery, it is most certainly associated with weight gain and obesity, which have a negative effect on tissue strength and integrity.

Kidney stones are a major source of pain and disability and are very much associated with weight gain, obesity, and dietary indiscretion. Excessive protein and salt intake are unequivocal risk factors for the occurrence of kidney stones.   Uric acid stones, in particular, occur more commonly in overweight and obese people.  Beyond a certain weight limitation, “larger” patients cannot be treated with the standard, non-invasive shock wave lithotripsy to break up a kidney stone and urologists must, therefore, resort to more antiquated, more invasive, more risky measures.

Hypogonadism, a condition in which there are insufficient levels of the male sex hormone testosterone, is an increasingly prevalent condition that is associated with a host of negative effects. Obesity has a pivotal role in the process leading to low testosterone. One’s waist circumference is a reasonable proxy for low testosterone. Fat has an abundance of the hormone aromatase, which functions to convert testosterone to the female sex hormone estrogen.  The consequence of too much conversion of testosterone to estrogen is the potential for gynecomastia, a.k.a. “man boobs.”  Too much estrogen slows testosterone production and with less testosterone more abdominal obesity occurs and even more estrogen is made, a vicious cycle of emasculation and loss of libido.

Erectile dysfunction is a very prevalent condition associated with aging and numerous other risk factors. Weight gain and obesity are major contributors to poor quality rigidity and durability of erections.   This goes way beyond simply low testosterone levels.  Erections in essence are all about sufficient blood flow to the penis. Obesity contributes to problems with penile blood flow that can interfere in a major way with sexual function.   Additionally, as the abdominal fat pad grows, the penis seemingly shrinks and it is estimated that for every 35 pounds of weight gain, there is a 1-inch loss in apparent penile length. In fact, penile shrinkage is a very common complaint among my obese patients.

Prostate cancer is the most common cancer in men.  Like all cancers, prostate cancer is caused by mutations that occur during the process of cellular division.   Prostate cancer has a multifactorial basis, with both genetic and environmental factors at play. There is a clear association between a Western diet and the occurrence of prostate cancer.   This has been witnessed in Asian men, who have a relatively low incidence of prostate cancer in Asia, but after migrating to the USA and assuming a Western diet and lifestyle, have an incidence of prostate cancer that approaches that of Caucasians.

The obese patient presents a real challenge to the urological surgeon in terms of care both during and after an operation.  Surgery on overweight patients is more complex and takes longer as it is much more difficult to achieve proper exposure of the anatomical site being operated upon.  Surgery on obese patients has a higher complication rate with increased respiratory and wound problems. Anesthesiologists have more difficulty placing the breathing tube through a thick, obese neck, and greater difficulty with regional anesthesia as well, because of fatty tissue obscuring the landmarks to place the needle access for spinal anesthesia.

Bottom Line: Fat puts one at risk…for many very unfortunate potentialities.  Maintaining a healthy weight is an important priority for overall health, as well as our urological health.  The good news is that a lifestyle “remake” is typically the first line of treatment for many of the problems that I have just delved into and has the capacity of mitigating, if not reversing, some of them.  This involves the adoption of healthy eating habits, weight loss to achieve a healthy weight, and exercising on a regular basis.   

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.