Posts Tagged ‘urinary tract’

Female Bladder Works

February 11, 2017

Andrew Siegel MD   2/11/17

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

                          6. bladder

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

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

Bladder Control Issues—More Than Just a Physical Problem

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

Bladder Function 101

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


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


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


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


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


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

Anatomical Position

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


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


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

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


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

Bladder Reflexes

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

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

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

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

Wishing you the best of health,

2014-04-23 20:16:29

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”:

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

He is also the author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health


Advice From My Patient

July 29, 2014

Andrew Siegel, MD   Blog # 165

Last week I had the pleasure of being invited to lunch and to play a round of golf at a beautiful private course with two of my patients who are club members. One gentleman is in his 60s and the other in his 70s. I received some very excellent technical golf advice from the younger of the two, of which my game is in dire need of (my goal that afternoon being not to embarrass myself…I believe I achieved that!).

In addition to sound advice about my swing mechanics, as we approached an on-the-course restroom, my patient also gave me some sage life advice for the aging male: “Never pass up the opportunity to use the bathroom; never trust a fart; and never waste an erection.”

 As I later thought about his adage that involved seemingly disparate entities—the urinary tract, the intestinal tract, and sexual function—it occurred to me that the common thread was altered pelvic organ and pelvic floor muscle function. What he was really saying was that there are age-related changes of the function of the pelvic organs and the pelvic floor muscles.

Allow me to deconstruct his advice. “Never pass up the opportunity to use the bathroom,” implies the presence of urinary urgency and frequency, often signs of an enlarging prostate and/or overactive bladder. What he was recommending was “defensive voiding,” a technique of keeping the bladder as empty as possible on as regular a basis as possible to try to avert urinary urgency as well as urgency incontinence, a situation that occurs as the bladder leaks urine before its owner is able to get to the bathroom.

With “Never trust a fart,” he was expressing the point that a young man has a very “intelligent” anal sphincter, smart enough to distinguish between liquid, solid, and gas and that, with the aging process, the sphincter, well… becomes less clever. The aging anal sphincter is no longer always accurate in making the distinction between these three physical states, a critically important distinction, a mistake of which can lead to some embarrassing consequences.

Never waste an erection,” reveals the truism that at some point in life getting an erection at will is no longer an option. As we age, erectile dysfunction, or altered function, strikes most of us. When we are so fortunate as to get an erection—which for some men may be a rare occurrence—the opportunity should not be squandered and full advantage of the fortuitous moment should be made.

Pelvic floor muscle exercises can bolster the strength and tone of the pelvic floor muscles, which can improve sexual, urinary and bowel health. Such exercises improve overactive bladder responsible for urinary urgency, anal sphincter weakness responsible for not being able to trust flatulence as such, and erectile dysfunction, such that one’s ability to perform is more in one’s own hands and less up to the whim of nature.

The adage is totally relevant to the aging female as well, except for the part about “never wasting an erection.” Women, in fact, suffer with overactive bladder and anal sphincter issues at a higher prevalence than men. Pelvic exercises can help improve these issues, as well as female sexual issues. Dr. Arnold Kegel popularized pelvic floor exercises in females in order to improve their sexual and urinary health, particularly after childbirth, and his legacy is the pelvic floor muscle exercises that bear his name, known as “Kegels.” Kegel believed that in females, well-developed pelvic muscles 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.

Bottom Line: Keep your pelvic floor muscles fit and you just might be able to pass up the opportunity to use the bathroom, trust a fart, and not think twice about wasting an erection.

Andrew Siegel, M.D.

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”:

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

I can’t think of a more relevant occasion to repeat the book’s dedication:

This book is dedicated to my patients, many who have opened up their lives and hearts and have shared very personal and intimate details with me. They have been among my most important teachers and have given me a wealth of information that is not to be found in medical textbooks or journals. Meaningful, enjoyable, and rewarding relationships have been developed and nurtured over the years and it has been a privilege and an honor to be entrusted with their urological care. Engaging their confidence and respect through our interactions has proven to be one of the most satisfying and fulfilling aspects of being a physician.

Private Gym website where pelvic floor instructional DVD and resistance training equipment are now available



What The Heck is Urology?

August 24, 2013

Andrew Siegel, MD  Blog #116

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

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

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

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

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

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

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

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

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:

Available on Amazon in Kindle edition

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

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