Underactive Bladder-Also a Quality of Life Condition

No one can listen to T.V. or watch their Internet screen without hearing about overactive bladder or OAB. However, and equally serious and common bladder condition is underactive bladder or lazy bladder. This condition is characterized by urinary symptoms such as hesitancy of urination, straining to urinate, and incomplete bladder emptying.

An underactive bladder is a chronic disease where the bladder holds large amounts of urine, yet the individual cannot feel when the bladder is full, nor does the bladder muscle contrct sufficiently for the bladder to empty completely.

Risk factors for under active bladder are damage to the nerves that go from the back to the bladder, diabetes, pelvic surgery which may cause injury to the bladder nerves, changes caused by aging, diabetes, urinary tract infections, medications that cause the bladder muscle to relax. Examples of these medications include anti-depressants, antihistamines, and bladder muscle relaxants, and spinal cord injuries.

Underactive bladder has no known cure. The management focuses on reduction of the residual urine or the amount of of urine left in the bladder after voiding, avoidance of over distention of the bladder, and protecting the kidneys from damage.

At the present time the treatments for underactive bladder include medications, scheduled voiding by the clock, i.e., going to the restroom every 2-3 hours whether you feel that you have to empty the bladder or not, double voiding, and intermittent catherization where a small tube is inserted through the urethra into the bladder and drain the bladder and the tube is removed and discarded. This is usually done 3-4 times a day depending upon the amount of fluids consumed.

For more information go to http://www.underactivebladder.org

OAB – WHEN YOU REALLY GOTTA GO!

OAB (over-active bladder) is found in both men and women and is associated with the symptoms of urgency, frequency, nocturia and urge incontinence.

Regulation of bladder storage and voiding involves both sympathetic and parasympathetic control.

Bladder voiding is primarily regulated by the parasympathetic nervous system via the neurotransmitter acetylcholine. Muscarinic receptors (M1-M3-M5) are mediated by acetylcholine in controlling the contraction of the bladder muscle and relaxation of the internal sphincter to facilitate voiding. M2 and M3 are predominate muscarinic receptors found in the bladder. The anti-muscarinic (Ditropan, Ditropan XL, Vesicare, Sanctura, Gelnique, Toviaz and Enablex) all work by blocking the receptor, leading to a reduction in bladder contractions. Because they block the acetylcholine receptor systemically, they can be associated with constipation and dry mouth.

Bladder storage is primarily regulated by the sympathetic nervous system via the neurotransmitter norepinephrine. Norepinephrine released from the sympathetic nerve activates the adrenergic receptors causing the bladder to relax and close the external sphincter. There are three types of beta adrenergic receptors expressed in the bladder. The beta-3 AR makes up 97% of bladder receptors and is predominately responsible for the detrusor muscle relaxation. The drug Myrbetriq has recently been released and is a Beta 3 adrenergic receptor agonist which leads to increased relaxation of the bladder. In contrast to the anti-muscarinics which cause constipation and dry mouth, this is much less common with Myrbetriq which has a small incidence of an increase in blood pressure. Monitoring the patient’s blood pressure is important in patients with a history of hypertension.

A Phase 3 trial in over 400 men and women complaining of OAB symptoms was recently conducted with 3 arms, Tolterodine ER (Detrol LA) Myrbetriq and placebo arm. The incidence of dry mouth was 5 times higher in the Detrol arm than in the Myrbetriq group (10% vs 2%).

It should be noted in all of the clinical trials with both Myrbetriq and the anti-muscarinics, the increase in urinary voided volume was typically in the range of only 1 or 2 ounces. Both approaches do result in a significant decrease in the incidence of urge incontinence.

A few key points that we have found important in treating OAB patients includes:
1. The treating doctor can use a combination of an anti-muscarinic and Myrbetriq to decrease symptoms of OAB especially in patients with severe symptoms that do not respond to either agent alone.
2. In contrast to prior thinking, there is a very small incidence of urinary retention with the use of either anti-muscarinics or Beta-3 agonists. However, caution should be used in men who really don’t have OAB but have impending urinary retention where they have large residual urine volumes as treatment with anticholinergics or a beta-3 agonist can only exacerbate the situation. Since most primary care physicians don’t have access to a bladder scan, but the PCP can use the tried and true old-fashioned way of simple percussion of the lower abdomen to determine if there is, indeed, significant residual urine.
3. The use of anti-muscarinics in patients with closed angle glaucoma is a contraindication. In patients with a history of glaucoma, we typically give the patients a prescription for their OAB suggest that the patient check with their ophthalmologist prior to initiating treatment.
4. There are a number of tips and coping suggestions in patients with over-active bladder that include: Timed voiding, reduction in caffeine and alcohol, reduction in fluids prior to bedtime and Kegel exercises when patients have strong urges to void. All of these suggestions can help. I provide the patient with a handout on coping suggestions which I have found effective. In fact, numerous studies have shown that behavior modification is as effective as medical therapy.
5. For patients who are unresponsive, an intake and output diary can be of help in determining how big a factor fluid intake can be, as well as, monitoring actual response to treatment.
6. It also is important to realize that many patients complain primarily of nocturia. Nocturia can be a result of numerous urologic as well as non-urologic conditions including CHF, venous insufficiency, and increased fluid intake at night. This is certainly a case where a voiding diary also can be of benefit. For patients whose primary complaint is nocturia, DDAVP .1 to .2 mg. can be used but it is important to monitor the serum sodium for hyponatremia.
7. For patients refractory to either combination or individual drug therapy, there are additional alternatives:
a. Percutaneous posterior tibial nerve stimulation involves a small acupuncture sized needle being placed in the ankle and a minimally perceived current transmitted up to the spinal lumbosacral nerve center where one can “reprogram” the bladder. This is indicated for patients unresponsive to oral medication.
b. For patients with refractory OAB symptoms, Interstim therapy can be utilized. Interstim involves an initial percutaneous trial followed by implanting leads from the spinal cord to the nerves supplying the bladder along with a programmed stimulator, which markedly suppresses and reduces urinary symptoms.

Please do not hesitate to contact me if I can be of assistance. I can be reached 504-891-8454 or email me at doctor whiz@gmail.com or via my website, http://www.neilbaum.com

Can’t Pee? It May Be Your Medications

Having the urge to urinate — and not being able to do so — is painful, as many men know.  Certain medications may make the emergency form of this condition, known as acute urinary retention, more likely.

Painful urination or difficulty urinating are listed as possible side effects of the drugs studied – sold under the names Atrovent, Combivent and Spiriva.

An article published in the prestigious Archives of Internal Medicine reported that men with chronic pulmonary or lung diseases who had just started taking inhaled anticholinergic medications, a common treatment for the breathing diseases, had 42% greater odds of developing the urinary problem than men who were not on anticholinergics.

Bottom Line: There is an association between respiratory inhaler use and urinary symptoms especially urinary retention.  This is particularly important issue in men who have enlarged prostate glands as they are at an increased risk of having the complication of urinary retention.

11 Suggestions For Decreasing Prostate Symptoms

The prostate gland is walnut sized organ at the base of the bladder.  In order men the gland increases in size and causes symptoms such as going to the bathroom frequently, dribbling after urination, and getting up at night to urinate.  Here are a 11 suggestions that you might consider to relieve those symptoms.

1.  Don’t drink anything several hours before you go to sleep.

2.  Avoid caffeinated beverages such as coffee and tea as the caffeine acts as a diuretic

3.  Limit your alcohol consumption especially at the dinner meal.

4.  Avoid spicy foods.

5.  Take medications such as your diuretics or water pills early in the day when going to the bathroom to urinate is not such an inconvenience.

6.  Avoid antihistamines and decongestants

7.  Don’t hold off going to the restroom

8.  Use the clock to help with urination. Make an effort to urinate every 3-4 hours.  Putting your bladder on a schedule is very helpful and a good habit to have.

9. Go and then go again. Stand at the toilet and empty your bladder, walk away from the toilet for a minute or two and then return and try emptying the bladder again.

10. Avoid cold seats such as at football games in the winter.

11. If you bike ride, especially for long distances, stand on the pedals every 10 or 15 minutes to take the pressure off of your prostate gland.

Bottom Line: These steps won’t cure the enlarged prostate but they will lessen the symptoms.  If your symptoms persist, consider a visit to your urologist

Living With Prostate Gland Enlargement-Lifestyle Changes

Prostate enlargement or benign prostate hyperplasia (BPH) is a common, non-cancerous condition affecting nearly 14 million men over the age of 50.

The symptoms of prostate gland enlargement include decrease in the force and caliber of the urinary stream, frequency or urination, urgency, feeling of not emptying the bladder and nocturia or the need to get up at night to urinate.

Although lifestyle changes will not cure the problem, they can alleviate some of the symptoms.

Making some lifestyle changes can often help control the symptoms of an enlarged prostate and prevent your condition from worsening. Try these measures:

Remember what goes in must come out.  Therefore don’t drink anything several hours before you go to sleep.  Especially avoid caffeinated beverages such as coffee (also causes insomnia) and tea as the caffeine acts as a diuretic and causes increased urine output that may result in getting up at night to empty your bladder,

Limit your alcohol consumption especially at the dinner meal.  Again alcohol acts as a diuretic causing increased production of urine causing your bladder to fill up sooner than you would like.

Avoid spicy foods.  These appear to irritate the bladder and can result in urinary frequency and nighttime voiding.

Check your medications.  Some medications like lasix and hydrochlorothiazide are diuretics and increase urine production.  I suggest you take those medications early in the day when going to the bathroom to urinate is not such an inconvenience.  You may also speak with your doctor about lowering the dosage of the diuretic especially the evening dose if you are bothered by nighttime urination.

Avoid antihistamines and decongestants as these cause the bladder to decrease the force of contraction and results in the bladder not to empty as well.  If you have to take anti-histamines, use them earlier in the day.

Don’t hold off going to the restroom.  This habit distends the bladder and can result in a weaker muscle to expel the urine from the bladder.

Use the clock to help with urination.  If you find that you are going to the bathroom infrequently and then more at night, make an effort to urinate every 3-4 hours.  Putting your bladder on a schedule is very helpful and a good habit to have.

Go and then go again.  Double voiding is a technique to ensure adequate emptying of the bladder.  If you stand at the toilet and empty your bladder, walk away from the toilet for a minute or two and then return and try emptying the bladder again.  This helps to expel more urine from your bladder than just standing there one time and voiding.

Avoid cold seats such as at football games in the winter.  The cold temperature seems to cause the muscles around the prostate gland to contract and makes urination difficult.  Instead take a blanket or a cushion. Your prostate gland will be glad that you did.

If you bike ride, especially for long distances, stand on the pedals every 10 or 15 minutes to take the pressure off of your prostate gland.  Also consider using a seat that has a groove down the middle which alleviates the pressure on your prostate gland.

Bottom Line: These steps won’t cure the enlarged prostate but they will lessen the symptoms.  If they don’t help, see your doctor for medication one of the treatments that reduces the obstruction of your prostate gland.

Treatment of the Enlarged Prostate Gland With Laser Therapy

The prostate gland is a walnut sized organ below the bladder, which surrounds the urethra.  For reasons not completely understood, the prostate gland begins to grow around age 50 and causes symptoms affecting urination.  The enlarged prostate gland is a non-cancerous condition that affects nearly 14 million men over age 50.

The symptoms of the enlarged prostate include frequency of urination, getting up at night to urinate, urgency to urinate, decrease in the force and caliber of the urine stream and feeling that the bladder is not emptying.

The treatment for enlarged prostate includes medication to shrink the prostate gland or to relax the muscles in the prostate to relieve the obstruction.  Surgical therapy includes transurethral resection of the prostate (TURP) or open surgery for very large prostate glands. Recently laser therapy has become available for treating the enlarged prostate gland and is considered minimally invasive therapy.

Laser therapy is a procedure performed with a small fiber that is inserted into the urethra, the tube in the penis that allows urine to go from the bladder to the outside of the body.  The fiber delivers high-powered laser energy, which quickly heats the prostate tissue, which causes the tissue to dissolve or vaporize.  This process is continued until all of the enlarged prostate tissue has been removed. The end result is a wide-open channel for urine to pass through the urethra.

Laser therapy can be performed in a hospital outpatient center or an ambulatory treatment center.  Usually no overnight stay is required.  However, in some cases when a patient comes from a great distance, has associated medical problems such as heart disease, diabetes, or severe hypertension, or is in frail condition, an overnight stay may be recommended.

After the procedure

Most men will go home within a few hours after treatment. If a tube or catheter was inserted after the procedure, it will usually be removed the next day after the procedure.

Most patients experience marked improvement in their urinary symptoms immediately after the procedure.  This improvement typically occurs within the first 24 hours after the procedure.  However, the past medical history, health condition and other factors can influence treatment recovery.

Some men may experience mild discomfort such as slight burring during urination and small amounts of blood in the urine for a week or two.  Also, depending upon the condition of a man’s bladder, he may experience greater frequency and urge to urinate.  This will resolve over time as the bladder adjusts now that the obstruction has been removed.

There is no change in a man’s sexual function after the procedure.  His ability to engage in sexual intimacy after the procedure is unchanged.  Most men can begin sexual activity two weeks after the procedure.  Approximately 25% of men will have a decreased or absence of ejaculation at the time of orgasm.  The fluid is still there but goes backwards into the bladder and passes in the urine the next time the man urinates.

What are the risks of the laser procedure?

Every medical treatment may have side effects.  The same is true for the laser treatment.  The most common side effects include:  blood in the urine, bladder spasms, and urgency of urination.  These symptoms are usually temporary and will subside in a few days or weeks.

Bottom Line: Enlarged prostate gland is a common condition that affects most men after age 50.  Treatment options include medications, surgery and minimally invasive treatment using lasers.  The laser treatment produces a rapid improvement in urine flow, a quick return to normal activities, short or no hospitalization.