Bladder

Male Incontinence

Overactive Bladder (OAB) / Urge Urinary Incontinence (UUI)

What is OAB?

An overactive bladder, also known as OAB, is a condition that can affects both men and women. It is characterised by urinary frequency with a sudden compelling desire to pass urine.

Symptoms of urinary urgency, with or without urge incontinence

There are several potential causes of OAB including:

In a majority of patients, a definitive cause is not found (idiopathic OAB).

Investigations might include:

  • History and examination
  • Blood & urine tests
  • Bladder diary
  • Trial of medication
  • Cystoscopy (telescope inspection of the bladder)
  • Urodynamics (bladder pressure testing)

Treatments might include:

  • Dietary modification
  • Lifestyle changes 
  • Medications
  • Botox injection into the bladder muscle
  • Surgery

What is UUI?

The episodic loss of urine, accompanied by, or immediately preceded, by urgency

  • Frequency
  • Urgency
  • Urgency Incontinence
  • Nocturia

  • Chronic bladder outlet obstruction (BPH)
  • Bladder inflammation e.g. interstitial cystitis, bacterial cystitis, bladder stones
  • Central nervous system disorders (Parkinson’s disease, stroke, spinal injury)
  • Pregnancy
  • Postmenopausal changes
  • Idiopathic (no known cause)

Male Incontinence Treatments

Potential management options include:

  • Behavioural therapy / bladder re-training
  • Dietary changes
  • Medical therapy

         - Oestrogen in post-menopausal females

         - Anticholinergic medications

         - Mirabegron (ß3 agonist)

  • Hydrodistension
  • Botox
  • Percutaneous tibial nerve stimulation (PTNS)
  • Sacral neuromodulation

  • Augmentation enterocystoplasty (very rare since use of Botox)
  • Urinary diversion

Lower Urinary Tract Symptoms (LUTS)

What is LUTS?

LUTS is the abbreviation used by Urologists for Lower Urinary Tract Symptoms. This is the correct term for voiding dysfunction, and was often referred to a “prostatism”.

Lower urinary tract symptoms (LUTS) is the overarching term used to describe the constellation of symptoms relating to abnormal passage of urine. The symptoms affect both men and women, though due to their differing anatomy the causes and effects can be different. As the symptoms can affect both genders, LUTS is thus preferable to the older term “prostatism”, as not all symptoms will relate to the prostate.

These lower urinary tract symptoms can be broadly grouped into storage LUTS and voiding LUTS, though in practice many patients will have issues with both.

As the following table from my book denotes, the causes of these symptoms can be broad. Thus, a one-size-fits-all approach to management doesn’t suit all individuals, and often a thorough medical evaluation can often be needed to get to the bottom of a patient’s symptoms.

For men, most of the symptoms relate to the prostate and the progressive pressure that is placed on the opening of the bladder (bladder outlet). As a man ages, the prostate naturally grows; this is known as BPH – benign prostatic hypertrophy. The swollen prostate squeezes the tube that carries the urine, increasing the pressure the bladder needs to produce in order to push the urine through. Over time, higher and higher pressure are required, which requires a stronger and stronger bladder muscle.

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Historically, the treatment of BPH is symptom driven, however we are increasingly realising that there can be benefits to long term bladder function in preventing the compensatory bladder muscle changes from ever developing.

  • To relieve the symptoms of LUTS (urgency, frequency, hesitancy, slow stream, incomplete emptying, intermittency, nocturia)
  • To treat bladder outlet obstruction (BOO)
  • To treat and prevent the complications of BPH
    • urinary retention with need for a catheter
    • urinary tract infections (UTIs)
    • obstructive uropathy (renal failure)
    • haematuria (blood in the urine)
    • bladder stones

The aim for most BPH treatment is decreasing the resistance to the passage of urine through the bladder outlet, as removing the obstruction often results in symptom relief and prevents further bladder changes and the complications of BPH.

Lower Urinary Tract Treatments

Treatment depends on the cause. A detailed history and examination is required, and will often involve additional imaging (Such as an ultrasound), trials of medication, and potentially a cystoscopy to for anatomical inspection. Urodynamics (pressure testing) can also be required in certain cases.

Dr Symons will often ask that you complete the following questionnaires to help with his assessment and treatment planning:

In deciding what treatment options will best suit a patient, Dr Symons will consider the symptom severity, symptom duration, a patient’s overall health and age/life expectancy, the expected durability of symptom relief, and treatment side effects, particularly where it might relate to preservation of sexual function. Many patients may initially prefer a reversible path with medications, whilst others will prefer a permanent solution with surgery.

Dr Symons has extensive experience is all current medical & surgical options available and will help guide the patient along a path that meeds their own individual needs and expectations.

Metabolic Syndrome and LUTS

Metabolic syndrome is a cluster of different conditions that often occur together, particularly in developed countries like Australia. These conditions include high blood pressure, high blood sugar, high cholesterol and excess body fat. Metabolic syndrome increases your risk of heart disease, stroke and diabetes. It is also associated with Urological problems, such as erectile dysfunction, difficulties with urinary control, and worse cancer survivorship.

 

Modern research has shown a link between high blood pressure, suboptimal erectile performance and symptomatic BPH. In some men, there is a relationship between progressive lower urinary tract symptoms (LUTS) and the presence of the metabolic syndrome, particularly so if the man also has sleep apnoea.  

 

The link between metabolic syndrome and LUTS relates to sympathetic nervous system overactivity combining with prostatic hyperplasia and bladder outlet obstruction, which results in the pathophysiological development of progressive urinary symptoms.

  • The main focus of treatment for the Metabolic Syndrome is lifestyle changes, particularly increased exercise and weight reduction, and potentially specialist endocrinology input.
  • The main focus of treatment for the LUTS associated with metabolic syndrome is decreasing bladder outlet obstruction and addressing sleep apnoea, if present.

Bladder Cancer Management / Haematuria (Blood in the Urine)

What causes haematuria?

There is no need to panic about seeing blood in your wee, but you should contact your GP or Dr Symons.

Whilst for most people the cause is benign, for around 1 in 3-5 (20-30%) it will be due to bladder cancer. Fortunately, when caught early, most of these can be treated.

For many people seeing blood can be a big surprise. What seemed like a normal urination is met with a red colour in the toilet! For others it is the “usual cystitis” that doesn’t go away. For other patients, your GP might call to say that there was unexpected blood found in your routine ckeckup.

The reason why your GP called is that “blood in the wee” is NEVER normal. Blood in the urine is one of the classical signs of bladder cancer.

Irrespective of the cause, the presence of blood in your wee = something is wrong, and it needs appropriate investigation.

However, it is also actually pretty common — nearly a third of adults will experience it over their lives — and there are a host of reasons why it happens. Many of these are issues that can be readily treated, once you have a diagnosis.

This guide below will help you figure out the reasons why there might be blood in your urine—and what tests you should ask for. First, though, you need to know about the two types of blood that can appear in your urine.

The correct medical term for blood in the urine is haematuria.

Depending upon how much blood is around, this is then classified as

  • Macroscopic haematuria – visible blood in the urine (either in the toilet or with wiping)
  • Microscopic haematuria – seen only with a microscope at the pathologist

It doesn’t take much blood at all to discolour your urine. Only a few small drops. Think of using food dye in the kitchen, or a school science experiment. Whilst it is natural to be alarmed by the site of blood, patients are not normally bleeding large enough volumes to make them acutely unwell.

Though the cancer risk for microscopic haematuria is lower than for macroscopic haematuria, ALL BLOOD is considered abnormal and needs investigation.

“From little things, big things grow”

Urologists take microscopic levels just as seriously as we do gross haematuria, since both types can be early signs of bladder or kidney cancer, particularly so if you are or were a smoker. Between 1-3% of patients with microhaematuria will be found to have a tumour.

There are many reasons why you might be weeing blood, and some of them are really common and readily treatable. Here are some of the other causes:

  • Cystitis / UTI (Urinary Tract Infection)
  • Kidney Stone
  • Exercised Too Hard
  • Kidney Trauma
  • Kidney Disease / Failure (potentially from diabetes or high blood pressure)
  • You Have Kidney Disease
  • No Reason for the Blood Found

Risk Factors:

  • Smoking
  • Inherited genes
  • Age > 50 years
  • Exposure to carcinogens (glycophosphates in pesticides, drycleaning fluid, dyes)
  • Chemotherapy drugs (for others cancers)
  • High alcohol intake
  • High body weight
  • Male gender

Symptoms:

  • Painless macroscopic haematuria

Other symptoms of bladder cancer may include:

  • Microscopic amounts of blood in the urine
  • Urinary frequency
  • Burning irritation
  • Difficulty passing urine
  • Pain
  • Weight loss
  • Fatigue
  • Anaemia
  • Fever

  1. What are the odds I have cancer if there’s blood in my urine?

It depends on a person’s risk factors and the volume of blood.

For most people under age 50, the chance of having either bladder or kidney cancer if you have MICROSCOPIC levels of blood is about 1-3%. However, if you have risk factors, it’s about 25%.

If you have VISIBLE, or MACROSCOPIC, blood, this increases the chances of cancer to 20-30%. If you can see blood, always get it checked out

 

  1. What tests should I ask for if I see blood in my urine?

Step 1 = see your local doctor and get a urine culture to check for a UTI.

If this is negative, and particularly if you are over 40 or a smoker, ask your local doctor to be referred to a urologist who specialises in cancer, such as Dr Symons.

Your Urologist can evaluate you see if you need more tests, such as a cystoscopy.

Before seeing a Urologist, it is helpful to do:

- Urinary Cytology x 3

- a CT or ultrasound of the renal tract.

 

  1. Why do UTIs cause blood in the urine?

The bacteria that get into your urinary tract multiply, inflaming the lining and causing it to bleed. Imagine biting the inside of your mouth. This is what millions of bacteria are doing at the microscopic level – the blood that then leaks out mixes with the urine and stains it red.

 

  1. Is blood in my urine dangerous?

It’s a sign that something is wrong, so you definitely want to get it checked out.

Chances are, it’s either an infection or a kidney stone, not cancer.

BUT 1:5 people (20%) who can see blood will have a bladder cancer – and higher if there is a history of smoking.

Bladder Cancer Treatments

There are several treatments and procedures that can be undertaken to treat bladder cancer:

Cystoscopy & Bladder biopsy / Diathermy

Transurethral Resection of Bladder Tumour(s) – TURBT

Installation therapy (Immunotherapy w BCG, or chemotherapy)

Radical Cystectomy – complete removal of the bladder in high grade disease

Chemoradiotherapy – for patients not suitable for cystectomy