Urinary Dysfunction

Stress urinary incontinence (SUI)

What is stress urinary incontinence?
Stress urinary incontinence (SUI) is the loss of small amounts of urine with coughing, laughing, sneezing, exercising or other exertions that increase intra-abdominal pressure. It is reported in Singapore that about 15% of women suffer from SUI, but fearing embarrassment, few speak of their condition.

What causes stress urinary incontinence?
The urethra is supported by the muscles of the pelvic floor. If the muscular support is weakened by previous pregnancy, childbirth or by intrinsic weakness of the urethra (urine pipe), stress urinary incontinence may result. Conditions that increase the intra-abdominal pressure, such as obesity, prolonged coughing, constipation and heavy lifting may further worsen the problem, resulting in stress incontinence eventually.

Are there any treatments available?
Yes. You do not need to suffer in silence. Make an appointment with your doctor early for assessment and advice. Treatment options can be divided into conservative and surgical treatment. Unfortunately, there are no effective medications for SUI at the present moment. Conservative management include pelvic floor muscle exercises (Kegel exercises) for mild to moderate stress urinary incontinence, and for patients who are unfit for surgery. For severe stress urinary incontinence, or if the incontinence affects the woman's quality of life, surgery can be performed. The most common surgical procedure for stress urinary incontinence is the insertion of a mid-urethral tape to support the mid-urethra (urine pipe), thereby preventing leakage or urine.

Urge incontinence

What is urge incontinence?
Urge incontinence is involuntary loss of urine while experiencing an overwhelming need to urinate (urgency). This occurs when there are involuntary and inappropriate bladder muscle contractions. The overall prevalence in the general population is 10%. It increases with age, with the prevalence being much higher in the elderly, and in hospitalised or nursing home patients. They may also need to urinate more than seven times during the day (frequency), and/or at night (nocturia). Patients can suffer from incontinence during sleep (nocturnal enuresis), after drinking a small amount of water, or when they touch water or hear it running (as when washing dishes or hearing someone else taking a shower).

What causes urge incontinence?
Idiopathic detrusor overactivity – unknown cause in the majority of patients. Local infection, inflammation, trauma or tumour may be risk factors for an overactive bladder. Neurogenic detrusor overactivity – It is due to central nervous system injuries like spinal cord trauma, injury, growths and demyelinating diseases like multiple sclerosis. Involuntary contractions of bladder muscles can occur because of damage to the nerves of the bladder, to the nervous system (spinal cord and brain), or to the muscles themselves. Multiple sclerosis, Parkinson's disease, Alzheimer's disease, stroke, and injury (including surgery-related injury) can all damage bladder nerves or muscles.

What are the treatment options?

1. Lifestyle management
   Moderate fluid intake (up to 2 litres per day), maintain an ideal weight, reduce caffeine intake, avoidance of certain food and drinks can improve the condition.
   
   
2. Bladder training
   This constitutes a programme of scheduled voiding with progressive increases in the time interval between each void.
   
   
3. Drug therapy
   This is the most popular mode of treatment in patients with urge incontinence, and act by reducing the symptoms. The dosages are titrated according to the tolerance level of patients to the side effects. Anticholinergic agents, tricyclic antidepressants and synthetic vasopressin are some examples of the medications used in treatment.
   
   
4. Pelvic floor exercise
   Pelvic floor exercises are designed to strengthen the bladder sphincter muscles thereby reducing incontinence episodes and severity.
   
   
5. Electrical stimulation
   Electrical stimulation reduces the contraction of the bladder muscles and improves the bladder capacity for urine storage.
   
   
6. Surgery
   This is used as a last resort in the management of urge incontinence because of the high complication rates of such procedures. Examples of such surgeries are sacral neuromodulation and bladder augmentation cystoplasty.
   

Overflow Incontinence

What is overflow incontinence?
This urinary condition causes people to feel that their bladder can never be emptied completely or continue to dribble for some time after they have passed urine. In others the condition also prevents voiding after the urge to urinate is felt and also causes frequent night-time voiding (nocturia).

What causes overflow incontinence?
This condition is attributable to weak bladder muscles or an obstructed urethra (urine pipe). Nerve injury from diabetes or other diseases (e.g. multiple sclerosis) can decrease neural signals from the bladder (allowing for overfilling) and may also decrease the expulsion of urine by the bladder muscle (allowing for urinary retention). Spinal cord injuries or nervous system disorders are additional causes of overflow incontinence. In addition, tumours and kidney stones can block the urethra.

Overflow incontinence is rare in women; common causes are fibroids, a retroverted uterus and ovarian tumors. Overflow incontinence in women can be caused by increased outlet resistance from advanced vaginal prolapse causing kinking of the urethra; or rarely after an incontinence procedure which has overcorrected the problem. Certain medications also cause overflow incontinence.

What are the treatment options for overflow incontinence?

1. Drug therapy
   Certain drugs relax the striated smooth muscles of the urethra (urine pipe), thereby decreasing urethral resistance and relieving symptoms. Certain drugs improve the contracting ability of the bladder detrusor muscle.
   
   
2. Clean intermittent self-catheterisation (CISC)
   CISC is a safe and effective method of completely emptying the bladder every 3 to 8 hours, or as recommended by your specialist, to keep urine volume low.
   
   
3. Indwelling catheter (IDC)
   IDC enables urine to be continuously drained without the need to empty the bladder manually. IDC is used in patients who find drug therapy ineffective, and decline or unable to use CISC, e.g. mobility difficulties. A silicone-based IDC needs to be changed every 3 months.
   

Stress and urge incontinence often occur together in women (30% of cases). A combination of urinary incontinence is referred to as "mixed urinary incontinence". Since the causes of mixed stress and urge incontinence may or may not be the same, each aspect of this disorder should be evaluated separately by a specialist in urogynaecology.

Fistula causing continuous or true incontinence

What is a fistula? What causes a fistula development?
A fistula is an abnormal connection or passageway between two organs or vessels that normally do not connect. Fistulas can be due to obstetric/surgical/radiation or disease causes. Obstetric fistula is an injury of childbearing. It is usually caused by obstructed labour, when prolonged pressure of the baby's head against the mother's pelvis cuts off blood supply to delicate tissues in the region. The dead tissue breaks down and a hole between the vagina and the bladder forms (known as a vesicovaginal fistula), or between the vagina and rectum (causing a rectovaginal fistula) or both. The result is leaking of urine or faeces or both via the vagina.

Surgical or radiation therapy are also known to cause vesicovaginal fistula, while inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis, can cause a fistula formation between the bowel and vagina.

Can a fistula be cured?
Yes, a fistula is treatable as well as preventable. Reconstructive surgery can mend the injury, and success rates are as high as 90% for uncomplicated cases. For complicated cases, the success rate is closer to 60%. Two weeks or more of post-operative urinary catheterisation is needed to ensure a successful outcome. Counselling and support are also important to address the emotional trauma. When surgery cannot correct the problem, women can undergo a procedure called a urostomy, where urine is diverted into a bag.

What are the medical consequences of a fistula?
Left untreated, a fistula can lead to frequent ulcerations and infections, kidney disease and even death.

Other types of incontinence
Transient incontinence is a temporary incontinence. It can be triggered by medications, urinary tract infection, mental impairment, restricted mobility, and stool impaction (severe constipation). Incontinence can occur while trying to concentrate on a task and avoiding using the toilet. Transient incontinence should abate upon addressing the cause for the disorder.

Urinary tract infection (UTI)

What is UTI?
Urinary tract infection occurs when bacteria is present within the lower urinary tract in significant numbers. 20% of women aged between 20 to 65 years suffer at least one episode per year. Approximately 50% of women will experience UTI at least once during their lifespan; and a further 25% of women with previous UTI will go on to have a recurrent UTI.

What are the symptoms of UTI?
The onset of UTI can be associated with one or more of the following symptoms:

• Passing urine more frequently than normal (frequency)
• "Burning" pain on urination (dysuria)
• The urge to pass urine which is overwhelming in nature (urgency)
• Passing blood-stained or cloudy urine
• Passing foul-smelling urine
  
• Lower abdominal or loin pain
• Fever
  

If a woman has any of the above symptoms, she is advised to consult a doctor as soon as possible.

What are the predisposing factors of UTI?
The occurrence of UTI varies with age and sex. The incidence of UTI is 10 times higher in women compared to men. The following are predisposing factors:

• Sexual activity
• Menopause
• Recent instrumentation of the urinary tract (e.g. catheterisation, cystoscopy, after urodynamic studies).
• Diabetes mellitus
• Foreign bodies (e.g. catheters, urinary tract stones)
• Neurological disorders, drugs or pelvic organ prolapse may cause incomplete emptying of the bladder
• Co-existing diseases involving the pelvis (e.g. tumours, inflammatory bowel disease)
  

What happens if UTI is left untreated?
If UTI is left untreated, the infection can spread upwards to the kidneys, causing infection of the kidneys and even renal failure. It can also spread via the blood stream (septicaemia), which may be fatal.

What are the investigations and treatment?
To confirm the diagnosis of UTI, a sample of your urine will be sent to the laboratory for testing. Empirical antibiotics will usually be prescribed. You may be prescribed alternative antibiotics after the urine culture and antibiotic sensitivity result is available. You may also be given medication to make the urine more alkaline and asked to drink more water.

Recurrent UTI
It is defined as having UTI three times or more within a year.

Further tests such as renal ultrasound, CT scan, cystoscopy, urine culture for tuberculosis and cytology may be necessary to identify the causes and complications of recurrent UTI.

You may also be given prophylactic antibiotics for a period of 3 to 6 months. You will be advised on good personal hygiene and other preventive measures.

Prevention of UTI
Although UTI can be easily treated with antibiotics, the prevention of UTI is more important.

As the source of the bacteria comes from one's own bowel, it is important to clean yourself from front to back to avoid faecal contamination. Potentially irritating vaginal deodorants and bubble baths should be avoided and a high standard of personal hygiene should be maintained at all times. This involves washing the genital area with water during bathing and especially after intercourse (as intercourse is a common predisposing factor for UTI). Voiding soon after intercourse is also encouraged, to empty the bladder of possible contaminated urine.

Any vaginal infection should be treated; otherwise the infection may spread to the urinary tract. In order to prevent recurrent UTI, a fluid intake of up to 2 litres a day is recommended (and more if exercising strenuously or on hot days). Oral fluids should be increased to 3 litres or more a day if symptoms of UTI are suspected, regardless of the degree of frequency of urine. Regular and complete bladder emptying is advisable to prevent the accumulation of infected urine in the bladder.

Conclusion
As UTI is a common occurrence in women, one should be aware of the symptoms of UTI. Early recognition and appropriate treatment is necessary to prevent complications.

Voiding disorders in women

What are voiding disorders?
Voiding disorders are common in women. Approximately 14% of women who present at our Urogynaecology Centre with bladder symptoms were found to have voiding disorders. It may be defined by an abnormally slow flow of urine during voiding, when the maximum urine flow rate is less than 15 ml per second, or a sensation of incomplete emptying of the bladder, when the residual urine volume is over 50 mls, within one minute post-voiding.

What are the complications that may arise?
It is important to diagnose voiding disorders because if left unrecognised, it may predispose one to frequent urinary tract infections. In more severe case, the kidneys may be damaged by the continuous back pressure that is created by an over-distended bladder.

What are the symptoms?
Symptoms of voiding disorders include:

• Delay in initiating urination (hesitancy)
• Slow urinary flow
• Sensation of incomplete emptying of bladder
• The need to immediately re-void
• The need to strain to void
• Post-micturition dribbling

Patients with voiding disorders may also present with symptoms such as frequency, urgency, nocturia, urinary incontinence, and urinary tract infection. Some patients may have associated prolapse of the womb, bladder or rectum.

What are the investigations?
When you consult your doctor, a detailed history is first obtained, followed by a comprehensive urogynaecological and neurological examination to ascertain the possible causes of voiding disorders. Various investigations may be ordered and these include:

What are the treatment options?
Prevention of voiding disorders is important. After pelvic or continence surgery, the use of temporary catheterisation can prevent immediate post-operative bladder over-distension. Early recognition of post-natal urinary retention and early catheterisation is crucial for early return of normal urinary function subsequently.

Medications
Drugs may be used to treat the underlying cause of the voiding disorders. A course of antibiotics may be used if there is an infection. In patients with anxiety disorders, a small dose of anti-anxiety medication or sleeping tablets may help. Vaginal oestrogen pessaries and creams may be used if atrophic changes are implicated in the voiding difficulties. Some drugs may be used to improve bladder muscle contractions.

Clean intermittent self-catheterisation (CISC)
In CISC, the patient is taught to insert a urinary catheter under clean conditions at regular intervals. This procedure is easy to learn. The use of CISC enables many women to live normal lives with efficient bladder emptying, free from discomfort and distress. For patients not willing or unsuitable to use CISC, indwelling catheters may be used.

Surgery
In cases where the urethral opening is narrowed, it may be dilated using metal rods called Hegar dilators. However, the main disadvantage is that voiding difficulty may recur following healing and scarring of the dilated area. Often, repeated dilatations are needed. If the woman is having bladder or uterine prolapse, it should be dealt with surgically.

Conclusion
Voiding disorders are common in women. If left unrecognised, it may lead to permanent damage to the bladder and kidneys. Hence, treatment should be started early and the causes dealt with promptly.

Painful bladder syndrome (PBS)/Interstitial cystitis (IC)

What is painful bladder syndrome (PBS)/interstitial cystitis (IC)?
There is a specific bladder condition causing extreme urgency, requiring the person to urinate many times in the day (frequency) and night (nocturia) in the absence of infection or other bladder pathology. They may feel pain in the lower abdomen, region above the pubis, the perineum, lower back, vulva and vagina. This condition is more common amongst women than men (female to male ratio = 9:1). The average age ranges from 42 to 53 years old. The incidence is 16 to 450/100,000 people.

What causes PBS/IC?
Currently, experts agree that the protective layer of the bladder (GAG layer) in most PBS patients is not well developed thereby allowing toxins or irritative substances to affect the nerve receptors in the bladder, thus causing unpleasant symptoms.

What are the treatment options?
As we do not fully understand the cause(s) for PBS/IC, treatment is difficult and often not optimal. Conservative treatment include instillation of various chemicals and drugs directly into the bladder to replace or replenish the GAG layer; such as chondroitin sulphate, hyaluronic acid, heparin, dimethyl sulfoxide (DMSO), or a combination of the above. Success rates range from 30% to 92%.

Oral medication such as pain killers, antihistamines, antidepressants, pentosan polysulphate, or a combination of treatments have been used, but their success rates have been equivocal.

Some patients have worsening urinary frequency and urgency after ingestion of certain food types (usually acidic food such as oranges, tomatoes, etc.). Dietary avoidance of these foodstuffs may decrease their symptoms.

Surgery for PBS/IC is associated with a low success but high complication rate. Hence, it is not commonly practiced or advocated.

Only two drugs, DMSO and pentosan polysulphate have been approved by the US Food and Drug Association (FDA) for use in PBS/IC.

Intravesical DMSO has been used in KK Urogynaecology Centre since May 2006 with good results, with patients experiencing a reduction in their PBS symptom.

Conclusion
The actual cause(s) of PBS/IC is unknown. A variety of empirical treatments have been used, but no single treatment works for all patients. The best approach is sequential treatment, starting with the least toxic choices, until satisfactory relief is achieved. PBS/IC is a difficult condition to endure, and patients are helped greatly when friends, relatives, medical and nursing practitioners are supportive, kind and understanding towards their condition.

Haematuria

What is haematuria?
Haematuria is the presence of red blood cells in the urine. It can be visible to the naked eye (macroscopic) or only picked up during laboratory testing (microscopic). Disease at any part of the urinary system (kidneys, ureters, bladder and urethra) can cause haematuria.

What causes haematuria?
There are many medical conditions in the kidney, ureters, bladder or urethra that can result in haematuria:

1. Kidney stones, infection, glomerulonephritis (swelling of the filtering tubes within the kidney) and kidney cancers can cause haematuria
2. Stone passage along the ureters can cause intense pain in the mid and lower back that travels down into the groin, causing haematuria
3. Haematuria may also result from bladder cystitis (infection), painful bladder syndrome (PBS), bladder stones and bladder cancer
   

There are also other causes of haematuria not listed in the above causes, such as contamination from vaginal bleeding, medical disorders such as systemic lupus erythematosus (SLE), sickle cell anaemia, vigorous exercise, physical trauma to your body, certain foods e.g. beetroot, and medications e.g. aspirin.

Evaluation
When you see blood in the urine, it is necessary to seek medical help. Your doctor will go through your medical history, in order to find the cause of haematuria.

The presence of urinary urgency, frequency, pain on urination (dysuria), abdominal pain or fever are useful in reaching a diagnosis. Risk factors for cancers, like smoking and certain chemical exposure can also be identified. After a physical examination, certain investigations and tests will be ordered.

Investigations

• Urinalysis: A raised white blood cell count in the urine may indicate the presence of a urinary tract infection (UTI), which is a cause of haematuria.
• Urine culture: The urine is cultured for the types of bacteria and their antibiotic senstivities. This will allow your doctor to prescribe an appropriate antibiotic.
• Urine cytology: Cells in the urine are examined to identify the presence of cancerous (malignant) cells, which may come from anywhere along the urinary tract, which warrants immediate attention and further evaluation.
• Urine phase contrast: This is used to visualise the red blood cells in the urine to determine the source of haematuria. Abnormal-shaped red blood cells (dysmorphic) usually implies a kidney source, whereas normal-shaped red blood cells (isomorphic) usually implies haematuria from the lower tract, e.g. bladder.
• Ultrasound of the kidneys, ureters and bladder: This ultrasound is used to visualise any abnormal growths/stones within the kidneys, ureters and bladder, assess the size of the kidneys, and abnormal swelling of the kidneys and ureters.
• CT urogram: Computed tomography (CT) examines the structure of the urinary tract. Kidney stones, masses, abnormalities of the ureters and bladder can be detected.
• Cystoscopy: This can be done under local or general anaesthesia where a camera is inserted through the urethra to look at the bladder, and biopsy samples can be taken to look for infection, inflammation, and cancerous growths.

What is the treatment for haematuria?
There is no specific treatment for haematuria since it is not a disease in itself. Treatment is directed at the cause of haematuria and can be discussed with your specialist doctor.

Conclusion
Haematuria is an alarming situation for most patients when it occurs. Do not to panic if you have haematuria. Please seek your doctor’s advice, as there are many causes for haematuria as described above, and the treatments can vary to a great degree for the different causes of haematuria. It is therefore important to seek treatment early.