Bladder Problems – GyneClinics

Cystitis, Urinary Tract Infections

Cystitis literally means “inflammation of the bladder” and is used to describe acute infection, irritation or damage to the bladder. The good news however, is that it is easily treatable and usually clears up after a few days without causing any long-term problems. Women are more likely to get cystitis than men. This is because they have a shorter urethra (the tube from the bladder to the outside opening) located nearer the anus, making the spread of infection more likely. Some women are more prone to infection than others as the nearness of the anal opening to the urethral tube varies from woman to woman. There are several clinical descriptions or types of cystitis:

Bacterial Cystitis- accounts for about half of all cases. Inflammation of the bladder is caused by bacteria (germ) passing through the urethra and travelling up to the bladder, irritating its lining. As the number of germs increases, the bladder is unable to flush them out properly casuing an infection.

Interstitial Cystitis (IC) – affects an estimated 400,000 women in Britain and is a chronic (long term) inflammation of the bladder wall. It is not believed to be bacterial and does not respond to conventional antibiotics. The condition carries the obvious signs of ordinary cystitis but there is no bladder infection and there are no germs present in the urine. The cause of the condition is still unknown and as yet, there is no cure for IC, however, there are treatments which may help reduce symptoms. (see Interstitial Cystitis)

Recurrent Cystitis- refers to repeated cystitis where the frequency of infection causes concern. If there have been at least 2 infections of the bladder in 6 months or 3 infections in a one-year period then this is classed as recurrent cystitis.

Cystitis during pregnancy- cystitis is more common in pregnancy as the bladder muscles are softer and do not always allow the bladder to empty properly. This can result in some urine staying in the bladder and becoming stagnant, which makes infection more likely. Later on in pregnancy, the enlarged womb presses on the bladder which may either worsen the ability to empty completely or can sometimes cause intermittent incontinence. Also, during pregnancy, breastfeeding and the menopause; oestrogen levels are lower and the protection it provides may be lost, making the lining of the bladder thinner and more vulnerable. Hormone Replacement Therapy (HRT) for women who have been through the menopause can help reduce recurrent cystitis.

Causes

Hygiene, wiping from back to front after visiting the toilet can spread germs towards the urethra. Inserting tampons can sometimes push bacteria into the urethra, thus spreading germs.
Vigorous sex can cause bruising and inflammation of the vagina and urethra which can then lead to infection.
A badly fitted diaphragm (contraceptive device).
Tight trousers or tights and thongs.
“Holding on” too long and not emptying the bladder regularly enough.
Inadequate bladder emptying- when not all of the urine in the bladder is passed.
Perfumed soap/bubble bath/etc.
Sexually transmitted infections
Urinary catheter- infection can happen more easily when catheters are used.
Some prescribed medications, for example; antidepressants.

Symptoms

Bacterial Cystitis

An almost constant urge to urinate, but only passing a small amount of urine each time.
Burning or stinging pain in the urethra when passing water.
Cloudy urine.
Getting up several times through the night to go to the toilet.
Blood in the urine.
A strong or “fishy” smell to the urine.
Fever or a temperature, generally feeling unwell and a dull ache in the lower abdomen and back – these symptoms may mean the infection has spread to the kidneys.

Interstitial Cystitis

Urgent desire to urinate.
Frequently needing to pass urine, in severe cases up to 70 times a day.
Pain – recurrent abdominal, urethral or vaginal pain, often with symptoms getting worse during menstruation.

Diagnosis and Treatments

In the early stages, bacteria can be flushed out by drinking plenty of water and diluting the urine, while over-the-counter remedies, such as cranberry juice extract tablets or sachets can also help.

If cystitis lasts for longer than 48 hours, you will need treatment including prescription of a course of antibiotics, once the bacteria causing the infection is identified. However, if the symptoms are mild and not causing too much of a problem, it may be best not to advise antibiotics, to avoid ‘antibiotic resistance’(where the bacteria gets used to an antibiotic and this treatment no longer works). If the cystitis keeps recurring, especially if there is blood in the urine, a cystoscopy may be needed; a tiny telescope is placed in the bladder, under local or general anaesthetic, to look for a cause of bleeding.

Prevention

There are many simple things that can help to prevent cystitis from occurring;

Drink plenty of fluids, preferably water (at least 2–3 litres per day/8 glasses) to keep the bladder ‘flushed’.
Wipe from the front to the back after passing urine.
Wear breathable cotton underwear and avoid tight trousers and tights.
Don’t “hold on” as it causes stress to the bladder which can result in an attack of cystitis.
Empty your bladder completely; this ensures there is no stagnant urine left in the bladder.
Avoid perfumed soaps, bubble baths and vaginal deodorants.
Avoid sex on a full bladder. Go to the toilet regularly and pass urine after sex.
If you have a badly fitted diaphragm you may be prone to cystitis, try other forms of contraception or have it refitted properly.
Cranberry juice- some women swear by drinking a glass a day to help prevent the onset of cystitis as it is said to contain a natural antibiotic. In the case of IC, cranberry juice or supplements can aggravate the infection. Women on the anti-coagulant drug Warfarin should not drink cranberry juice or take cranberry capsules.
If you already have cystitis, it is best to avoid the following: Alcohol and caffeine- as they dehydrate the body, Acidic fruit juices and carbonated drinks, Spicy food and Sex.

Cystitis, Urinary Tract Infections

Bacterial Cystitis– accounts for about half of all cases. Inflammation of the bladder is caused by bacteria (germ) passing through the urethra and travelling up to the bladder, irritating its lining. As the number of germs increases, the bladder is unable to flush them out properly casuing an infection.

Recurrent Cystitis– refers to repeated cystitis where the frequency of infection causes concern. If there have been at least 2 infections of the bladder in 6 months or 3 infections in a one-year period then this is classed as recurrent cystitis.

Cystitis during pregnancy– cystitis is more common in pregnancy as the bladder muscles are softer and do not always allow the bladder to empty properly. This can result in some urine staying in the bladder and becoming stagnant, which makes infection more likely. Later on in pregnancy, the enlarged womb presses on the bladder which may either worsen the ability to empty completely or can sometimes cause intermittent incontinence. Also, during pregnancy, breastfeeding and the menopause; oestrogen levels are lower and the protection it provides may be lost, making the lining of the bladder thinner and more vulnerable. Hormone Replacement Therapy (HRT) for women who have been through the menopause can help reduce recurrent cystitis.

Causes

Hygiene, wiping from back to front after visiting the toilet can spread germs towards the urethra. Inserting tampons can sometimes push bacteria into the urethra, thus spreading germs.
Vigorous sex can cause bruising and inflammation of the vagina and urethra which can t hen lead to infection.
A badly fitted diaphragm (contraceptive device).
Tight trousers or tights and thongs.
“Holding on” too long and not emptying the bladder regularly enough.
Inadequate bladder emptying- when not all of the urine in the bladder is passed.
Perfumed soap/bubble bath/etc.
Sexually transmitted infections
Urinary catheter- infection can happen more easily when catheters are used.
Some prescribed medications, for example; antidepressants.

Symptoms

Bacterial Cystitis

An almost constant urge to urinate, but only passing a small amount of urine each time.
Burning or stinging pain in the urethra when passing water.
Cloudy urine.
Getting up several times through the night to go to the toilet.
Blood in the urine.
A strong or “fishy” smell to the urine.
Fever or a temperature, generally feeling unwell and a dull ache in the lower abdomen and back – these symptoms may mean the infection has spread to the kidneys.

Interstitial Cystitis

Urgent desire to urinate.
Frequently needing to pass urine, in severe cases up to 70 times a day.
Pain – recurrent abdominal, urethral or vaginal pain, often with symptoms getting worse during menstruation.

Diagnosis and Treatments

In the early stages, bacteria can be flushed out by drinking plenty of water and diluting the urine, while over-the-counter remedies, such as cranberry juice extract tablets or sachets can also help.

Prevention

There are many simple things that can help to prevent cystitis from occurring;

Drink plenty of fluids, preferably water (at least 2–3 litres per day/8 glasses) to keep the bladder ‘flushed’.
Wipe from the front to the back after passing urine.
Wear breathable cotton underwear and avoid tight trousers and tights.
Don’t “hold on” as it causes stress to the bladder which can result in an attack of cystitis.
Empty your bladder completely; this ensures there is no stagnant urine left in the bladder.
Avoid perfumed soaps, bubble baths and vaginal deodorants.
Avoid sex on a full bladder. Go to the toilet regularly and pass urine after sex.
If you have a badly fitted diaphragm you may be prone to cystitis, try other forms of contraception or have it refitted properly.
Cranberry juice- some women swear by drinking a glass a day to help prevent the onset of cystitis as it is said to contain a natural antibiotic. In the case of IC, cranberry juice or supplements can aggravate the infection. Women on the anti-coagulant drug Warfarin should not drink cranberry juice or take cranberry capsules.

If you already have cystitis, it is best to avoid the following: Alcohol and caffeine- as they dehydrate the body, Acidic fruit juices and carbonated drinks, Spicy food and Sex.

Painful Bladder Problems, Interstitial Cystitis

Interstitial Cystitis (IC) or Bladder Pain Syndrome (BPS) is a chronic, oftentimes severely debilitating disease of the urinary bladder. Of unknown cause, it is characterized by: pain associated with the bladder, pain associated with urination (dysuria), urinary frequency (as often as every 10 minutes), urgency, and/or pressure in the bladder and/or pelvis. The disease has a profound impact on quality of life. A study concluded, “the impact of interstitial cystitis on quality of life is severe and debilitating”, stating that the quality of life of interstitial cystit is patients resembles that of a person on kidney dialysis or suffering from chronic cancer pain. The condition is officially recognized as a disability. It is not unusual for patients to have been misdiagnosed with a variety of other conditions, including: overactive bladder, urethritis, urethral syndrome, trigonitis, other generic terms used to describe frequency/urgency symptoms in the urinary tract.

IC/BPS affects women of all cultures, socioeconomic backgrounds, and ages. Although the disease previously was believed to be a condition of menopausal women, growing numbers of women are being diagnosed in their twenties and younger. IC/BPS is not a rare condition, early research suggested that IC/BPS prevalence ranged ]

Signs and symptoms

The symptoms of IC/BPS are often misdiagnosed as a “common” bladder infection ( cystitis ) or a UTI. However, IC/BPS has not been shown to be caused by a bacterial infection, and the mis -prescribed treatment of antibiotics is ineffective. The symptoms of IC/BPS may also initially be attributed to endometriosis and uterine fibroids . The most common symptom of IC/BPS is pain, which is found in 100% of patients, frequency (82% of patients) and nocturia (62%). In general, symptoms are:

Painful urination

Pain that is worsened with bladder filling and/or improved with urination. ^[9]

Pain that is worsened with a certain food or drink.
- Some patients report dysuria (burning sensation in the urethra when urinating).

Urinary frequency (as often as every 10 minutes), urgency, and pressure in the bladder and/or pelvis.

Some patients report nocturia (waking at night to urinate), hesitancy (needing to wait for the stream to begin, often caused by pelvic floor dysfunction and tension), pain with sexual intercourse, and discomfort and difficulty driving, travelling or working.

During cystoscopy, 5 to 10% of patients are found to have Hunner’s ulcers . Far more patients may experience a very mild form of IC/BPS, in which they have no visible wounds in their bladder, yet struggle with symptoms of pain, frequency and/or urgency. Still other patients may have discomfort only in their urethra, while others struggle with pain in the entire pelvis. For the most part, people with interstitial cystitis will either have lots of pain and very little frequency or they’ll have lots of frequency and very little pain.

Association with other conditions

Some people with IC/BPS suffer from other conditions that may have the same etiology as IC/BPS. These include: irritable bowel syndrome (IBS), fibromyalgia, chronic fatigue syndrome, endometriosis , vulvodynia, chemical sensitivities and anxiety disorder. The presence of endometriosis has a strong association with typical IC findings on cystoscopy including glomerulations, ulcers, and reduced bladder capacity.

Causes of Interstitial Cystitis

The cause of IC/BPS is unknown, though several theories have been put forward (these include autoimmune theory, nerve theory, mast cell theory, leaky lining theory, infection theory and a theory of production of a toxic substance in the urine. Other theories are neurologic, allergic, genetic and stress -psychological. In addition, recent research shows that IC patients may have a substance in the urine that inhibits the growth of cells in the bladder epithelium. An infection may then predispose those patients to get IC. Regardless of the origin, it is clear that the majority of IC/BPS patients struggle with a damaged urothelium, or bladder lining. When the surface glycosaminoglycan (GAG) layer is damaged (via a urinary tract infection (UTI), excessive consumption of coffee or fizzy drinks, traumatic injury, etc.), urinary chemicals can “leak” into surrounding tissues, causing pain, inflammation, and urinary symptoms. Oral medications like pentosan polysulfate and medications that are placed directly into the bladder via a catheter sometimes work to repair and rebuild this damaged/wounded lining, allowing for a reduction in symptoms.

Anxiety and Stress – Numerous studies have noted the link between interstitial cystitis, anxiety, stress, hyperresponsiveness, and panic Autoimmune – The body’s immune system attacks the bladder. Biopsies on the bladder walls of people with IC usually contain mast cells. Mast cells gather when an allergic reaction is occurring. They contain histamine packets. The body identifies the bladder wall as a foreign agent, and the histamine packets burst open and attack. Thus, the body attacks itself (basis of autoimmune disease.

Genes & Leaky Bladder Lining – Some genetic subtypes, in some patients, have been linked to the disorder. There is an antiproliferative factor secreted by the bladders of IC/BPS patients which inhibits bladder cell proliferation, thus possibly causing the missing bladder lining. Most literature supports the belief that IC’s symptoms are associated with a defect in the bladder epithelium lining which allows irritating substances in the urine to penetrate into the bladder — essentially, a breakdown of the bladder lining (also known as Adherence Theory). The deficiency in this glycosaminoglycan (GAG) layer, on the surface of the bladder results in increased permeability of the underlying submucosal tissues. GP 51 is a Urinary Glycoprotein that functions as a protective barrier to the bladder wall. A study evaluated urinary GP 51 levels in patients with and without interstitial cystitis and found that these levels are significantly reduced in patients with the disease.

Mast Cells – were once thought to be responsible for allergic reactions. Mast cells release histamine. Histamine causes pain, swelling, scarring and prevents healing. Current evidence from clinical and laboratory studies confirms that mast cells play a central role in IC/PBS. Research has shown that there is proliferation of nerve fibers in the bladders of IC patients that does not exist in the bladders of people who have not been diagnosed with IC.

Nerve Damage Theory – An unknown toxin or stimulus causes nerves in the bladder wall to fire uncontrollably. When they fire, they release substances called neuropeptides that induce a cascade of reactions that cause pain in the bladder wall.

Diagnosis of IC

Diagnosis has been greatly simplified in recent years with the development of two new methodologies. The Pelvic Pain Urgency/Frequency (PUF) Patient Survey, created by C. Lowell Parsons, is a short questionnaire that will help doctors identify if pelvic pain could be coming from the bladder. The KCl test, also known as the potassium sensitivity test, uses a mild potassium solution to test the integrity of the bladder wall. Though the latter is not specific for IC/BPS, it has been determined to be helpful in predicting the use of compounds, such as pentosan polysulphate, which are designed to help repair the GAG layer.

The previous gold standard test for IC/BPS was the use of hydrodistention with cystoscopy. Researchers, however, determined that this visual examination of the bladder wall after stretching the bladder was not specific for IC/BPS and that the test, itself, can contribute to the development of small glomerulations (that is, petechial hemorrhages) often found in IC/BPS. Thus, a diagnosis of IC/BPS is one of exclusion, as well as a review of clinical symptoms . In 2009, Japanese researchers identified a urinary marker called phenylacetylglutamine that could be used for early diagnosis.

Treatment of IC

Medication

As recently as a decade ago, treatments available were limited to the use of astringent instillations, such as chlorpactin (oxychlorosene) or silver nitrate, designed to kill “infection” and/or strip off the bladder lining . Rather, IC/BPS treatment is typically multi-modal, including the use of a bladder coating, an antihistamine to help control mast cell activity and a low dose antidepressant to fight neurogenic inflammation.

Pentosan polysulfate – Oral pentosan polysulfate is believed to provide a protective coating in the bladder, but some studies have found that a minority of patients do respond to pentosan polysulfate. Amitriptyline can reduce symptoms in patients with IC/BPS. Patient overall satisfaction with the therapeutic result of amitriptyline was excellent or good in 46%. Amitriptyline may be beneficial in doses greater than 50 mg. DMSO (Dimethyl Sulfoxide), a wood pulp extract, is the only approved bladder instillation for IC/BPS yet it is much less frequently used nowadays. This is because the approved dosage of a 50% solution of DMSO had the potential of creating irreversible muscle contraction. However, a lesser solution of 25% was found to be reversible. Long term use is questionable, at best, particularly given the fact that the method of action of DMSO is not fully understood. Rescue instillations – More recently, the use of a “rescue instillation” composed of pentosan polysulfate or heparin, sodium hyaluronate, lidocaine and sodium bicarbonate, has generated considerable excitement in the IC/BPS community because it is the first therapeutic intervention that can be used to reduce a flare of symptoms. Published studies report a 90% effectiveness in reducing symptoms. Sometimes these rescue instillations are given on a regular basis for treatment. It is important to note that this is off-label use for both pentosan polysulfate and heparin, as neither medicine has been approved to be used this way. Bladder Coatings – Other bladder coating therapies include Cystistat (sodium hyaluronate) and Uracyst (chondroitin). They are believed to replace the deficient GAG layer on the bladder wall. Like most other intravesical bladder treatments, this treatment may require the patient to lie for 20 – 40 minutes, turning over every ten minutes, to allow the chemical to ‘soak in’ and give a good coating, before it is passed out with the urine.

Diet

It has been reported that most (but not all) people with IC find that certain foods make their symptoms worse. In 2007, a study done at Long Island University, USA reported that over 9 0 percent of interstitial cystitis patients experience an increase in symptoms when they consume certain foods and beverages, especially coffee, tea, soda, alcoholic beverages, citrus fruits and juices, artificial sweeteners and hot pepper. The challenge with diet triggers is that they vary from person to person: the best way for a person to discover his or her own triggers is to use an elimination diet. The foundation of treatment is to modify the diet to help patients avoid those foods which can further irritate the damaged bladder wall.

Pain that worsened with a certain food or drink and/or worsened with bladder filling and/or improved with urination was reported by 97% of patients, in one study. Avoiding citrus fruits, tomatoes, coffee, tea, carbonated and alcoholic beverages, spicy foods, artificial sweeteners, and vitamin C has been recommended. It also found that many patients had reduced sensitivity to trigger foods if they consumed calcium glycerophosphate and/or sodium bicarbonate.

Bladder distension a procedure which stretches the bladder capacity, done under general anaesthesia) has shown some success in reducing urinary frequency and giving pain relief to patients.^[52] However, many experts still cannot understand precisely how this can cause pain relief. Unfortunately, the relief achieved by bladder distensions is only temporary (weeks or months) and consequently, it is not really viable as a long-term treatment for IC/BPS.

Surgery – Surgical interventions are rarely used for IC/BPS, non is totally effective. Surgical

intervention is very unpredictable for IC/BPS, and is considered a treatment of last resort when all other treatment modalities have failed and pain is severe. Some patients who opt for surgical intervention continue to experience pain after surgery.

Pain control Pain control is usually necessary in the IC/BPS treatment plan. The pain of IC/BPS has been rated equivalent to cancer pain and may lead to central sensitization if untreated.

Neuromodulation – Neuromodulation can be successful in treating IC/BPS symptoms, including

pain. Electronic pain-killing options include stimulators have also been used, with varying degrees of success. Percutaneous sacral nerve root stimulation (PNS) was able to produce statistically significant improvements in several parameters, including pain

Acupuncture – there are some good results reported when acupuncture is combined with other treatments. In others, no benefit has been noted.

Prognosis – A survey showed that among people with interstitial cystitis:

40% were unable to work
27% were unable to have sex due to pain
27% had marriage breakdown
55% contemplated suicide
12% had attempted suicide

Overactive Bladder

An overactive bladder (OAB) is when the bladder contracts suddenly without you having control, and when the bladder is not full or expected to contract. Overactive bladder syndrome is a common condition where no cause can be found for the repeated and uncontrolled bladder contractions. Overactive bladder syndrome is common. Symptoms include an urgent feeling to go to the toilet, going to the toilet frequently, and sometimes leaking urine before you can get to the toilet (urge incontinence). Treatment with bladder training often cures the problem. Sometimes medication may be advised in addition to bladder training to relax the bladder. Overactive bladder syndrome is sometimes called an irritable bladder or detrusor instability. (Detrusor is the medical name for the bladder muscle).

Symptoms include:

Urgency. This means that you get a sudden urgent desire to pass urine. You are not able to put off going to the toilet.
Frequency. This means going to the toilet often – more than seven times a day. In many cases it is a lot more than seven times a day.
Nocturia. This means waking to go to the toilet more than once at night.
Urge incontinence occurs in some cases. This is a leaking of urine before you can get to the toilet when you have a feeling of urgency.

Causes of Overactive Bladder

The cause is not fully understood. The bladder muscle seems to become overactive and contract (squeeze) when you don’t want it to. Normally, the bladder muscle (detrusor) is relaxed as the bladder gradually fills up. As the bladder is gradually stretched, we get a feeling of wanting to pass urine when the bladder is about half full. Most people can hold on quite easily for some time after this initial feeling until a convenient time to go to the toilet. However, in people with an overactive bladder, the bladder muscle seems to give wrong messages to the brain. The bladder may feel fuller than it actually is. The bladder contracts too early when it is not very full, and not when you want it to. This can make you suddenly need the toilet. In effect, you have much less control over when your bladder contracts to pass urine. In most cases, the reason why an overactive bladder develops is not known. Symptoms may get worse at times of stress. Symptoms may also be made worse by caffeine in tea, coffee, cola, etc, and by alcohol. In some cases, symptoms of an overactive bladder develop as a complication of a nerve- or brain-related disease such as following a stroke, with Parkinson’s disease, with multiple sclerosis or after spinal cord injury. Also, similar symptoms may occur if you have a urine infection or a stone in your bladder. These conditions are not classed as overactive bladder syndrom e as they have a known cause.

Treatments for overactive bladder syndrome

Some general lifestyle measures may help.
Bladder training is a main treatment. This can work well in up to half of cases.
Medication may be advised instead of, or in addition to, bladder training.
Pelvic floor exercises may also be advised in some cases.

General Lifestyle Measures

Getting to the toilet. Make this as easy as possible. If you have difficulty getting about, consider special adaptations like a handrail or a raised seat in your toilet. Sometimes a commode in the bedroom makes life much easier.
Caffeine. This is in tea, coffee, cola, and is part of some painkiller tablets. Caffeine has a diuretic effect (will make urine form more often). Caffeine may also directly stimulate the bladder to make urgency symptoms worse. It may be worth trying without caffeine for a week or so to see if symptoms improve. If symptoms do improve, you may not want to give up caffeine completely. However, you may wish to limit the times that you have a caffeine-containing drink. Also, you will know to be near to a toilet whenever you have caffeine.
Alcohol. In some people, alcohol may make symptoms worse. The same advice applies as with caffeine drinks.
Drink normal quantities of fluids. It may seem sensible to cut back on the amount that you drink so the bladder does not fill so quickly. However, this can make symptoms worse as the urine becomes more concentrated, which may irritate the bladder muscle. Aim to drink normal quantities of fluids each day. This is usually about two litres of fluid per day – about 6-8 cups of fluid, and more in hot climates and hot weather.
Go to the toilet only when you need to. Some people get into the habit of going to the toilet more often than they need. They may go when their bladder only has a small amount of urine so as “not to be caught short”. This again may sound sensible, as some people think that symptoms of an overactive bladder will not develop if the bladder does not fill very much and is emptied regularly. However, again, this can make symptoms worse in the long run. If you go to the toilet too ofte n the bladder becomes used to holding less urine. The bladder may then become even more sensitive and overactive at times when it is stretched a little. So, you may find that when you need to hold on a bit longer (for example, if you go out), symptoms are worse than ever.

Bladder training (sometimes called Bladder Drill)

The aim of Bladder Drill is to slowly stretch the bladder so that it can hold larger and larger volumes of urine. In time, the bladder muscle should become less overactive and you should become more in control of your bladder. This means that more time can elapse between feeling the desire to pass urine, and having to get to a toilet. Leaks of urine are then less likely. A doctor, nurse, or continence advisor will explain how to do bladder training. The advice may be something like the following:

You will need to keep a diary. On the diary make a note of the times you pass urine, and the amount (volume) that you pass each time. Also make a note of any times that you leak urine (are inconti nent). Your doctor or nurse may have some pre-printed diary charts for this purpose to give you. Keep an old measuring jug by the toilet so that you can measure the amount of urine you pass each time you go to the toilet. When you first start the diary, go to the toilet as usual for 2-3 days at first. This is to get a baseline idea of how often you go to the toilet and how much urine you normally pass each time. If you have an overactive bladder you may be going to the toilet every hour or so, and only pass ing less than 100-200ml each time. This will be recorded in the diary.

After the 2-3 days of finding your baseline, the aim is then to hold on for as long as possible before you go to the toilet. This will seem difficult at first. For example, it you norm ally go to the toilet every hour, it may seem quite a struggle to last one hour and five minutes between toilet trips. When trying to hold -on, try distracting yourself. For example: a) Sitting straight on a hard seat may help. b) Try counting backwards fro m 100. c) Try doing some pelvic floor exercises (see below).

With time, it should become easier as the bladder becomes used to holding larger amounts of urine. The idea is gradually to extend the time between toilet trips and to train your bladder to stretch more easily. It may take several weeks, but the aim is to pass urine only 5 -6 times in 24 hours (about every 3-4 hours). Also, each time you pass urine you should pass much more than your baseline diary readings. (On average, people without an overactive bladder normally pass 250-350 ml each time they go to the toilet.) After several months you may find that you just get the normal feelings of needing the toilet, which you can easily put off for a reasonable time until it is convenient to go. Bladder training can be difficult, but becomes easier with time and perseverance. It works best if combined with advice and support from a continence advisor, nurse, or doctor. Make sure you drink a normal amount of fluids when you do bladder training (see above).

Medication

If there is not enough improvement with bladder training alone, medicines in the class of drugs called antimuscarinics (also called anticholinergics) may also help. They include: oxybutynin, tolterodine, trospium chloride, darifenacin, propiverine, and solifenacin. These also come in different brand names. For example Fesoterodine (Toviaz) – Fesoterodine is the most recent anticholinergic agent to be approved. It is available in 2 doses, and the 8-mg dose has been shown to be superior to tolterodine (Detrusiol LA) 4mg in the reduction of symptoms. It shares a similar muscarinic receptor affinity as tolterodine. They work by blocking certain nerve impulses to the bladder, which relaxes the bladder muscle and so increases the bladder capacity.

Medication improves symptoms in some cases, but not all. The amount of improvement varies from person to person. You may have fewer toilet trips, fewer urine leaks, and less urgency. However, it is uncommon for symptoms to go completely with medication alone. A common plan is to try a course of medication for a month or so. If it is helpful, you may be advised to continue for up to six months or so and then stop the medication to see how symptoms are without the medication. Symptoms may return after you finish a course of medication. However, if you combine a course of medication with bladder training, the long -term outlook may be better and symptoms may be less likely to return when you stop the medication. So, it is best if the medication is used in combination with the bladder training.

Side-effects are quite common with these medicines, but are often minor and tolerable. Read the information sheet which comes with your medicine for a full list of possible side-effects. The most common is a dry mouth, and simply having frequent sips of water may counter this. Other common side -effects include dry eyes, constipation and blurred vision. However, the medicines have differences, and you ma y find that if one medicine causes troublesome side-effects, a switch to a different one may suit you better.

Pelvic floor exercises

Many people have a mixture of overactive bladder syndrome and stress incontinence. Pelvic floor exercises are the main treatment for stress incontinence. Briefly, this treatment involves exercises to strengthen the muscles that wrap underneath the bladder, uterus (womb) and rectum. It is not clear if pelvic floor exercises help if you just have overactive bladder syndrome without stress incontinence. However, pelvic floor exercises may help if you are doing bladder training (see above).

Surgery for OAB

If the above treatments are not successful, surgery is sometimes suggested to treat overactive bladder syndrome. Procedures that may be used include:

Sacral nerve stimulation. An overactive bladder can be treated by sacral nerve stimulation. A small pulse generator device is implanted under the skin of the buttock to send a burst of electrical signals to the nerves that control the bladder.
Augmentation cystoplasty. In this operation, a small piece of tissue from the intestine is added to the wall of the bladder to increase the size of the bladder. However, not all people can pass urine normally after this operation. You may need to learn self-catheterising (put a small tube) o empty your bladder.
Urinary diversion. In this operation, the ureters (the tubes from the kidneys to the bladder) are routed directly to the outside of your body. There are various ways that this may be done . Urine does not flow into the bladder. This procedure is only done if all other options have failed to treat your overactive bladder syndrome.

Treatment of OAB with Botox (Botulinum toxin A)

This is an alternative treatment to surgery if other treatments including bladder training and medication have not helped your symptoms. The treatment involves injecting botulinum toxin A into the sides of your bladder. This treatment has an effect of damping down the abnormal contractions of the bladder. However, it may also damp down the normal contractions so that your bladder is not able to empty fully. If you have this procedure you usually need to insert a catheter (a small tube) into your bladder in order to empty it. Note: botulinum toxin A has not been licensed for the treatment of overactive bladder syndrome in the UK..