Problems with our personal plumbing are incredibly common — from cystitis to incontinence after childbirth or prostate troubles.
In the final part of our series, we look at what can go wrong with your waterworks — and what can be done to help…
Although rarely talked about, urinary incontinence affects millions of people in the UK.
And it seems many are too embarrassed even to talk to their doctor about it — one survey found that 60 percent of women with incontinence problems would not go to their GP for help.
Many suspects they may have a bladder problem but suffer in silence because they are too embarrassed to discuss it with their GP
But just putting up with it means you miss out on treatment that can improve the situation. There are various types of incontinence, which have different causes and therefore require different solutions. But the key thing is you don’t have to live with it.
Stress that’s no laughing matter
Small leakages of urine when you cough or laugh is known as stress incontinence. It happens when the bladder neck cannot remain closed under physical stress.
‘In women, this can happen after childbirth, when the neck gets stretched during delivery, or because the pelvic floor muscles are weakened, causing the neck to sag,’ says Mike Bowen, a consultant gynecologist based at the Nuffield Health Oxford Hospital.
In men, removal of the prostate gland (prostatectomy) ‘is the principal cause for stress urinary leakage’, says Giles Hellawell, a consultant urological surgeon at The London Clinic, and at Imperial College Healthcare NHS Trust. This may only be temporary — though men may have to wear pads while it settles down.
To diagnose stress incontinence, a GP can perform a bladder stress test, which is usually done lying down: fluid is inserted into the bladder using a thin tube — you’ll be asked to cough and the doctor will check for fluid loss. The test may be repeated standing up.
There is also a pad test when you will wear an absorbent pad for a period of time. It will be weighed afterward to work out how much urine you have lost without going to the loo.
Pelvic floor exercises are very effective at helping to alleviate stress incontinence. A review of studies published in 2010 found up to a 70 percent improvement in symptoms of stress incontinence in women after appropriately performed exercises (see overleaf for how to do these, as well as gadgets that can help).
For stress incontinence that persists, and seriously affects the quality of life, there are surgical options. Over the past decade or so, women have been given synthetic mesh slings, also known as transvaginal slings or tension-free vaginal tape (TVT), which support internal organs and ‘lift’ the bladder neck, and urethra.
However, recently there have been concerns about the material in these shredding and cutting into the bladder and nearby tissue. More than 92,000 women had vaginal mesh implants from 2007 to 2015 in England, and a 2012 Government report found that around 15 percent experienced complications.
Campaigners, including doctors and women who have been affected, are calling for a return to older sling techniques, including the open Burch colposuspension, which used the woman’s own tissues to recreate a stable pelvic floor.
There is a newer sling procedure known as a trans-obturator tape (or TOT) — available on the NHS and privately — which supports the urethra using a tension-free tape slung between the two obturator foramens (holes in the pubis bones of the pelvis which allow passage of nerves and blood vessels).
Unlike the TVT operation, the tape does not go close to the bladder to keep it in its correct position.
‘Trans-obturator sling procedures have a success rate of 85 percent,’ says Mr. Bowen. ‘Research has shown it is much less likely to lead to bladder damage.’
Men with stress incontinence after prostate surgery, which hasn’t improved after 18 months, can also opt for a sling procedure, where a synthetic mesh is positioned to give the urethra support.
There isn’t any long-term data for this relatively new operation, but so far about 80 percent of men are able to stop using pads afterward or their urinary leakage is halved.
When you can’t hold on
If you feel a near-constant need to urinate or feel as though you can’t ‘hold on’ when you do need to go, this is likely to be urge incontinence. This differs from stress incontinence when the pelvic floor muscles are too weak to prevent urination.
Urge incontinence is twice as common among women as men and is caused by damage to nerves in the bladder or muscle, bladder stones, infection, or bladder inflammation. But in most cases, no cause can be found.
Leakage occurs because the bladder muscles squeeze or contract at the wrong times, not just when your bladder is full.
Overactive bladder, when the bladder muscles contract too often, is one cause of urge incontinence. It creates an uncomfortable feeling of wanting to urinate all the time.
Some men suffer overactive bladder and flow problems because of an enlarging prostate, which can block the urethra — the tube which carries urine from the body. ‘The bladder is having to increase the pressure to maintain flow.
Eventually, it becomes unstable, leading to overactivity,’ says Mr. Hellawell.
It can be diagnosed through urodynamic testing, which includes noting if someone can stop urine flow mid-stream, using sensors to check the pressure within the bladder, and measuring nerve activity. This can evaluate how well the bladder, sphincters, and urethra are storing and releasing urine.
Unlike stress incontinence, there are drug treatments for urge incontinence and an overactive bladder. It can be stabilized with anticholinergic drugs, which work by dulling the autonomic, or involuntary, nervous system which controls the functioning of organs such as the bladder, heart, lungs, and genitals.
‘But the side effects of these medications are not great,’ says Mr. Hellawell. ‘Not only will they lessen the bladder contractions, but they will also lessen bowel contractions, leading to constipation.’
Anticholinergic drugs will also affect the lacrimal glands behind the eyes and the salivary glands, leaving patients complaining of dry eyes and dry mouth. They take 12 weeks to take full effect — and while the idea is to take the drugs for life, patients are unlikely to want to take them long-term.
But there’s a new prescription drug available called mirabegron, marketed as Betmiga, which works by relaxing muscles in the bladder.
Injecting Botox into the bladder muscle has been found to be effective because it paralyzes the muscles for up to two months. It is available in a few centers on the NHS, but it is not currently licensed to treat urge incontinence so doctors need to go through all the risks before a patient can decide to go ahead.
Constant trickle linked to prostate
Overflow incontinence is caused when the bladder never fully empties and small amounts dribble out all the time, rather than only when the bladder is under stress. People with this type of incontinence may not always sense that their bladder is full.
It is more common in older men and is often due to an enlarged prostate. Women can suffer from this type of incontinence too when the urethra is blocked by prolapsed organs or kidney stones. It is often diagnosed when someone has frequent bladder infections caused by a backup of urine, which grows bacteria.
Overflow incontinence is caused when the bladder never fully empties and small amounts dribble out all the time
To diagnose it, you may be asked to go to the loo and completely empty your bladder before a doctor inserts a catheter to see if more urine comes out — if more urine is produced it could indicate overflow incontinence.
Men with an enlarged prostate may be helped by drugs called alpha adrenergic agonists, such as clonidine, which reduces contractions of the bladder and the urge to pass water.
Medicines, such as the ‘alpha blockers’ tamsulosin and alfuzosin, can also be prescribed to relax the muscle in the prostate, taking the pressure off the urethra. Many herbal and other alternative treatments can be found online, but there is no evidence to show any is effective at countering an enlarged prostate.
Leakages can be controlled by absorbent pads or men can use a urinary sheath, worn like a condom with a tube leading to a bag.
For treatments for overflow incontinence in women caused by prolapse, see panel, right.
When going to the loo at night is a problem
For both men and women over 50, getting up to pee once a night is normal, and twice a night over 65. In men, enlarged prostate or (more rarely) prostate cancer can be a cause. But because it happens to men and women, all the blame for ‘nocturia’ — needing to go at night — can’t be laid on the prostate: disturbed sleep patterns and medications including blood pressure drugs can all play a part.
It is, says Mr. Hellawell, important to check that the issue isn’t an undiscovered cardiac problem, which can cause fluid retention.
Lifestyle can play a part. ‘I have patients who have a couple of strong coffees or teas last thing.’ Caffeine encourages urination, and ‘is also known to cause bladder instability’ — triggering a need for frequent or urgent weeing.
How to cure those painful urine infections for good
Cystitis, or inflammation of the bladder, is one of the most common types of urinary tract infection (UTI) and affects more than 90 percent of women.
It is typically caused by bacteria invading the bladder wall, explains Con Kelleher, an obstetrician, and gynecologist based at Guy’s and St Thomas’ NHS Foundation Trust.
Pain when urinating or passing frequent, small amounts of urine are signs of cystitis. So, too, is blood in the urine, which can make it pink and cloudy — but it can indicate other problems such as bladder cancer, too, so always talk to your GP.
It’s far more common among women than men. ‘The anus is closer to the urethra [the tract that carries urine from the bladder out of the body] in women and the urethra is shorter,’ explains Mr. Kelleher. ‘This makes it more likely that bacteria will invade.’
‘UTIs should not be ignored since they can lead to more serious complications such as kidney infection as the bacteria travel up from the bladder,’ says Emma Soos, a nurse with a special interest in urology and director of the Women’s Health Clinic.
For mild cystitis, drinking plenty of water can help flush out bacteria. Although many people believe that cranberry juice can help, recent research found no evidence that the fruit, taken as capsules, made any difference to bacteria in the urine.
The antibiotic trimethoprim (Monotrim) is the main treatment and works in 80 percent of infections. Adults with UTIs who are not responding to treatment should have their urine tested to identify the bacteria causing the problem so they can be targeted with the most effective drugs.
Professor James Malone-Lee, based at University College Hospital, advocates, for some patients, high-dose, long-term treatment with highly-targeted antibiotics, combined with an antiseptic medication called Hiprex, prescribed by a specialist.
To prevent UTIs, wearing clean cotton underwear, avoiding perfumed products and wet wipes, which can be irritating, and wiping front-to-back is effective. Always passing urine at bedtime and after sex —during which bacteria can transfer to the urethra — can also help.
‘MALE CYSTITIS’
Although men can get cystitis, more common is prostatitis — inflammation of the prostate gland which affects half of the men and is sometimes called ‘male cystitis’.
Symptoms include pain when urinating, frequent urination and the urgent need to pass water, cloudiness or blood in the urine, and pain in the abdomen, groin, or lower back. Sometimes it causes sexual problems such as low libido and erectile dysfunction.
Prostatitis is diagnosed by ruling out other conditions that could be causing symptoms, such as cancer. A doctor may give you a physical examination, order urine and blood tests, and sometimes a scan of your urinary tract and prostate to check for underlying issues.
In about 10 percent of cases, it can be down to bacterial infection. ‘This type comes on quickly and can cause a high fever, chills, muscle aches, and joint pain, as well as pain in the perineum and around the base of the penis and difficulty passing urine,’ says Professor Roger Kirby, from the Prostate Centre.
Treatment is with antibiotics. ‘In severe cases, a man may need antibiotics for four to six weeks, or even longer,’ says Professor Kirby.
Professor Christopher Eden, a urological surgeon at Royal Surrey County Hospital, says the quinolone class of antibiotics is most effective at entering the prostate gland.
‘You often find that GPs prescribe the wrong sort, such as trimethoprim, penicillins, and nitrofurantoin which won’t have much effect,’ he says.
The most common type of prostatitis is not caused by bacteria at all.
Chronic prostatitis without bacterial infection, also known as chronic pelvic pain syndrome (CPPS) is diagnosed when men complain of pain around their back passage and discomfort passing urine — yet tests reveal no bugs in the urine.
‘Most experts believe this is caused by scar tissue left after a bacterial infection has resolved — this can stimulate nerves which continue to send signals to the brain that there is inflammation,’ says Professor Eden.
New evidence suggests it may be down to chronic spasms in the pelvic floor. Treatment for CPPS includes alpha blockers, which can help by relaxing the bladder neck, and muscle fibers within the prostate.
Some patients seem to benefit from Cialis, used to treat erectile dysfunction, in doses of 5 mg per day which can also improve sexual function. Botox injections into the prostate have been used to reduce muscle spasms.
And physical therapy to relax the pelvic floor muscles has been shown to help.
Frequent sex and masturbation are sometimes cited as ways to reduce the pain of prostatitis, but Professor Eden says that this is probably a myth. ‘But some men do say that it helps.’
‘For some men, surgical removal of the prostate is worth considering as a last resort,’ adds Professor Eden.
Prolapse: What really does work?
The worst cases of prolapse can make women feel as if their insides are literally falling out.
But some are too minor even to cause symptoms and are discovered during an examination for something else.
‘The ligaments and muscles that make up the pelvic floor start to stretch, and the organs in the abdomen slip down,’ says Dr Philip Owen, a consultant obstetrician, and gynecologist at the Princess Royal Maternity Hospital in Glasgow.
Stretching can occur during pregnancy and childbirth. Being overweight and aging are risk factors. According to the Royal College of Obstetricians and Gynaecologists, half of the women over 50 will have some degree of prolapse.
‘Menopausal women are at risk as muscle tone deteriorates and estrogen levels fall, which cause the wall of the vagina to become thin and less able to support itself,’ says Dr. Owen.
TYPES OF PROLAPSE
Utero-vaginal: The uterus protrudes into the vagina and in some cases slips out. Up to 30 percent of women who have had children develop a utero-vaginal prolapse later in life. They are common in postmenopausal and overweight women as the weight puts pressure on the abdomen.
Bladder: The bladder pushes into the vagina and ‘this can create a “reservoir” of urine that cannot be emptied which can lead to irritation, spasms, and incontinence,’ says Dr. Owen. It can also result in leaking when a woman laughs or coughs.
Rectocele: This occurs when a loop of the bowel presses into the vagina, creating an S-bend where feces can collect. ‘In some cases, women find it difficult to empty their bowels,’ explains Dr. Owen.
Rectocele mostly occurs in women who have undergone a hysterectomy.
TREATMENTS
Losing weight can help to lessen the pressure on the abdominal area. Physiotherapy can reduce the symptoms of any pelvic organ prolapse. Your doctor can refer you.
Ring-shaped pessaries can add support to the vagina. They are worn all the time and need to be replaced every six months.
Surgery may be offered for severe uterine prolapse. One option is synthetic mesh to support the pelvic floor, but this has been linked to long term side-effects. Other options include autologous slings, created from a woman’s tissue.
See your doctor if you have chronic constipation, as long-term straining contributes to prolapse.
Prostates: What every man needs to know
When it comes to men’s ‘plumbing’ issues, the culprit in many cases is the prostate, the gland which produces the fluid that mixes with sperm to create semen.
In a piece of inarguably poor design, the walnut-sized prostate, which is positioned below the bladder, is wrapped around the urethra, the tube that carries urine out of the body through the penis.
That arrangement works just fine when men are in their prime. But as men grow older, the prostate gradually enlarges, placing increasing pressure on the urethra and interfering with the flow of urine.
That, says consultant urological surgeon Giles Hellawell, is when alarm bells start ringing for most men.
‘Of course, prostate cancer is the first thing that goes through their minds,’ he says — difficulty urinating, or needing to urinate more often are common symptoms of prostate cancer. ‘But the first thing I say to patients referred to me is that about half of the men over the age of 50 have some degree of prostatic enlargement — a benign condition — and quite a high proportion of those will have some reduction in flow.’
In fact, most men who go to see their GP have been spooked by symptoms caused by a harmlessly enlarged prostate. They might have a poor flow of urine — what once was a river in flood becomes a mere stream. Or, if they have tolerated poor flow for a number of years, as many men do, they may have started to experience secondary effects on the bladder.
These effects can include ‘urinary frequency’ — having to go to the loo a lot — or ‘urgency’, a sudden, overwhelming urge to go. But for many, says Mr Hellawell, the trigger to go and visit the GP is having regularly to get up once or twice during the night to pass water.
A GP confronted with a man worried about urinary problems will usually conduct a physical examination of the prostate to see if it is, indeed, enlarged. If it is, the next step will be a blood test to check for levels of a protein called Prostate Specific Antigen, or PSA. This is produced by cancerous cells in the prostate, but also by normal ones, and PSA levels rise naturally as men grow older.
An S A result, a raised PSA level is just an indication that further tests might be necessary, says Mr Hellawell. The PSA throws up ‘false positives and many men with an elevated reading do not have prostate cancer.
Conversely, though less often, some men with a low PSA reading do prove to have the condition. So increasingly we don’t rely just on that’, he says.
‘In my NHS practice, we always do an MRI scan of the prostate once the patient has come in with elevated PSA before deciding whether to do a biopsy.’
Prostate cancer ‘affects more than 300,000 men in the UK and kills one man every 45 minutes’, says Ali Rooke, a senior specialist nurse at Prostate Cancer UK. ‘However, it’s a disease which can be successfully treated, if caught early enough.
In many cases, prostate cancer doesn’t have any symptoms at all, especially in its early stages. ‘Therefore, being aware of your risk is crucial and is a man’s best line of defense,’ she says. Men over 50, black men, or men with a father or brother who has had the disease all face a higher than average risk.
‘If you fall into one of these high-risk groups, or have noticed any changes in your waterworks, it’s important to have a conversation with your GP about your risk.’
Anyone with concerns about prostate cancer can contact Prostate Cancer UK’s specialist nurses on 0800 074 83 83.
If cancer has been ruled out, a benign enlarged prostate can be treated. This can mean lifestyle changes — cutting down on caffeine, which irritates the bladder, and alcohol, generally drinking less in the evening — and learning to ‘double void’: peeing, waiting a few seconds, and peeing again.
Some men with an enlarged prostate develop overflow incontinence — where they leak urine (See previous pages) .
In cases of ‘chronic urine retention’, in which peeing is really difficult, a man may have to regularly insert a catheter through the penis to drain the bladder.
When cancer is found, or in some cases of a severely enlarged but benign prostate, a prostatectomy, in which part or all of the prostate is removed, will be carried out. This can lead to other problems.
The problem is that the prostate ‘is not a greatly located organ: it’s very close to the bladder and the voluntary sphincter, which allows you to relax and have a wee. If one is going to surgically remove it you have to be careful,’ says Mr Hellawell.
Even then, following a standard prostatectomy, the risk of incontinence is about 5 percent or higher. Sometimes this is only temporary.
‘We usually wait 12 to 18 months after the operation to see what the eventual baseline incontinence levels will be, and luckily in the majority of patients it does improve,’ explains Mr Hellawell. During this time men may have to wear pads.
WHEN YOU FIND A LUMP…
Understandably, many men become worried when they find a lump in their scrotum — but only four in 100 is likely to be cancerous. Frequently what they have found is a harmless testicular cyst, says Giles Hellawell.
By the age of 50, between 15 and 20 percent of men can expect to have a testicular cyst of some kind, a lump they can feel at the top of one of their testicles.
Cysts are situated in the epididymis, a duct that carries sperm from the testes, and which is often tender in its own right. ‘Typically, somebody has a slightly tender epididymis, which can happen from a bit of inflammation, and they examine it and find a lump,’ says Mr Hellawell. ‘But it’s not actually in the testes, it’s in the bit above.’
A cyst is best left alone, says Mr Hellawell. It rarely causes pain or discomfort and removing it is not without possible consequences: ‘The testes area is not a great place to operate on because the risk of infection is so high.’
To reassure a man his lump is harmless, ‘we would almost automatically get an ultrasound scan, certainly up to the age of 40 and probably beyond.’ This can also pick up hernias and hydrocele testis, a build-up of fluid around the testes.
‘Men should get to know how they usually look and feel, which can help you spot if something changes,’ says Fiona Osgun, Cancer Research UK’s senior health information officer.
Any lump, swelling, change in firmness or texture of the testicles, or a feeling of heaviness or pain in the testicles or scrotum should be checked out by a doctor.