Tuesday, April 21, 2009

Blood in the Urine: Hematuria

Blood in the urine is never normal, but it can be present for benign and not-so-benign reasons. "Microscopic hematuria" is when blood is only seen on a urine test (urinalysis), or "gross hematuria" where actual blood or clots are seen in the urine.

There are many urinary tract issues that can lead to both, but essentially, blood in the urine can come from the kidney, ureter, bladder or urethra. Often menstural blood, or if urine contacts labial skin/hair on the way out prior to hitting the cup, can both lead to false positives.

Common benign reasons for blood in the urine are: urinary tract infection (active or resolving), kidney or bladder stones, foreign objects in the urinary tract (stitches or mesh that have eroded into the bladder), urinary tract deformities from birth, interstitial cystitis, estrogenic changes to the bladder base (common and benign) and benign polyps. Sometimes medications can lead to blood "leak" into the urine- often these are blood thinners such as warfarin (coumadin), aspirin, plavix or pain medications such as prolonged motrin, Celebrex and the like.

More serious conditions that lead to blood in the urine can be tumors of the kidney, ureter or bladder. Of all the urinary organs, the bladder is the most common place to find tumors. Biopsy confirms the findings.

Smoking and exposure to certain chemical agents used in heavy manufacturing of dyes, paint, leatherstripping can lead to urinary tract tumors.

False positives can also happen with food dyes, pyridium, beets, and certain antibiotics.

Gross blood in the urine or persistent microscopic blood should be investigated.

Tuesday, April 14, 2009

Weight Loss Can Reduce Incontinence in Women

It is now common knowledge that weight loss decreases the risk of developing type 2 diabetes, high blood pressure, high cholesterol, and enhances mood and quality of life. Obesity is known to be a risk factor for developing urinary incontinence.

Recent research has shown that weight loss in obese women significantly reduces the incidence of stress incontinence. Even though weight loss may be difficult, losing weight by whatever mechanism or program will lead to results.

This very interesting 6 month trial from San Francisco was performed in obese women between the ages of 42 and 64. A reduced-calorie diet and exercise program was followed by half the women, while the other half were only given reading material on weight loss. The women in the structured program had a mean weight loss of 8% (17 lbs), vs. those women who were not, who lost 1.6% of their weight (3.5 lbs).

The women in the weight loss group had a greater decrease in frequency of stress incontinence compared to the control group: 58% vs. 38%, as well as a decrease in all incontinence episodes: 47% vs. 28%. The women in the weight loss group at the end of the study perceived their incontinence had become less of a problem and had a higher satisfaction rate with this change in their incontinence.

Now, this study may also hold true for women who are overweight but not "obese". In general, less overall weight does mean good over health. Those women who are probably within 20 lbs of their expected weight for their height and age and who have stress incontinence, likely have stress incontinence due to other reasons. These include: vaginal birth, genetic predisposition, chronic straining (cough, heavy exercise), menopause or hysterectomy.

Saturday, April 11, 2009

Is Your Bladder Getting in the Way in the Bedroom?

The title is a little different, but the theme is the same. This is nearly the same article that I recently published in the April 2009 edition of Perfectify:

Women’s bodies are very resilient, but many women notice changes to their bodies below the belt after major life events. Because women are living healthier and longer lives, the chances of having a problem with your bladder, and how it affects the activities in your life is expected to only become more bothersome over time.

Problems with bladder control are quite common in women of all ages, but starting in the 30s and 40s, many women notice that going to the bathroom or accidental urine loss becomes embarrassing and restricting. Despite being healthy or physical fit, the muscles and connective tissue supporting the bladder, vagina, uterus and rectum can become weak or stretched and declare itself in a variety of ways.

Urinary incontinence (UI) is the involuntary loss of urine in any situation. It can be stress-induced, meaning, urine loss during exercise, running, jumping, laughing coughing and even sex. This is known as Stress Urinary Incontinence (SUI). Very often, the sense of needing to go to the bathroom never goes away and you may feel like you have to know where every bathroom is no matter where you go, otherwise there will be trouble. The constant sense of urge, frequency and leaking before you can even pull your pants down is known as Overactive Bladder (OAB), and can coexist with SUI in many women.

Giving birth is an exciting life-changing event, yet even one vaginal childbirth increases a woman’s risk of bladder and other pelvic floor problems. Having a C-section does not seem to be protective over time. The aging process, menopause, repetitive straining such as with a chronic cough, constipation, obesity, and surgery such as a hysterectomy, are other common predisposing factors. In fact, the lifetime risk for an American woman to need surgery for problems related to pelvic floor weakness is 11%. Urinary incontinence affects 13 million adults in the US, 85% of them being women. Often women with urinary incontinence are reported to be depressed and/or embarrassed about their appearance and odor. Consequently, social interaction with friends and family, activities with the kids, and sexual activity is often avoided.

Sexual complaints are very common in women with pelvic floor weakness. Besides urine leakage with sex (which we’ll explore further below), a dropped bladder (cystocele) also impacts sexuality. Women with urine leakage, in general or during sex, have less libido, have vaginal dryness and irritation, lack of sexual excitement and lack of orgasm. Coital incontinence (urine leakage with sex), is noted to be a big cause of sexual inactivity. Intuitively, a dropped bladder or uterus can cause pelvic pressure and pain with sex and lead to avoiding intimacy as well.
Coital Incontinence (CI) has been reported to occur in 10-24% of sexually active women with pelvic floor weakness yet is probably under-reported. It can occur with a sexual partner or with masturbation. Women will rarely bring it up on their own or even after direct questioning by their family doctor.

There are two types of CI: urine leak with penetration, and urine leak with orgasm. Urine leak with penetration is caused by a weak urethra or bladder sphincter, the same cause of urine leak with exercise or laughing. Urine leak with orgasm is seen in women with severe OAB symptoms. Urine loss from penetration is more common than with orgasm. Leakage can occur even if a woman tries to empty her bladder before becoming intimate. Diagnosing CI should be included in the overall diagnosis and evaluation of any female pelvic health issue, since many often coexist.

An important question to be asked is: Does treating CI or bladder drop help improve a woman’s sexual experience? Many treatments for UI, whether it be from Stress Incontinence or OAB, are available, as well as repairing a dropped bladder or loose vagina. They range from conservative treatments, to medicine, to minimally invasive procedures. Often, pelvic floor muscle retraining, or Kegel exercises, can tone up a weak sphincter, help retrain an OAB, or tighten up the vagina just enough to make sex more pleasurable. They’re easy to perform but must be continuously done. Some common OAB medications have been shown to help orgasm-induced urine leakage. Common side effects of these meds are dry mouth and constipation. Minimally invasive surgery, such as slings, are placed in less than a ½ hour, have high success rates, low complication rates, and relatively short recovery times. These will often treat penetration-induced leakage. Bladder lift and vaginal tightening can be performed to help reduce dropped pelvic organs and reduce a wide vagina opening.

Correcting urinary incontinence has been shown to greatly reduce CI, and as a result, women report improvement in all sexual domains: desire, arousal, lubrication, orgasm, satisfaction and pain. Resolving CI leads to greater self-confidence and greater sexual interest. Bladder lift leads to less vaginal bulge sensation, and less pain with sex.

My goal in treating women with CI and other pelvic health problems is a comprehensive and tailored approach in addressing all potential concerns. The only thing holding you back is the courage to regain those life activities that may have been lost from embarrassment and avoidance.