Tuesday, December 13, 2011

How Does Diabetes Affect the Bladder?


Diabetes is a staggering health burden. There are approximately 26 million Americans with diabetes, and about 79 million who are “prediabetic”. Bladder dysfunction in those with diabetes has been reported in 80% of diabetic individuals. By comparison, neuropathy occurs in about 60% of diabetics, and kidney dysfunction in 50% of diabetics. The effect of diabetes on the bladder can be wide ranging: from underactive bladder (with retained urine that can lead to UTIs), to Overactive Bladder, to urinary incontinence.

Damage from diabetes can occur on various levels: nerve dysfunction, muscle dysfunction, and urothelial (lining of the bladder) dysfunction.

Nerve dysfunction- this is a type of neuropathy, where sensation is lost, meaning, the urge to void is not perceived until the bladder is overfilled, or the nerves that control bladder contraction are weakened leading to less urine expulsion and more retained. This leads to chronic stretch and loss of elasticity. Bladder capacity can increase slowly, like a sinking boat, “taking on water”, till the bladder loses its ability potentially to contract. Mini-strokes or major strokes, brought on by diabetes can exacerbate bladder dysfunction, as the stroke may affect also perception of a full bladder till too late when incontinence may occur, or with sever stroke, bladder retention occurs outright.

Muscle dysfunction- This may be related to neuropathy as described above. Direct damage from diabetes to bladder muscle does not occur, unlike direct nerve damage to axons leading to neuropathy, by impaired nerve signals lead to muscle weakness, poor contraction, poor emptying, chronic stretch, loss of elasticity, thinning of the muscles. The urethra, or bladder opening, can be directed affected, by impaired relaxation/opening when voiding should occur, leading to elevated urinary residual levels. Impaired contraction combined with impaired sensation and perception can lead to urgency, frequency, retained urine, UTIs and incontinence.

Urothelial dysfunction- The inner bladder lining in contact directly with urine is not simply a barrier, but also acts a signaling way station as well between deeper surfaces. Rat models show that in diabetes, the urothelium thickens, releasing certain chemicals that can contribute to overactive bladder symptoms. This bladder overactivity has been reported in 48% of diabetics, and is the most common finding on urodynamics testing, followed by poor muscle contraction in 30%, and poor compliance in 15%.

Diabetics are already more susceptible to developing infections, and elevated bladder urine residuals simply increases this risk. Interestingly, certain types of E coli bacteria adhere more readily to the urothelium of diabetic patients.

So, what is diabetic patient to do? Tight sugar control minimizes the deleterious effects on blood vessels and all organs including the bladder. Timed bathroom trips and “double urinating”, can help empty a bladder that is weak. Fluid management helps prevent over production of urine that may stress the bladder. Consistent hygiene around the genitals helps to reduce the chance of infection. Medications are available that help reduce the tone of the urethra to help bladder emptying, and self catheterization can be used to empty bladders without any function. In addition, Interstim sacral neuomodulation can be attempted in bladders with poor contractile function as well.

Wednesday, November 2, 2011

Is Advanced Maternal Age a Risk Factor for Stress Urinary Incontinence- What is the Medical Evidence?

It is well known that birth trauma ( pregnancy and vaginal birth) and age are two of the well known and common risk factors for developing stress urinary incontinence (SUI) (leaking urine with coughing, sneezing, laughing, lifting, exercise and sex). But, is delivering a child when a woman is “older” an additional risk factor for developing SUI? And, what is considered “older”? Is it 30, 35, 40, or over 45?

The injury that occurs during pregnancy and birth is both stretch and compression injury to the supportive ligaments of the bladder and urethra and the nerves that control the urethra. A prolonged labor or large baby head can worsen the birth trauma that occurs, but bear in mind that not all women who deliver ultimately develop SUI. In fact most don’t, but if a woman does deliver when older, are the tissues of the pelvis “less resilient” and more subject to long term changes that lead to SUI?

Further, if a woman develops SUI during pregnancy, the majority will recover within a few months to a year after delivery. Partial recovery or no recovery is a predictor for development of SUI within the next decade.
Though common sense would dictate “yes” to the question of “advanced maternal age”, some researchers recently looked at the medical literature to glean the answer from papers that review risk factors for SUI.

The results were mixed, but skewed heavily towards older age. In fact, of the papers, 15 showed that advance age was a risk, while 3 papers did not. Most of the papers did show a risk for women older than 35 yrs old, while some showed a risk from women older than 40-45 yrs. Interestingly, there were a few that showed risks for SUI for mothers of young age, less than 22.

Other risk factors noted include high BMI (>30), incontinence early on in pregnancy, and pre-pregnancy SUI. As the studies mount, further weight to the existing evidence will confirm our current theories and even uncover further risks. For women planning pregnancy, reducing risk factors such as high BMI and family planning for the best age to deliver can be very relevant issues.

Thursday, October 6, 2011

Time From First Sex to First Sexually Transmitted Disease: What Age Women/Girls Are at Risk, and What to Do About It

The time of first sexual activity in young women has always been a subject of debate as it relates to complex social and ethically issues but also for serious health issues. This has been highlighted recently by the debate over the cervical cancer vaccines, Gardasil and Cervarix, as it raises the issue about if/when to vaccine girls/women against a serious form of cancer that is contracted as an sexually transmitted disease (STD) or sexually transmitted infection (SDI).

Screening for STDs in young women/teenage girls is appropriate given sexual behavior in younger women and the high level of morbidity/complications that can occur from untreated STDs, such as pelvic inflammatory disease (PID), ectopic pregnancy, infertility, premature births, and increased risk of contracting HIV.

A group of researchers from Indiana recently tried to determine the age at first sexually intercourse among girls aged 14 to 17, the time interval from the first sexual intercourse to first STD, and the time between infections. The most common infections that were screened for were Chlamydia, Gonorrhea, and Trichomonas.

The goals of the study were to try to establish when it would be appropriate to begin screening sexually active girls once they begin having sex, and then what is the appropriate screening interval to be sure they do not have a 2nd/3rd, etc infection.

A group of 386 girls were studied and followed. They were mostly urban and black ethnicity (89%). The follow up period for the study was 2 yr, and the average number of sexual partners was 3.

The age at first sexual intercourse was on average 14 years old. By age 15, 25% of the girls acquired their first STD, most often Chlamydia, although the median interval between first sex and first STD was 2 yrs. Other infections, as noted were gonorrhea and trichomonas. The time between the 1st and then 2nd infection was on average between 3-6 months, often with the same organism. This concerning fact points to the either the prevalence of STDs among the teenage boys infecting these girls, or the fact that the boys may or may not be treated and may be reinfecting their same sex partners. Interestingly, the younger the girl, the longer it took to screen her from her first sexual encounter, for example, for girls age 10 or 11 who were sexually active, they were not screened for 3-5 years later, while for girls ages 13 or 14, they were usually screened within 1-2 yrs after their first sexual encounter.

What can we learn from such a study? May girls become sexually active while still teenagers, and young teens or pre-teens, and early age of sexual intercourse is correlated with a higher risk of STDs. Multiple sex partners and an urban population increases the risk for STDs, but the finding allows doctors, health advocates, teachers, parents and teens to understand that among the many potential pitfalls with early age sexual activity, also comes the risk and reinfection of STDs. Since often Chlamydia and gonorrhea may not lead to symptoms in girls, untreated infection can lead to serious gynecologic and fertility health concerns, as well as promoting transmitting infection to other sex partners.
If screening for STDs were to be adopted in girls within 1 yr or less from when the begin engaging in sex, it would benefit them by catching them often before they acquire an STD, and can be appoint of education for sex education and prevention.

Monday, July 18, 2011

Complications of TVT vs TVT-O slings; Which is Better or Worse, or Are They the Same?

Modern slings for the treatment of stress urinary incontinence took a huge technological step forward after the TVT was invented and debuted in 1996. The “tension free vaginal tape” (TVT) is a narrow mesh sling that goes under the urethra and supports it during exercise, running, coughing, laughing, etc, in order to prevent leakage of urine during these activities.
Over the years there have been many variations of the TVT, and many companies have copied the method of placing this sling, and have also developed new methods for placing slings. Variations develop because of some dissatisfaction with the original concept. So in 2001, the TVT-O was developed. It is placed sideways through the pelvis, instead of behind the pubic bone. Is this difference relevant?

Many studies comparing these 2 methods have been performed and the latest one reviewed 1081 patients from Russia. Group 1 consisted of women undergoing the TVT, while Group 2 underwent the TVTO. All the entry criteria for the women were equal between the two groups, except that Group women had a slightly higher BMI.

Both sling approaches have equal efficacy in treating stress urinary incontinence as has been shown in many prior studies as well as in this study, but this study was specifically looking at complication details.
In the women who received a TVT there were higher rates of hematomas (large bleeding) (9.1% vs 1.5%), and bladder injury (5.4% vs 0.6%), vs the TVTO, while the women who received the TVTO had a higher rate of injuring the vagina (3.8% vs 0) compared to TVT. If the injuries are recognized during the surgery by the astute surgeon, then they can be dealt with immediately.
Importantly, the risk of urinary dysfunction (trouble with too strong an urge, or weak stream, or not emptying the bladder) were higher in the TVT group. This is not news and is expected given prior research, but the chance of developing NEW urge incontinence and NEW overactive bladder were at least 3-4 times higher in the TVT group.

Ultimately, the best method to treat stress incontinence is based on the patient’s condition, pre-operative assessment, and which surgery is most successful in your surgeon’s hands. Make sure to ask your surgeon which slings they have done and would they feel comfortable handling complications should they occur.

Tuesday, June 21, 2011

After Hysterectomy, Which Women Are at Risk for Developing Stress Incontinence?

Approximately 30% of women report having some form of urinary incontinence, but only those the most troubled by it, or those where fluid restriction and Kegels fail to help will be considered candidate for correcting it with a sling. We also know that many things predispose to the development of stress incontinence, among them: menopause, birth trauma, hysterectomy, and chronic straining (from high impact exercise, coughing, constipation).

But, in those women undergoing a hysterectomy how likely is it that the patient will develop stress incontinence? The majority don’t, but for those who do, it can be disheartening, embarrassing and restrictive on their quality of life.
The hysterectomy (removal of only the uterus, NOT the ovaries) operation itself leads to unavoidable damage to supportive structures of the bladder and urethra, as well as affecting the nerve supply to these structures. Can we separate the risk factors for developing stress incontinence from the risk of the hysterectomy by itself, since many women undergoing hysterectomy have some of the risk factors for stress incontinence already.

I must compliment a very ingenious and simple methodology for calculating this risk factor to Dutch researchers who devised a simple equation to predict of a woman is more likely or not going to experience stress incontinence after her surgery.
They surveyed 234 women after three years from their hysterectomy and collected data. Bothersome stress incontinence developed in 22% of the women by three years. Among the women, abdominal hysterectomy was performed in 3 times as many, vs vaginal hysterectomy.

What’s amazing, even before getting to the equation, is that 22% (!!!!!) of women by just years after surgery, developed bothersome stress incontinence. That is a lot of women.

What the researchers found is that 3 variables helped to predict the risk for stress incontinence (SUI). They are: BMI, age, and surgical route. Women with higher BMI simply have more pelvic pressure due to their higher weight that can affect the support of the urethra. Secondly, the YOUNGER the women was the more likely she was at risk for developing SUI. One would think the converse would be true, since with menopause, the risk for SUI increases. But here, if the woman is younger, she has longer to develop SUI in her lifetime where it would also be more bothersome if more physically active, versus an older woman who may have made it to an older age prior to hysterectomy with having developed SUI, and if not very active, may not experience SUI as bothersome or at all. Vaginal approach may put special strain on the bladder during dissection that is not seen with an abdominal approach. On the other hand, vaginal hysterectomy is preferred for those with dropped uteruses, who already are predisposed by virtue of this condition to developing SUI.

RISK FOR SUI score= 32 + BMI –age + (7.5 x route of surgery), where abdominal route =0, vaginal = 1.

For example, a 40 year old woman with a BMI of 25 scheduled for have an abdominal hysterectomy would have a risk score of 17. This would equate to a 23% chance of SUI at 3 yrs according to the graph developed by the researchers. If the surgery were done vaginally, the risk score would be 32 +25 – 40 + 7.5= 24.5, which would translate to a 40% risk, according to the graph developed by the researchers.

This fascinating predictive model finds its biggest utility in counseling women prior to their hysterectomy, what their risk of SU I may be. All women prior to hysterectomy should at least know that SUI is a risk, but now we can estimate just how much a risk it may be. With this knowledge in hand, those women at higher risk for SUI can be advised to begin Kegel muscle exercises more dutifully to mitigate development of SUI. Of course this represents only one researcher’s data, and to be truly accurate must be validated and repeated, but it holds potential.

Thursday, May 26, 2011

Giggle Incontinence (Leaking with Laughing): It’s Not So Funny If It’s Happening to You

Giggle Incontinence was first reported in 1959 in children. Unlike adult women who leak urine with laughing, due to stress incontinence, in children the reason for GI is not entirely known. It has been proposed that perhaps it’s due to an overactive bladder, or some release of pelvic muscle control with extreme emotional discharge.

How Does It Happen?

Think of total loss of muscle control when an extreme emotion overtakes you: fear is good example. Under heavy emotional stress, control of the urethral sphincter or a spontaneous bladder contraction can occur leading to full on urination. Is it a brain reaction or a bladder reaction? It is not clear, but in a small subset of female children, extreme laughter can lead to full on urination and bladder emptying, not simply a little squirt of pee with a heavy laugh like mom.
Some industrious researchers in Korea set out to study GU in teenage girls, and tried to see what was happening to the bladder during urination before and after treatment. Past treatments for GI included overactive bladder medications.

They treated 9 teenage girls between the ages of 12 and 19 who had pure giggle incontinence with methylphenidate (Ritalin) for 1 year. All had resolution of their symptoms, and none suffered side effects of the medication. They noted high urethral pressures after treatment, and it took approximately 7 months to see full resolution.

What is the significance of such a study? It may be useful in children with ADD/ADHD who may be considered for Ritalin treatment. Treating children with medication is a complex and individualized issue. In the absence of ADD/ADHD and if GI is severe and debilitating or embarrassing for the patient, there is an available option, and this study adds to available evidence already.

Monday, May 16, 2011

What Makes Women Satisfied with Their Sling Surgery for Urinary Incontinence?

Stress urinary incontinence is a significant bother to women beginning in their 30s all the way into their 80s, as more and more women remain physically and sexually active into their later years. It can be very restricting in terms of odor, embarrassment, as well as interfere with exercise, and even sex. Approximately 30% of women in their 40-60s will report some urinary incontinence.

After fluid restrictions and Kegels fail to improve stress urinary incontinence, the most common and most successful procedure to correct it is the sling. There are a variety of sling types and different methods of placement. Slings have supplemented and replaced the older open surgical methods, and have become the technique of choice for surgeons as well as requested by many patients in consultation (often after their friends have had successful procedures). Tissue slings harvested from the patient’s own tissue used to be the most common way 15 yrs ago, but these days, mesh slings dominate the most common types of slings placed.

We know that the success rate of modern mesh slings is approximately 90% in the longest term studies (11 yrs follow up), and so you would say, “that’s great”. But, is being dry the only thing that makes the woman satisfied after such a surgery, and, are there things that would predict lower levels of satisfaction after the surgery? This quality of life question is very important.

A recent study published from researchers in Minnesota asked and answered this very question. The purpose of the study was to ass which pre-operative and post operative variables correlated with patient satisfaction after sling surgery for stress urinary incontinence. They used extremely stringent criteria for grading how satisfied the patients were after surgery, on a scale from 1 to 5, 5 being “completely satisfied”, and 4 being “somewhat satisfied”, while 1 was “completely dissatisfied”.

A total of 367 women returned surveys of 428 total women who underwent either a mesh sling or a sling from tissue harvested from their own body. At a median follow up period of 2.9 years, 61% answered that they were “completely satisfied”. Broken down, 65% of the mesh sling patients were completely satisfied, while 48.3% of the tissue sling patients were completely satisfied. Women with the mesh sling were twice as likely to be satisfied with their surgical outcome.

What pre-operative characteristics predicted less satisfaction? These would be higher age, higher BMI and having had a tissue sling performed. Of the patients completely satisfied, 90% said it was because they had resolution of their incontinence. For those who were less than satisfied, it was mainly for reasons of incomplete resolution of the incontinence, or development of a stronger urge to urinate, urge incontinence, or even the inability to empty the bladder. Some of these urinary symptoms predated the surgery, and others developed after the surgery.

Despite a high chance of success, no surgery is perfect. It can help many women regain their prior “normal” lives, but even if the sling works to prevent stress incontinence, patients should know that adverse effects on urination can occur. Interestingly, the women who received the mesh slings were more satisfied that those who received their own tissue for a sling. This is likely due to the extra bikini line incision that is required for harvesting tissue which is not required for mesh slings.

Wednesday, April 20, 2011

Radio Interview on Toginet

Julianna Lyddon, who is an Intuitive Therapist, with a masters degree in marriage and family counseling, and who works and resides here in the metro Phoenix area, hosts a one hour weekly show, on Toginet radio. I had the pleasure of being interviewed by her on her show about, yes, female urinary incontinence.

Please find the show at the following link:

http://toginet.com/shows/connectwithjulianna

then look to the right side column for a link to my show interview from April 15, 2011

Is Being a Yoga Instructor a Risk for Having Urinary Incontinence?

We all know that yoga is a te4rrific way to stay in shape, become fit, and get a good cardio work out. Most full time yoga-holics are in shape, and certainly this is true for yoga instructors. But like most women, yoga instrcutors are no different, especially in experiencing urinary incontinence.

A recent study from Norway evaluated hundreds of yoga instructors, most were women, by no surprise. Six hundred and eighty five women, with a mean age of 32.7 years answered a specially designed questionnaire. Interesting results were found.

26.3% of all the female instructors experienced urinary incontinence, with about 21% reporting that it occured about once a week, while 3% reported that it occured about 2-3 times a week. Only 1.7% reported that it occured more than once a day.

About 24% reported that the leakge was mild to moderate, but 15% reported leakage of urine during physical activity, and about 11% reproted incontinence during coughing and sneezing.

So what does this prove?

It means that physically fit women are more in tune with their bodies and may pay more attention to urine leakage that can occur which may be embarrassing or restrict activities, such as urine loss. Yet it may also more likely occur and be reported by women who actually were physically fit, and thus perhaps bother them more. A more sedintary woman may not experience urinary incontinence as much due to relative inactivity, or may not realize that she would pontenetially have it since she is not necessarily exercising regularly. Of course, if severe enough, urinary incontinence can occur no mater your body size.

Yoga positions themselves do not lead to urinary incontinence, but I wouldn't be surprised if certain positions put stress on the pelvis and bladder leading to leaking during yoga. The common life events that are risk factors for developing urinary incontinence are childbirth, aging, menopause, hysterectomy, and chronic straining (such as with high impact aerobics, chronic cough or constipation).