«|1 About the Authors Margie O’Leary, R.N., MSN, MSCN Clinical Supervisor Department of Neurology UPMC Multiple Sclerosis Clinic University of ...»
A Patient’s Guide
to Underactive Bladder
About the Authors
Margie O’Leary, R.N., MSN, MSCN
Department of Neurology
UPMC Multiple Sclerosis Clinic
University of Pittsburgh School of Medicine
Pittsburgh, PA USA
Janet Okonski, B.S.
Department of Urology
University of Pittsburgh School of Medicine
Pittsburgh, PA USA
Michael B. Chancellor, M.D.
Professor, Department of Urology
Director, Aikens Research Center
Oakland University William Beaumont School of Medicine Rochester, MI, USA Director of Neurourology Program Beaumont Health System Royal Oak, MI, USA |2 Preface There are researchers, physicians, nurses and many other health care professionals in the world dedicated to finding both causes and effective treatments for those who experience symptoms of underactive bladder (UAB).
The first international meeting to identify and discuss UAB was held in February 2014, with the second scheduled for December 2015.
A special issue of the International Urology and Nephrology, Volume 46, Supplement 1, pages 1-46, was published as a result of the first meeting in Washington DC. This issue discusses this disease definition, clinical guidelines, therapeutic directions, and suitable animal models to allow accurate testing of potential therapeutic candidates for UAB. Additional professional material and videos remain available online.
Another major outcome of the international meeting was the National Institute of Health’s Program Announcement that encourages new grant applications focusing on UAB. Furthermore, the need for greater patient education was identified and this is the inspiration for this handbook.
Bladder symptoms can control one’s life. Though no cause or cure has yet been identified, the authors hope that this book will provide helpful information to those who suffer with UAB, their families, significant others and their caregivers. We hope that these suggestions may be able to make life a little easier. Knowledge can result in tremendous power.
|1 Table of Contents 3 Chapter 1 | What is Underactive Bladder 4 Chapter 2 | Normal Bladder Function 6 Chapter 3 | Bladder Function in UAB 9 Chapter 4 | Symptoms of UAB 10 Chapter 5 | Working with Your Physician and Health Care Team 13 Chapter 6 | Diagnosis of UAB 16 Chapter 7 | Treatments 22 Chapter 8 | You Can Manage Symptoms 26 Chapter 9 | Research 27 Chapter 10 | Resources |2 Chapter 1 | What is Underactive Bladder Underactive bladder is a name given to a troubling group of urinary symptoms that result in the incomplete ability of the bladder to completely empty. With UAB, you may experience difficulty emptying your bladder, straining to urinate, or the inability to empty your bladder at all. When the bladder cannot not fully empty, it may fill more quickly, resulting in discomfort, frequency of urination, infection and/or leakage.
The term "Underactive Bladder" has not always been used to describe this condition.
Other common or medical terms that may be used to describe this condition include:
There is no consensus among the medical experts on the true definition of UAB. This is due to a lack of scientific evidence of this condition, the wide range of terminology that describes the condition and the absence of accepted criteria that supports this diagnosis. Physicians and scientists are working to standardize the definition of UAB so that the diagnosis and treatments can be applied appropriately.
There is a need for further study of this condition so that effective treatments can be offered accordingly. To date this is an area in medicine that has received little attention or research funding yet has significant impact on and individual’s health.
Both individuals and significant others are affected by this condition as it alters one’s ability to work, sleep, socialize, exercise, function sexually. It may also lead to decreased socialization, hospitalizations and/or nursing home placement.
|3 Chapter 2 | Normal Bladder Function The following is a list of terms for parts of the body that are involved in urine production and storage Kidney: Organ that filters blood and removes water and chemical waste from the body Ureters: Hollow muscles that connect the kidney to the bladder Bladder: A muscle which is able to stretch and hold urine Urinary Sphincter: A muscular mechanism that controls the retention and release of urine from the bladder Urethra: The tube that leads from the bladder and transports and discharges urine outside of the body Pelvic Floor Muscles: The layer of muscles that support the pelvic organs and span the bottom of the pelvis.
Pelvic Organs: In men includes bladder and bowel. In woman, includes bladder, bowel and uterus.
Kidneys are located high in the abdomen. Most people have 2 kidneys. The kidneys are responsible for filtering blood and removing excess water and waste products from the body. This filter process produces urine down to the bladder by gravity through tubes known as ureters.
The bladder is a hollow balloon like structure that expands as it collects and stores urine. When the bladder is at or near capacity the muscles of the bladder will contract. This contraction pushes the urine out of the body through the narrow tubular opening known as the urethra.
The urethral sphincter muscle controls when urine passes through the urethra.
Relaxation of this sphincter muscles allows the urine to pass through the urethra.
Once all the urine passes, the muscles then resume squeezing the urethra closed to prevent future urine from passing.
|4 As the bladder becomes stretched as it fills, the nerves within the bladder send a message to the brain by way of the spinal cord. This message alerts the brain that the bladder needs to empty. Nerve activity in the brain sends signals back to the bladder telling it to contract so that the urine can be released. Signals are also sent to the urethral sphincter telling it to relax in order for the urine to leave the body.
When we are young we learn where and when to empty our bladders. Many people maintain voluntary control over their bladders throughout life. For others a variety of conditions contribute to problems with emptying the bladder. These issues will be explored in the next chapter.
The nerves are just as important as the muscles of the bladder for the purposes of storing and emptying urine. Damage to either muscle or nerves can impact normal bladder function.
Many medical conditions can cause nerve damage either in the brain or spinal cord, which in turn prevents proper functioning of the bladder. Conditions which interfere
with nerve transmission within the brain that impact bladder function include:
Differences in Men In men the prostate gland sits underneath the bladder and wraps completely around the urethra and is located in the area of the sphincter. As men age, the prostate may enlarge which may block the urethra and thus cause urination problems.
Differences in Women Women can experience a variety of urination problems that differ from men. Pelvic floor muscles support the pelvic organs, which includes the bladder and the uterus.
These muscles can weaken with age, after multiple pregnancies and/or vaginal deliveries.
Weakness of pelvic floor muscles may cause the bladder to drop and protrude into the vagina thereby obstructing urine flow from the bladder out of the body. Hormonal changes can also impact bladder function.
Medical conditions can impact the function of kidneys and cause kidney failure.
These conditions are not related to UAB but could occur in conjunction with UAB.
Such conditions include: Acute tubular necrosis, autoimmune kidney disease, decreased blood flow due to very low blood pressure, (a potential result of burns, dehydration, hemorrhage, injury, septic shock, serious illness, or surgery).
Infections, such as acute pyelonephritis or septicemia can directly injure the kidney as can, pregnancy complications, including placenta abruption or placenta previa. The exact correlation between kidney failure and UAB is unknown, however, medical issues such as infection and kidney stones must be evaluated by your health care provider to limit risk of kidney damage.
|8 Chapter 4 | Symptoms of UAB Each person has a different set of symptoms. Typically no two people have the same symptoms or order of their symptoms.
Symptoms of UAB may include:
| 10 On the Day of Your Appointment
Please make sure you have the following on the day of the appointment:
• Your insurance card
• Any required referrals
• Paperwork that the physician or healthcare team member has asked you to complete prior to the visit which may include a list of symptoms and questionnaires
• Previous medical records for any related medical condition
• Previous diagnostic testing results (scans, lab reports)
• A completed bladder diary - a diary kept over at least three days will provide the best information (see Chapter 10: Resources)
• A complete list of your medication and dosage and any supplements (See Chapter 10: Resources) an example list is provided in the resource section)
• Your detailed symptom list (review with significant others who know you well to ensure completeness of your list)
• A list of all past surgeries During Your Visit The physician and staff should review your past medical history, request a urine sample and perform a physical exam with a concentration on the genitourinary system.
Before you leave the office you should understand the physician’s goals and future plans for any testing or follow-up care. If you are to be scheduled for testing, make sure you understand next steps related to scheduling. Are you to schedule the tests yourself or is the office staff to assist you with scheduling? When are the tests to be scheduled? Does your insurance require a referral? What is the required test preparation? How will you be notified of results? When do you return to the physician’s office? Who will you see at the return visit?
| 12 Chapter 6 | Diagnosis of UAB A urologist or urogynecologist will be able to make the diagnosis of UAB based on assessments, a clinical exam diagnostic testing and a review of a bladder diary.
Your past medical history will be explored as many medical conditions impact
bladder function. Risk factors include:
• Nerve damage resulting from a medical condition
• Previous pelvic surgery
• History of obstructions (size of prostate in men, vaginal prolapse in women)
• History of urinary tract infections
• Spinal cord injury - (minor to complete) Diagnostic Tests Urodynamics: A group of tests, which together measure bladder function and pressure. Cystometrogram (CMG) measures bladder pressure and volume, while the electromyogram (EMG) measures the activity of your bladder. This test may have a video component where images of your bladder are recorded and analyzed to determine the location and structure of the bladder. This is the preferred test, known as the "gold standard”, available for diagnosing problems as a result of damage to the bladder. The following are typical test results with UAB: decreased sensation of bladder filling, increased post void residual urine volume and decreased bladder contraction and ability to empty.
Urinary Catheterization: A small plastic tube covered with lubrication and placed in the urethra to drain the bladder. When the tube is removed immediately upon draining all the urine from the bladder, it is known as "intermittent catheterization". A catheter may be placed in the bladder when continuous drainage of urine is indicated. The tube is left in place with a small saline filled balloon and is called an "indwelling catheter".
Computerized Tomography (CT Scan), Abdomen and Kidneys: A procedure which uses computers to produce full views, in this case of the kidneys, ureters, or bladder to assess size and structure of the tissue, stone, or tumor.
Ultrasound, kidneys and pelvis: A study that can identify location of the kidneys, differences within the two kidneys, and blockages or stones within the kidney or bladder. This test can also view the prostate gland and determine its size and shape.
Cystoscopy: An examination of the bladder by using a small catheter (cytoscope) with light and magnification. This catheter is placed in the bladder through the urethra. This allows for the physician to directly observe the urethra and bladder for inflammation, stones, tumors, or structural damages.
Intravenous Pyelogram (IVP): A test requiring an injection of dye followed by an x-ray, which provides images of the kidneys and bladder. This test also requires bowel cleansing prior to the study to view the urinary system adequately.
Pelvic Exam (for females only): This test is for females only to examine the vagina, cervix, and uterus to evalutate the strength of the pelvic floor muscles, and locations of bladder and other pelvic organs. This exam also assesses the extent of prolapse.
| 14 Blood Tests The following blood tests reveal how well the kidneys are functioning.
Serum Blood Urea Nitrogen (BUN)- This test measures the amount of nitrogen in your blood that is a result of the waste product urea. Urea is made in the liver when protein is broken down in your body and passes out of your body in urine.
Creatinine (Cr): Creatinine is a chemical waste molecule that is generated from muscle metabolism. Creatinine is produced from creatinine, a molecule of major importance for energy production in muscles. Creatinine is transported through the bloodstream to the kidneys. The kidneys filter out most of the creatinine and dispose of it in the urine.
Glomerular Filtration Rate (GFR):