Gettysburg Medical News
The Clinical View
13 December 2006
by Phillip Hoffsten

Those Embarrassing Bladder Problems

            Bladder problems rarely kill a person.  But the embarrassment and inconvenience of leaks and clogs with a person's urinary habit can be maddening.  Recently, I had four patients in the hospital at one time either dealing with bladder leaks or bladder neck obstructions.  The leaks tend to happen in women while the obstructions tend to happen in men.  The surgery can be used to treat both but results are often less than ideal and sometimes very disappointing.  Below are steps one can take to deal with bladder problems.

Recently a 58 year-old gentleman came to the clinic with 103^o fever and no other symptoms that he acknowledged.  On further inquiry he did say that he was having trouble passing his urine.  He described difficulty starting his stream especially in the morning.  He also said that at the end of urination he seemed to “dribble" and often left several drops of urine in his pants.  This was embarrassing and he didn't really want to talk about it.  A urine specimen and a urine culture were both done showing that he had a urinary tract infection.   He had never had urinary tract infections before.  He was started on an antibiotic and was feeling much better in two days. 

But the real problem was the bladder neck obstruction secondary to an enlarged prostate gland.  Now came the part he didn't want to hear.  He was told that he needed an appointment with the urologist to have an examination of his bladder.  So he went to the urologist and after examination, he was told that his bladder had gotten very thick.  After all, the bladder is a muscle that squeezes the urine out when a person urinates.  If there is a urinary block such as a big prostate gland keeping the urine from coming out, the bladder has to get thicker and stronger in order to squeeze the urine out.  If the obstruction becomes too great the bladder will fatigue.  Then it is unable to completely empty in one trip to the bathroom.  The man then goes to the bathroom and 10 minutes later has to go again.  Even then the bladder is not completely empty and so called “residual urine” remains in the bladder.  If a few bacteria are present and begin to grow in residual urine pretty soon there is a swarm of bacteria in the bladder and the person becomes sick.  While an antibiotic will treat an infection recurrences are expected unless the residual urine problem is dealt with.

Step one is to be sure the man is not on a medication that contributes to bladder neck obstruction.  Ephedrine used to be in sinus pills and is still used as an “upper” can stop a man right up.  Benadryl used as a sleeper, amitrptiline used as a sleeper, or pain pills, or morphine used for pain can all stop a man’s urine stream.  Stopping an interfering medication is a quick and cheap solution.

Bladder neck obstructions secondary to an enlarged prostate can be dealt with medically or surgically.  Often the problem is best dealt with medically.  There are two types of medications that can relieve bladder neck obstructions often very quickly.  The side effect profile is minimal but the expense of one of the medications can be $90/ month.  The surgical alternative deals with the problem more permanently although “redos” are sometimes needed.  The potential side effects of urinary incontinence and sexual impotence make the surgical choice unacceptable to some men.  My personal advice to my patients is to try medications first if the person can afford them.  If cancer of the prostate is discovered at the time of bladder neck examination a complicated other set of considerations become necessary.

For women bladder leaks are the most common problem.  The problem can range from slight leakage when a person laughs or strains.  Alternatively there may be a constant leak that requires the use of adult diapers often limiting the person to their own home.  There are multiple solutions to try for the leak problem.  The so-called Kegel exercises may be a help sometimes decreases the symptom but rarely is a permanent solution.  Medically the first step is to rule out the presence of a bladder infection which is very common in women.  Second for postmenopausal women the use of an estrogen cream will sometimes improve the symptoms.  Thirdly there is a use of a product such as ephedrine.  Lastly there is a whole host of products still under patent protection and therefore expensive that are substantially more effective. 

As for men, review of the woman’s medications is needed.  There is a family of antihypertensive medications that can cause urinary incontinence.  Included in this family is doxazosin (Cardura), terazosin (Hytrin), and prazosin (Minipress).  If a woman is using these medications, simply stopping them can solve the problem of urinary incontinence.

Surgery to treat urinary incontinence is a last resort.  Sometimes the decision to proceed to surgery is easy such as when there is a severe cystocele or a prolapsed uterus.  But medication should always be tried first in a woman with urinary incontinence.

The health care providers at your local clinics are aware of the bladder problems that arise in men and women and can be of help in starting the patient in the right direction.  Most often medications or a change in medications can be very helpful and arranged in the clinic.  When medications are ineffective, referral to an appropriate specialist for surgical consideration can be arranged.