Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

Dear Dr. Pat:

I am 55 years old, and it has been two years since my last menstrual period. I am married, but have not had intercourse for the last two years, due to the problem that I have.

I have always had problems with urinary frequency. My mother made a big deal out of emptying the bladder before we went anywhere so that we would never have an “accident.”  I thought I was normal until I went to college and my sorority sisters began to tease me because I had to visit the bathroom before leaving my room and because I needed to know where the bathrooms were on every trip off campus.  I limited my fluid intake in order to survive trips.  I saw a gynecologist, who told me not to be so anxious and encouraged me to increase the time  between awareness of urgency and going to the bathroom. These instructions actually helped, but now that I am postmenopausal, this condition has worsened.  I had no children, so unlike some of my friends I don’t have a dropped bladder.  I don’t lose urine with coughing or laughing.  I have gained weight since menopause and weigh about 40 pounds more than I should.  I never smoked and drink very little alcohol. 

The constant urge to urinate, every hour or less, is driving me crazy. It has been such a problem that I no longer have intercourse, since I am afraid that the urgency and urine loss might occur then.  In addition, I wear pads all the time.  It is interesting that I don’t have to get up during the night once I fall into a deep sleep, but may need to empty my bladder every 15 minutes for the first one and half hours every night.

I saw a gynecologist in a big group recently and got 15 minutes of her time.  I said that I was having problems with urinating too frequently, with small amounts each time. I told her I wore pads all the time to prevent an accident and that I was afraid to have sexual relations with my husband because I feared I would lose urine.  She told me that she did not find any pelvic masses on exam and that I did not have any drop in pelvic organs that might be associated with these symptoms.  She said there was no evidence of urinary retention or inflammation of my bladder or urethra on the physical exam.  She found out that I don’t have diabetes, that there was nothing wrong with my basic urine test: there is no infection, and the Pap smear of the urine showed no cancer cells.

She told me that urinary urgency and frequency are common problems for older women past menopause. She offered to prescribe a drug that might help. She mentioned that it might cause dry mouth and constipation. She said most women just learn to live with this. I felt that she didn’t care about my quality of life. I already have constipation, and I don’t want it to get worse from this prescription drug she recommended. What suggestions do you have?

Florence

Dr. Pat Responds:

Dear Florence:

The condition that you have is likely to be Overactive Bladder. There are many causes of your symptoms, but your doctor has done a basic evaluation to initially rule out most of these:
 
1.    infection (the exam found normal urine analysis and culture)
2.    inflammatory conditions of the bladder or urethra (no tenderness on pelvic exam of the bladder or urethra and no red or white blood cells on microscopic evaluation of the urine
3.    Stones in the urinary tract (no past history, no evidence of blood in the urine)
4.    urinary retention (no evidence of a distended or tender bladder on examination after the patient has voided, and you reported no pelvic or vaginal surgery that might cause these symptoms
5.    malignancy (lifelong course of symptoms, worsened post-menopause, no evidence of malignant cells on cyto-pathologic evaluation of the urine decrease the chance of this diagnosis)
6.    prolapse of pelvic organs (pelvic exam normal)
7.    use of medications that could cause these symptoms (none by your history)
 
She was reassured that you have had these symptoms for most of your life, sometimes controlled and sometimes not.  She did the basic evaluation but did not help you become part of the team to address these symptoms that are affecting your quality of life. She just offered a prescription of a medication that will cost money and have side effects that are not acceptable to you as the first treatment suggestion.

There are other steps in evaluation and management that you may want to consider before returning to the doctor to discuss other treatment options.

Primary Care doctors and gynecologists should take time to discuss bladder habits with their patients as part of every well woman exam. The needed questions take very little time, and in these busy new practices a physician extender (medical assistant or nurse) can ask the questions in advance of the patient’s meeting with the health care provider if there is no time to extend that consultation, due to demands of efficiency and cost controls. The health care provider can review the areas that are noted to be of concern from the questions asked by the support staff.

These are the basic questions that should be asked regarding bladder habits:

1.    Do you have any problems with bladder control?
2.    How long have you had these problems, and are they getting better or worse?
3.    Do these problems interfere with the quality of your life?
4.    Do you feel urgency to empty your bladder?
5.    Do you lose urine? Is this associated with urgency? Is it associated with laughing, sneezing, coughing, or exercise?
6.    Does loss of urine occur during sexual activity?  How often?
7.    Do you empty your bladder frequently?
8.    Do you wear pads in case of accidents?
9.    Do you need to get up to empty your bladder more than once at night?
10.   Do you feel that you empty your bladder completely each time, or are you more likely to double or triple void each time?

You should write down the answers to these questions, and then keep a voiding diary. You can download the one that most doctors offer their patients from this site: Your Daily Bladder Diary. This diary will let you and the health care provider know what you are drinking and when, and how badly these symptoms are affecting your quality of life.  Behavior modification may decrease the need for prescription medication or further evaluation.

Behavioral therapy is an excellent first-line approach to the management of this condition. This involves you, the patient, in the work and may be so helpful that you can choose to avoid medication. Once you have information about your voiding patterns from this diary, you can discuss “timed voiding” practice with your health care provider. In addition, pelvic floor therapy can be very helpful for control of these symptoms. Therapists who specialize in pelvic floor work take the time necessary to help patients understand how to best use all the components of behavioral therapy while training patients to do the exercises that may diminish the symptoms.

One last suggestion to share with your doctors: Loss of estrogen does have an impact on urinary urgency symptoms for many women. Suggest the use of a small amount of estrogen cream to be inserted just inside the vaginal opening at the top of the vaginal wall where the bladder and vagina share a very estrogen-sensitive space. This may help, especially since you mentioned that your symptoms became worse after menopause.

When you find a way to control the urinary symptoms with behavioral therapy, pelvic floor physical therapy, and exercises, do work on rebuilding your sexual life. Intimacy is such an important part of many relationships and improves the quality of life for many.
 
One last caveat: The success of non-drug management of overactive bladder symptoms requires a real and consistent commitment on the part of the patient. Do remember that if you do all that you can do and still have a poor quality of life, there are many new medications that work in tandem with patient-centered therapy and provide an excellent chance of recovery of a normal life.

Dr. Pat