Medical Mondays 2Dr. Patricia Yarberry Allen is a collaborative physician. This week, she consults with a urogynecologist to answer the question of a woman who, for three years, has been dealing with “a terrible urge to urinate”—every 30 minutes.

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I am 52 years old and have not had a period for two years. I am physically fit, not in a relationship, and own a restaurant. I don’t drink much anymore, and last year I gave up cigarettes . . . after 30 years of a pack or so a day. I am healthy in spite of long hours at work, but I have a problem that is driving me crazy.

For the last three years I have had terrible urgency to urinate. I spend most of my waking hours thinking about finding the time to urinate.  I wear a pad because even though I go to the bathroom every 30 minutes, I have sometimes not made it in time. Funny, but I don’t get up at night to urinate. I guess it could be worse. I thought this kind of problem only happened to women who’ve had lots of children.

I saw my doctor several times for this problem. Each time he checked my urine for an infection and I never had an infection.  He told me that I just have a hyperactive bladder and gave me a pill called Detrol to take to “calm the bladder muscles down.” The medicine did decrease the urgency some but I could not tolerate it, since it made my mouth and eyes dry and caused constipation. I am desperate. Did menopause cause this problem?  What suggestions do you have for treatment for this condition?

Phyllis

 

Dr. Pat Responds:

Dear Phyllis:

Urinary incontinence and urgency and frequency to urinate are serious problems for many women, especially as they age.  You need to see a urologist or a urogynecologist to have important basic evaluations performed. It will be helpful if you keep a 24-hour diary of how much you drink and when, and when you urinate and how much. Then bring this diary to the first visit with the specialist.

Since you were a serious smoker, you have an increased chance of bladder cancer. Cystoscopy, an in-office procedure, allows the specialist to evaluate the lining of the bladder for both malignancy and inflammation. The urologist will also send a urine sample to be evaluated for malignant cells and once again do a test for infection.  If the cystoscopy is normal and you have no evidence of malignancy or infection, then you might need special tests that document why you feel the urge to void so frequently. It is true that loss of estrogen with menopause may affect the lining of the bladder, increasing the urge to urinate more frequently. Use of an estrogen cream may be helpful.  In addition, behavioral interventions may help you to learn to urinate less frequently.

When genital estrogen and behavioral interventions do not control the symptoms enough for a significant improvement in the quality of your life, there are newer treatments that may not cause produce the same side effects as Detrol and other drugs in this category of medication.

I have asked Dr. Lauri Romanzi, a urogynecologist who is a member of our Medical Advisory Board, to discuss urinary urgency and incontinence, its diagnosis, and treatment options. Dr. Romanzi is a clinical associate professor in the Female Pelvic Medicine and Reconstructive Surgery Division of the Department of Urology at NYU Langone Medical Center.

 

Dr. Romanzi Responds:

Dear Phyllis:

At first glance, your symptom complex is consistent with overactive bladder syndrome. Overactive bladder has no known cause, and symptoms may include frequency (voiding more than 8 times in 24 hours), urgency (a sudden, intense urge to urinate that is difficult or impossible to control), urge urinary incontinence (incontinence resulting from uncontrollable urgency), and nocturia (waking often during the night to urinate). Sound familiar?

Overactive bladder is more common in women over 50 and men over 60. The diagnosis of overactive bladder is made when no clear cause—such as infection, or bladder stone, or tumor, or underlying neurologic condition, or, in men, an enlarged prostate—is the clear source of symptoms. According to the American Urologic Association Guidelines on Overactive Bladder, the minimum requirements for this evaluation include a careful history, physical exam, and urinalysis. People diagnosed at first visit with Overactive Bladder may be treated with bladder retraining, pelvic floor physical therapy, and/or overactive-bladder medications without further evaluation. If one medication does not work, you may respond well to a higher dose, or a different overactive bladder medication.

Other urologic diagnostic aids may be considered, including a catheterized or sonographic evaluation of how well the bladder empties when you urinate (this is more important for men than women, since enlarged prostates may affect how well the bladder empties itself), bladder diaries, validated bladder symptom questionnaires, and urine culture to check for infection. More advanced tests, such as urodynamics bladder function evaluation, kidney sonogram, and cystoscopy are not considered necessary in the uncomplicated patient.

As Dr. Allen points out, you have a history of smoking. Bladder cancer is most common in people over 50 who smoke(d), or who have exposure to certain solvents and chemicals known to increase bladder cancer rates. While bladder cancer is more common in men than women, in the U.S. about 17,000 women are diagnosed with bladder cancer each year.While overactive bladder is far more common in women than is bladder cancer, given your smoking history your doctor may choose to recommend cystoscopy or other methods of evaluating for bladder cancer before trying another overactive-bladder medication or recommending several months of bladder retraining and pelvic floor physical therapy.

Menopause is another common instigator of irritative bladder symptoms. In women, the urethra and lower bladder contain a generous concentration of estrogen receptors. In some women, this natural reduction in stimulation of lower urinary tract estrogen receptors is associated with higher rates of urinary tract infection and non-infection symptoms of reduced bladder capacity and overactive bladder. In some, but not all, women with peri-menopausal onset of irritative voiding, low-dose vaginal estrogen suppositories and creams restore normal bladder function.  Oral and trans-dermal (skin patch or gels) estrogens do not help in this regard; only the low-dose vaginal preparations have been shown to help.

Several trips to the doctor, various tests, and trials of therapy are common when treating lower urinary tract symptoms with such an array of potential contributing factors.  A combination of therapies, personally tailored to your test results and therapeutic responses, is the most likely solution to your lower urinary tract symptoms.

 

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