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Programme 2. - The bladder
RADIO 4
THURSDAY 10/08/06 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
MARK SLACK
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
MYERS
Hello. How often do you need to spend a penny? Under normal circumstances the bladder shouldn't need emptying more than eight times in 24 hours. If you need to go a lot more than that, if you have to get up more than once in the night to go and if you need to dash to the loo, then you may have a problem. There are many causes of bladder dysfunction - infections in the urinary tract can cause you to pass water frequently and painfully; neurological problems can cause you to lose control of the bladder completely and then there is stress and urge incontinence, familiar to women after childbirth or the menopause. Well if you have any of these issues and would like to share your concerns with our expert please call us now. The number 08700 100 444 or you can e-mail checkup@bbc.co.uk and you can put your questions today to Mr Mark Slack, he is a consultant urogynaecologist at Addenbrookes Hospital - that's quite a mouthful.
Okay we've got our first caller on the line, she's waiting to speak to us, she's in Kent and she's Christine. Your question please for our expert today Christine.
CHRISTINE
Oh good afternoon. Does caffeine act as a diuretic in everyone or just those who are sensitive to it?
MYERS
Do you find that taking coffee makes you want to pass water?
CHRISTINE
Not me no but I've got a relative who's been told to go on to a caffeine free diet and they suffer from detrusor muscle instability. Have done this and found it makes no difference at all.
MYERS
Alright, well it's a clear question - Mark what would you say - caffeine makes you want to pee?
SLACK
Good afternoon Christine.
CHRISTINE
Good afternoon.
SLACK
A very good question, a very important one. Caffeine is slightly diuretic, it makes you pass more water and it also slightly irritates the bladder in susceptible bladders. So common advice for people who've got overactive bladder - that's when they're going a lot and having to rush to the loo - is to try a diet avoiding caffeine. So that's caffeine in tea, coffee and carbonated cold drinks. It won't make an appreciable difference to everybody, so the advice should be try a diet without caffeine, if it improves things you have an answer, if it makes no difference at all well then I wouldn't condemn you to a life without your favourite drink.
MYERS
Hope that's helpful. Thank you very much.
CHRISTINE
Yes thank you very much.
MYERS
If you don't drink so much coffee or caffeinated drinks a lot of people struggle because we're told to drink quite a lot and yet a lot of people don't want to drink water, so how much should we drink and in what form should we take it?
SLACK
In direct fluid that you're drinking, because remember you get a lot of fluid in your food as well, and direct fluid that you're drinking you should drink about one and a half litres a day. And that would be water - and I don't advocate that everybody rushes out and buys bottles of water - but water people can drink, cool drinks - things like cranberry juice are very good for the bladder, other juices. And then decaffeinated teas and decaffeinated coffees have come a long way and are quite tasty.
MYERS
Okay, thanks for that. We'll go to Edith Davies, who's in Kent and is waking up every two or three hours during the night and needs the loo. I guess you're a bit tired Edith?
DAVIES
Well yes I am and this is really why I'm ringing because I'm constantly tired all day and I seem to wake up out of a deep sleep and then - it's not that I'm not going back to sleep again, it's just that in another couple of hours I'm up again. Now this used - I think I've told you that in the past it was always a case if we were going out anywhere I had to know that somewhere there'd be a loo because I seemed as though everything I drank was going straight through me but now I can for hours during the day. And I've asked my doctor about this and said well what happens to what I'm drinking, he said it goes round the system. Well my system ...
MYERS
Edith you've given us a lot of information there and I think probably enough to help Mark Slack give you some advice. So Mark what are you going to say to Edith?
SLACK
Edith the problem you describe is a very distressing problem and is one that actually lots of people suffer from, so there are lots of ladies, especially over the age of 65, 70 that suffer with this problem, we call it nocturnal enuresis or nocturia, which means that you've got to get up a lot. Now the first thing we need to really know is when you get up do you pass large amounts of water or do you get up frequently and pass small amounts of water?
DAVIES
It's usually quite a lot, the first one is about two o'clock in the morning and is usually quite a lot and it's never just a trickle, the third time is still a fair amount.
SLACK
Well Edith one of the very important things you can do here is to get advice from your general practitioner or from the continence advisor in your area or from one of the urogynaecologists and what we'd get you to do would be to keep a diary for a few days where you actually measure how much urine you pass every time you get up at night. And then that would help us work out whether the cause is with the bladder or possibly with something else. As people age their kidneys change their function slightly and they can make a bit too much urine at night and that may not necessarily be your bladder. But with that diary we'd be able to work that out and then there are quite a lot of things we can do, we'd advise you to drink less fluid in the evening before you go to bed and then there are some medications that we could prescribe for you which could improve it, not necessarily cure it, I don't know that we can cure the problem but we could go a long way to improving the way you are and getting you a better night's sleep.
MYERS
Hope that's helpful Edith, I mean in general terms if people are concerned about how much they pass and getting up in the night to do it and indeed in the day, are you suggesting Mark that it would be a good idea to keep a diary and then go with that to their doctor in the first instance?
SLACK
Very, very useful, most people shouldn't get up more than once at night, once at night is not uncommon. But if you're getting up two or more times that's clearly not right. And a diary where you actually measure the amount that you pass at night, which can be tricky.
MYERS
I was wondering, I mean have you got a simple tip for that?
SLACK
No we don't actually ...
MYERS
Bottles, pans.
SLACK
Yeah generally so, just to buy a very cheap measuring flask from the supermarket. The Americans have some lovely devices for measuring but they're not available in the UK at the moment.
MYERS
They're ahead of us on that one. Okay. We'll go to an e-mail because Mike has heard that to ward off incontinence in older age, he says, it's a good practice to interrupt the flow of urination by muscle contraction. Is this true? Is it true?
SLACK
Well the answer to Mike is no, in a simple question. As a man incontinence is not really related to weakness or strength of the pelvic floor. Weakness of the pelvic floor is a female problem. In men incontinence is generally a prostatic complication or a complication of surgery that the men have had for prostatic cancer.
MYERS
This is the prostate gland which often does enlarge anyway in older men.
SLACK
It does, it enlarges in older men and it gives them symptoms of bladder problems and when they get operated on they can often get incontinence. However, it does raise a very, very important question, which is should a woman do this? And the simple answer is please don't, it is a very, very unphysiological and unnatural thing to interrupt the flow of urine and it can actually create more problems than it can solve. So ...
MYERS
Well that will come as a surprise I think to a lot of women, including me, because I've certainly seen it said that it's a helpful thing to do from time to time, almost to see that you can still hold the bladder and it's actually a good exercise. But it's not a good exercise you're saying?
SLACK
A significant percentage of women who've had children are unable to actually interrupt their flow of urine, it's a boy trick not a girl trick. And they really shouldn't do it. It's a bad habit and there are many other ways of exercising the pelvic floor, much, much more effectively, so please don't do that.
MYERS
Alright, thank you very much. We'll go on now to a call from Tony Ellison, in London, who again finds herself tripping to the loo quite frequently, how frequently Tony?
ELLISON
Well round about every sort of half hour really.
MYERS
Oh that is frequently.
ELLISON
Yeah it's really often and I really need to go and kind of when I go out anywhere for the day I constantly have to know that there's a loo going to be around somewhere.
MYERS
And you're in the younger age group.
ELLISON
Yeah I'm in my 30s.
MYERS
So that's quite awkward isn't it, if you're having to think about where you're going to find the next loo, given that you want to go within the half hour. So does that limit your lifestyle a bit?
ELLISON
Well not too much, I just noticed that it's more than other people that I'm with really, so if we've been on a journey I'm the first one to say, as soon as we get anywhere, I've got to go straight to the loo really. So it's kind of not too limiting but I think I have to sort of plan around it a little bit really.
MYERS
Let me hand you over to Mark.
SLACK
Tony, you're describing a very, very common problem. Do you have children?
ELLISON
No.
SLACK
No children yet, right, well it's less common in people who've not had children but it's very, very common and we call it overactive bladder, which is just a simple explanation - people go too many times. Now generally speaking in your sort of age group, without children, it's bad habits that create this and people tend to be fussed, so they go to the loo and gradually what they do is they don't stretch their bladder, they lower the capacity of it and then make it a bad habit. And I would give similar advice that I gave to Christine earlier - try the avoiding the caffeine and see if that makes a difference and then remember that your brain controls your bladder, so when you were a little child you initially void by reflex and as you get older, when you find it's inconvenient to wet your pants, your brain teaches you how to hold on. And basically you've got to go back to that and we call it bladder retraining. So what we'd like you to do is when you get the need to go see if you can hold on.
MYERS
Are you saying then Mark that this is psychological - people feeling the urge to go is actually just that, a feeling rather than the bladder telling them please empty me I'm full now?
SLACK
No it's both. I think in Tony's case she's describing a situation where there is a psychological element but then there is also a pathological condition where the bladder doesn't distend to its full capacity and it triggers early. But this can also show significant improvement by retraining it - by stretching it - holding on to the urine inside the bladder and getting it to stretch to a slightly larger capacity.
MYERS
So you can't see Tony, we can't see you of course, and you're not about to diagnose whether she might have this other condition that causes a problem within the bladder. Are you suspecting that in the first instance it's to do with the need to retrain the bladder, to hold on longer and not to feel the urge to go quite so frequently?
SLACK
Yes I think in the first instance it is, she may well have an overactive bladder due to what we call detrusor instability, which is where the muscle of the bladder contracts too prematurely, she may well have that. But that too would also be initially treated by bladder retraining - holding on, trying to increase the gaps between voiding. And it takes a long time Tony for those sensations to go away.
MYERS
Well I'm thinking - how are you reacting to all this, we're talking about ...
ELLISON
I think it's really interesting because the only thing - the only connection I've every thought about - I don't know if it does relate - is I had a really bad bout of cystitis when I was in my teens, like it was really - I was absolutely desperate to go and when they treated it, you know it was really, really bad and I think I felt it was ever since then whether any damage has happened. My only concern really with holding on is whether you can do any damage to the bladder by actually holding on and not letting yourself go?
SLACK
No you won't do - you won't do any damage Tony. The relationship between infection and these symptoms we're not entirely sure about, we do think infections can cause some of these conditions but we don't really have the research to back it up. You won't cause damage, if you're holding on to the bladder it will not let you over distend it, if it's a normally functioning bladder. And you know you can always check that by measuring how much you pass and you'd be wanting to pass somewhere between 350 and 450 mils, that's about the normal amount. And then if that didn't help you could also get additional help from taking medication, which would just help you in your first two to three months - holding on and getting this slightly - getting your bladder to distend itself a bit.
MYERS
Tony, I hope that's helpful, I suppose if you were to sum the slogan then - if you feel like going resist, resist, resist - would that be about right Mark?
SLACK
Yes, within reason, I mean if you're absolutely desperate you might have an awful accident. So these training programmes are best done at home in the safety and confines of your home. But yes you don't want to just go for the sake of going, that's not a good idea.
MYERS
Can you say how long would be too long to wait?
SLACK
Well it depends again on how much you're drinking. I normally would say to people start off setting yourself modest goals, hold on for two minutes ...
MYERS
Really and then build up.
SLACK
And then once you can do that make it five.
MYERS
On the drinking question, if you drink more are you therefore likely to make your bladder full quicker, therefore you will want to go more often or will you be retraining it to hold more, simply because you're more used to taking in more?
SLACK
We don't want people to distend their bladders above what's normal, so we don't want people holding more than 450 mils in their bladder. If you drink more yes you will go more often but that's a direct relationship.
MYERS
Let's go to Mary in Penzance who has what is described as stress incontinence and just so that we get the terminology right, what we've just been talking about comes under the category urge incontinence?
SLACK
Yes that's right.
MYERS
So Mary what do you mean then by your stress incontinence?
MARY
I'm now 58 and I had a number of pregnancies resulting in long and heavy labours and a lot of cystitis in those pregnancies. I'm now left with stress incontinence, as I understand it, I can't run without risk, I can't laugh a lot without risk and I can't cough. But - so certainly I have all that and I wear little thin pads all the time, prophylactically so to speak. But another thing is that I have - the wall of the vagina has herniated - I suppose it would be - it protrudes now as a result of these long births of big babies and I'm wondering if that makes any difference to my condition, should I - at one time I was offered to go and see a surgeon and another health problem kicked in and it sort of didn't happen and I haven't worked up the guts to start the whole thing again.
MYERS
Well you worked up the guts to at least make this call, to exactly the right person, because Mark Slack is a consultant urogynaecologist and in a way exactly the right person then for someone like Mary to talk to and perhaps to see. What would you advise?
SLACK
Well Mary you describe the other very common incontinence problem which is stress urinary incontinence and that's the loss of small amounts of urine with activities - coughing, laughing and jumping, moving and sometimes even as little as walking off a pavement. And that's stress urinary incontinence. Generally speaking people with your condition don't have urgency, they won't have to rush to the loo too terribly and that's a very common problem affecting thousands of people and there's a lot that can be done for that. In the first instance the simple thing is for people to do physiotherapy and pelvic floor exercises and we can probably train 60% of people to be continent without any surgical intervention.
MYERS
Even if they've had their babies some time ago?
SLACK
Even if they've had their babies, there's always some residual function in the pelvic floor and a lot can be done by my physiotherapy colleagues to help that. And that would certainly be the first line of attack with that condition. You can also do other things - if you're overweight, losing about 10% of weight will make a significant difference. And exercise helps a little, general exercise helps a bit. But you mentioned in conjunction with this that you have a prolapse. Now prolapse and incontinence are both caused by childbirth. So therefore they both occur commonly and they occur commonly together. But the prolapse is not necessarily causing your incontinence and incontinence is not necessarily caused by prolapse. And so if you have a prolapse and if the vaginal wall is hanging out and that's protruding, as you described it yourself, or if it's hanging down it gives you a feeling of dragging something down below, that in itself independently may need to be treated. But the treatment for that, if - which is usually surgical is different from the treatment for the incontinence. But they can be done together.
MYERS
But first things first by the sounds of it.
SLACK
First things - simple things first, which is physiotherapy and training.
MYERS
I can't believe Mary that you've had this condition and haven't been told at least that the pelvic floor may have some part to play in this - is it ...
MARY
No, I do try and do pelvic floor exercises and incidentally I was told to interrupt the flow as part of those exercises.
MYERS
Yes you're not the only person who's been told that but we're told now that that's wrong. But doing the pelvic floor exercises obviously is right. But it's harder work than perhaps we tend to think, those of us who practise it occasionally at the bus stop, there's a bit more to it than that isn't there Mark.
SLACK
I think the real problem is pelvic floor exercises are extremely difficult to do, they're not muscles you can see, it's difficult to know whether you're doing them correctly and the real strength of advice here is to see a physiotherapist with an interest because they can teach you how to do them properly. But Mary it requires a lot of hard work and it takes at least three to four months before you'd see any appreciable improvement. But I do think you would benefit greatly from seeing a physiotherapist and then you could lead on from there, if that didn't work because the surgical interventions are very, very successful.
MYERS
Thanks very much for that, if I may I'll move on Mary because I want to slip in an e-mail which has come from someone who prefers to remain anonymous and it rather touches on the fact this is still quite an embarrassing subject for a lot of people, Mark, to raise.
SLACK
This is the - this is one of the last remaining medical taboos, people don't talk about it and don't present with it which is terribly sad because there's so much that can be done for it.
MYERS
Indeed, well this e-mailer has - clearly is using medication for urgency - urgency incontinence - but she's been told that it can trigger glaucoma. What are the problems if you are prescribed drugs for incontinence, are side effects quite a big consideration?
SLACK
They are, the medications for the overactive bladder, that's the frequency, urgency, urge incontinence, and there's also a medication for stress incontinence - and they're completely different types of medication. The ones for overactive bladder all fit into the same category, there's a whole range of them, and they're designed to try and relax the bladder, so that you can hold on longer and you don't get the feeling of urgency and you don't get the frequency. The trouble about them they act on receptors all over the body and so you do get side effects such as dry mouth, you can get indigestion and yes in people who've got one of the types of glaucoma it can aggravate it. But not all types of glaucoma will be troubled. So if a person has glaucoma they need to go and see their doctor, find out which type they have and whether or not they can have the medication. But those medications really can help appreciably in reducing the amount of times you go and how urgently you need to go and the leaking episodes.
MYERS
So for listeners who may have already tried some of these medications but find them difficult to cope with are you suggesting that there are new and perhaps better drugs coming along all the time, which perhaps they could try again?
SLACK
Yes, all the drugs are similar category but the drug we used to use about 10 years ago had horrific side effects and nobody could take it for more than about a month because the side effects were so bad. But they've changed the way we deliver them, we have long acting preparations which have much lower side effects, only taken once a day, there are also ones that you can put on patches on the skin, which lessen the side effects. And also people react differently to different drugs, so if you didn't react to one you may react differently to another. So it's worthwhile exploring those avenues.
MYERS
So the hierarchy then really is lifestyle changes where they will help, medication, but then of course you can come to surgery and we've got a call from Louisa in Solihull who I think has already had an operation to give support to the bladder. What's happened to you Louisa and has it worked?
LOUISA
Oh hello. Well I suffered incontinence - both types - that is stress incontinence where when I went to keep fit with my friends it was absolutely dreadful, I was using maternity pads it got so bad at one point. And the other type where I would be dying to go to the loo and wouldn't quite make it. And I did go through my GP, who was wonderful, a fabulous gynaecologist etc., and I did go to the physiotherapy and they were excellent but I think mine had got on to such a point where it did need surgical intervention. And I did have an operation at the beginning of this year which I can honestly say is a miracle and I would advise anybody who has suffered, if they are offered it, to go for it because it is such an embarrassing, horrible problem and I was so ashamed of it - I'm only 48 and I've got young friends and it got to the stage where it was spoiling our lives, I couldn't play cricket on the beach or anything like that. And my mother actually was offered a while ago the same operation and she was too embarrassed to go for it and since I've had mine done my mum's going to go as well.
MYERS
Well that's very encouraging to hear, we like to hear good news stories and it does help other people. So Mark, just say a little bit more, if you will, I guess this is the kind of operation that you routinely perform, are there any downsides to this procedure?
SLACK
Well yeah thanks Louisa for sharing that with us. It is nice to hear the positive side effects and I am glad to hear that you had the physiotherapy first and the conservative treatment because that's so important. But yes there are a range of operations, there's two or three operations that can be done, some are quite large operations and some are what we would call minimally invasive operations. And they get really good results in over 90% of people but it is surgery and surgery can have complications and in a small percentage of people there could be difficulty passing water afterwards and so on. So yes I'm glad you shared that with us and the real point there is when you come to surgery it's terribly important that you see an expert who genuinely does lots of these operations regularly and you will probably then get a good outcome.
MYERS
Thank you very much for that. A quick e-mail just to finish with and it refers to a child wetting the bed, we haven't really dealt with that, it's a subject on its own - training children to be dry at night. But in general, since you were talking earlier about this business of going to the loo too often and perhaps going to the loo before you need to, do we - how should we train our children to deal properly with being dry, getting dry and managing to hold on to the urine appropriately?
SLACK
Oh I think we're really naughty, I think we have a real problem in society, every time mothers go out they turn to their daughters and say have you been to the loo yet and you can see the look on the kid's face, they think gosh do I need to. And I think we instil bad habits, so they go and empty their bladder prematurely and they contribute to this over frequently emptying with small amounts. Children should go to the loo when they need to, there are lots of loos out in public now and they can always get to them and I think the advise to parents is don't be overly fastidious about bladder training.
MYERS
Thank you very much. There we will leave it, thank you to Mark Slack for his expertise and to you for all your questions. You can listen to this programme again, if you wish, on our website or you can get more information by calling our free and confidential help line, that's 0800 044 044. And join me again if you will at the same time next Thursday when we'll be taking your questions on hot, sweaty and itchy summer skin.
Ends
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