Incontinence: FAQs Answered
Frederick R. Jelovsek MD
Does anyone have any info/advice regarding urinary incontinence (not stress/bouncing type) that seems to be connected to running, especially due to overheating? I'm having a hard time increasing the intensity of my workout because every time I do I experience urine leakage. Am I drinking too many fluids? Not enough elecrolytes? Symptom of heat exhaustion? Improper form? Any advice welcome.
As I understand, you don't lose urine from increasing intrabdominal pressure (stress) but you do have urgency when running and that is the time when you leak urine? Do you have any leakage with any other activities other than running? Can you tell when you have the leaking if there is a large or normal amount of urine in the bladder or just a very small amount? A small amount would be against drinking too much fluid. Electrolytes don't seem to make that much of a difference for this problem. On the surface this sounds like urge incontinence or overactive/uninhibited bladder contractions.
I experience the same thing during aerobics classes. If I make sure that I have had not had fluids for the 3 hours prior to class AND/or wear a tampon then, I am safe. Otherwise it is leak city. I know the amount is probably nominal but SEEMS like a lot. I'm trying to find out the difference between stress or urge incontinence and what to do about it. Can you help?
Now I'm not sure if it's stress incontinence or urge incontinence. As a patient, we would do an exam with a full bladder and have you cough and strain lying down and look to see if there was any urine loss. If none, this would be repeated standing up and holding a brown paper towel over the vaginal and urethra area. If there is a fluid stain on the towel, that is proportional to the amount of urine lost. Either of these would diagnose stress incontinence. You can do the paper towel test at home. This wouldn't mean that there wasn't also urge incontinence also. Actually a mixed incontinence is more common than either alone.
Next we would check to see if the bladder neck descends with straining. A Q-tip lubricated with xylocaine gel is placed in the urethra and as you strain down, the change in angle of the Q-tip is measured to see if the bladder neck drops more than 30 degrees. This would be confirmatory of stress incontinence and mean that surgical repair would more likely be successful than if there wasn't any movement.
The next study is a cystometrogram which may be part of urodynamics studies. In this, a catheter with a pressure measuring device is placed thru the urethra into the bladder and the bladder filled. Measurements are then taken to see if the bladder muscle is contracting on its own, uninhibited bladder contractions. If it is, you have an urge component. That is treated thru bladder retraining and medical therapy.
In your case (loss with vigorous exercise) it is possible that you might not have leakage with just coughing but with extremely high intraabdominal pressure still have stress. That degree of pressure needs to be simulated with cough or you may need to have a stress urethral pressure profile test done as part of the urodynamics.
What you describe sounds like urge incontinence or possibly overflow incontinence. The tests to diagnose this are catheterization for the amount of urine left in your bladder after voiding and a cystometrogram (involves a catheter and filling of the bladder). While it is never comfortable, these tests aren't that bad especially when diagnosis and treatment can significantly help you. The mainstays of treatment are bladder retraining and medical therapy.
Bladder retraining you can do yourself at home. It involves keeping the bladder empty before you get the urge to void. To do this, we start women out at voiding every hour during daytime hours for a week. You void whether or not you have the urge to void. You need a timer to do this such as a kitchen timer from Radio Shack that you can carry around or a watch that you can set to "beep" every 60 minutes. If you get an urge at 55 minutes to void, try to suppress if you can until time is up. The next week you go to 1.5 hours (90 min), the following weeks to 2.0 hr, then 2.5 hr, then 3 hours. Don't go longer than 3 hours in the daytime without voiding. It takes 5 weeks or sometimes longer of this bladder retraining to get better. If you can do this, I guarantee your symptoms will improve.
Medical therapy for urge incontinence is usually Ditropan®, imipramine or a new medication Detrol®. The Detrol® has less dry mouth side effects than Ditropan®. All of the meds are only about 50% effective and must be combined with bladder retraining. You may be able to talk your doctor into treatment without testing. I'm not sure that's best but I understand why.
This can be recurrent infection of the bladder or urethra, recurrent trauma to the urethra (from sexual relations) or an entity called urethral syndrome which probably is a very low grade infection of the tiny glands in the outer portion of the urethra. If they are doing urinary cultures and they are always positive, you are having recurrent infection of the bladder. If you have some blood but no bacteria, then it's trauma with or without urethral syndrome.
The treatment is an active 7 day course of antibiotics (sulfa like Bactrim DS® or Septra DS® if not sulfa allergic) then, if symptoms all gone, one tablet of sulfa immediately before or right after sexual relations. Occasionally I've had to put women on one a day with an extra tablet after relations. This almost always works. See if your doctor will let you try this.
I've included some abstracts below. Some primary care physicians may not be aware of this. Usually permanent college health service physicians are quite aware of this entity but sometimes if there are just moonlighting MDs, they may not be attuned to this.
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Managing urinary tract infection in women.
Drug Ther Bull 1998 Apr;36(4):30-32
Each year, around 5% of women present to their GPs with dysuria and frequency. About half have a urinary tract infection, as confirmed by the presence of a threshold ('significant') number of bacteria in their urine (usually defined as > or = 10(5)/mL). In the remaining women, symptoms occur in the absence of bacterial infection: this condition is referred to as urethral syndrome. In this article, we discuss the diagnosis and treatment of urinary tract infection in women.
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The urethral syndrome and its management.
Hamilton-Miller JM
J Antimicrob Chemother 1994 May;33 Suppl A:63-73
Department of Medical Microbiology, Royal Free Hospital School of Medicine, London, UK.
The urethral syndrome and its management are reviewed. Urethral syndrome is defined as 'symptoms suggestive of a lower tract urinary infection but in the absence of significant bacteriuria with a conventional pathogen' with three provisos concerning symptomatology and the definition of significant bacteriuria and conventional pathogens. The urethral syndrome is a very common condition; about half the patients visiting their General Practitioner by reason of frequency and/or dysuria do not have significant bacteriuria. Both infective causes (such as lactobacilli and sexually-transmitted pathogens) and non-infective causes (such as trauma, allergies, anatomical features and co-existing medical conditions) have been suggested as causes and are discussed. Treatment options include antibiotics in the case of acute urethral syndrome, since it is not possible to distinguish between urinary infection and the urethral syndrome in the consulting room. For those with chronic urethral syndrome, treatment depends upon whether attacks are associated with bacteriuria or if urological investigations reveal any abnormalities.
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Female urethral syndrome. A female prostatitis?
Gittes RF, Nakamura RM
West J Med 1996 May;164(5):435-438
Department of Surgery, Scripps Clinic and Research Foundation, La Jolla, California, USA. The cause of the female urethral syndrome has previously been obscure, as it has been associated by definition with a lack of objective findings but a plethora of subjective complaints of retropubic pressure, dyspareunia, urinary frequency, and dysuria. There is now strong evidence that the microscopic paraurethral glands connected to the distal third of the urethra in the prevaginal space are homologous to the prostate. They stain histologically for prostate-specific antigen and, like the prostate, are subject to both infection and cancer. The most important aspect of recognizing this microscopic "female prostate" as an anatomic feature is that its infections may completely explain many cases of the urethral syndrome. Further, the diagnosis is not elusive if trained clinicians palpate for localized and objective paraurethral tenderness through the anterior vagina wall to one or both sides of the urethra. Treatment parallel to that for male prostatitis is usually rewarded by the elimination of symptoms and the objective finding of the loss of tenderness of the paraurethral glands. As with prostatitis, the localized problem often recurs. It is time to alert primary care physicians to this disorder and to eliminate the widespread practice of treating affected women with either invasive urethral dilation or tranquilizers.
It is difficult to say for sure without examining the urine microscopically and examining your vulvar area when you are having symptoms. If this is happening primarily on the mornings after sexual relations, urethral syndrome comes to mind. This is a direct irritation of the urethra due to sexual relations (often referred to as "honeymoon cystitis" although it can happen long after the initial relations with a new partner). Usually the urine culture is negative but sometimes there is blood cells in the microscopic.
If this is happening everyday regardless of sexual relations, it may represent an active urine infection that has not been well treated or just keeps coming back.
If you think it is just burning because the urine hits an irritated vulva, try to void when you get up in the morning by sitting in a bath tub and void in the water. If the burning is not present then, it is because of vulvar irritation and that is what needs to be checked out. This would be called an irritant vulvitis. If the burning is still present, it is urethral in origin and that should be the focus of diagnosis.
By not functioning I assume you mean you cannot void at all, even if the bladder is quite full. That is different than being able to void but not completely emptying the bladder.
If you are unable to void at all, it is usually due to swelling around the urethra (opening from bladder to outside), spasm of the urethra due to irritation of the catheter, swelling around the bladder contraction muscle (detrusor), medications that affect the urethra or detrusor, and finally, if you had extra repair work to correct urinary incontinence, the stitches near the urethra may be too tight (usually due to swelling).
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