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How Dry I am ...: and other concerns of the aging American.

If you are one of the more than 35 million Americans who currently have some form of bladder trouble, that old familiar drinking song, "How Dry I Am," takes on a whole new meaning, and it is becoming big business. We have all seen the television commercials, "Gotta go, gotta go right now"... featuring a fairly young woman with a distraught look on her face. Do not be fooled, although a minority of young people do have a bladder-control problem.

In general, bladder problems become worse with age. They range from infection to cancer, with the bonus feature of a number of forms of incontinence. As the swell of the population known as "baby-boomers" trade in their thongs for granny bloomer products, service, medicine, and surgery grow in prominence and availability.

It is a simple mechanism. A healthy bladder fills throughout the day and night, expanding gently to accommodate urine, which is constantly produced by the kidneys. The outlet valve or sphincter muscle and the muscles of the pelvic floor, as well as the bowels, are closed. In women, the uterus helps to hold the bladder in place, keeping the outlet tube, the urethra, closed.

Our bodies monitor how full the bladder is. Eventually, we begin to pass the signal that we need to empty the bladder, way before it is actually full. How well before depends on a lot of things, including how well we were trained from infancy onward. Most of us need to empty our bladders between four and eight times a day. (1)

If the bladder is diseased, displaced, or stressed, we may feel the need to void as much as three or four times as often. Worse still, we may find that we have missed the signal or are too far from a toilet to reach it in time.

Embarrassing, yes, but we are not alone. Approximately 3.6 percent of adults aged 20 and older report having some sort of bladder infection lasting three months or longer, and about 65 percent of women aged 65 years or older report having urinary incontinence. (2) Actually, many believe these numbers to be deceptively low because embarrassment serves to keep sufferers silent. After all, most of us have always understood the appropriate use of a toilet. Somewhere something has gone horribly wrong.

Actually, many things can go wrong, usually with women. Starting with a bladder infection, the simplest form is often caused by bacteria traveling up the urethra--which is why women, who have a shorter urethra than men do, generally have more bladder problems compared with men. (3)

Itching and burning while urinating or feeling the need to urinate are the most common symptoms of a urinary tract infection in younger women. However, more subtle signs, such as loss of appetite, a change in eating habits, or the onset of confusion, may be signs of an infection in older folks, making it more difficult to diagnose. After an infection is diagnosed, it is relatively easily treated with antibiotics.

Interstitial cystitis, also called painful bladder syndrome, is a chronic inflammation of the bladder wall. Approximately 700,000 people are affected in the U.S., and 90 percent of them are women. (4) Several treatments are available, surgery being a last resort. Oddly, some believe that the disorder is actually several different diseases because patients report widely varying symptoms and often respond differently to various treatments.

One of the most common and distressful disorders is an overactive bladder. This condition occurs when the detrusor muscle contracts without warning, resulting in sudden and often noticeable leakage of urine. Approximately 20,000 people in the U.S. have this disorder, but only about 20 percent seek medical help. Instead, most patients employ a coping strategy either by knowing all of the locations of toilets in an area they frequent or by simply staying home.

People with an overactive bladder need to urinate so frequently that work, social life, and even a good night's sleep are disrupted. Even though many believe that nothing can be done about the problem, there are a number of treatments, including oral medications, bladder retraining, and surgery. (5)

On the other side of the spectrum is the flaccid bladder. In this case, the bladder does not empty when it is full; instead, it becomes dilated and stretched by excess urine buildup. Patients can experience damage to the bladder walls, overflow leakage, and an increased incidence of urinary tract infection because of the bacterial buildup. Coping strategies range from manually pressing on the bladder to assist in voiding to self-catheterization and injecting botulinum toxin into the detrusor muscle, a new therapy with some promising results. (6)

Specific to women is bladder prolapse. The walls of the vagina help to support and maintain the position of a woman's bladder. When the vaginal wall is stressed during childbirth, the bladder can slip or drop, positioning itself partially outside of the abdomen. Women with this condition often experience incontinence episodes from laughing, coughing, and other activities that squeeze the abdominal muscles down. Further, a prolapsed bladder is uncomfortable. Women feel pressure, almost as if a small ball were lodged inside the vagina. Sexual function may also suffer.

Kegel exercises, which can strengthen the vaginal walls and pelvic floor muscles, may alleviate the condition. The physician can also insert a pessary, a stiff ring-like device that holds the bladder in its correct position. Women with serious prolapse may require surgery to reposition the bladder, which is supported by stitches placed in the front and back walls of the vagina. (7)

Surprisingly, bladder cancer strikes men more often than women, and it is the fourth most common cancer in men. It is also more prevalent in the U.S., France, and Canada, occurring at a rate of 70 percent, compared with its frequency in Asia and South America. (8)

Although several chemical links to bladder cancer are suspected, cigarette smoking ranks among the top avoidable risk factors. The most common symptom of bladder cancer is hematuria, or blood in the urine. Because blood is not always visible, people should watch for other symptoms, such as painful urination or having the urge to urinate frequently: If men have these symptoms, they might have bladder cancer, so it is a good idea to see a physician. Ruling it out is the best choice.

If a person does have bladder cancer, there are surgical and nonsurgical treatment options. One nonsurgical option is intravesical therapy; a liquid medication is inserted directly into the bladder with a catheter.

Radiation therapy is another form of treatment for invasive bladder cancer. High-energy x-rays are used to kill cancer cells locally, but treatment may need to be administered up to five times a week. (9)

The good news is that up to 80 percent of bladder cancers are found to be superficial. Most of these cancers can be removed by transurethral resection of a bladder tumor (TURBT). This is the most conservative of surgeries, and it takes place in the hospital with the patient under general anesthesia. The surgeon uses a high-frequency electric current or a laser to obliterate the tumor with the aid of a lit camera inserted through a scope placed through the urethra. For obliterating cancer that has not spread, this is often the weapon of choice.

If cancer has penetrated the muscular layer of the bladder, the most common therapy is surgical removal of the bladder. During a radical cystectomy, the surgeon also removes nearby lymph nodes and part of the urethra. The procedure may also include removal of the prostate gland; in women, the ovaries, fallopian tubes, and part of the vagina may be removed. Any area in direct contact with the cancer cells is removed.

When the bladder is removed altogether, a new one must be constructed either by using part of the intestines or by using synthetic orthotopic neobladders. In some cases, surgeons still attach an ostomy (a pouch to hold urine) that sits outside of the body. (8)

Generally, survival rates for bladder cancer are good, especially when it is diagnosed and treated early.

Far less worrisome than bladder cancer is common incontinence (less worrisome but more prevalent). Uncontrolled leakage is categorized into three basic types:

1. Stress incontinence happens as a result of abdominal muscles pressing down on the bladder, such as when we are laughing or coughing.

2. Urge incontinence refers to the need to urinate far more frequently than normal.

3. Mixed is simply a little of both.

Unlike the old days, when patients were forced to live out their lives in silence near to the closest toilet, today we have a number of strategies for dealing with the problem; more therapies are likely on the way. As baby-boomers age, medical researchers, pharmaceutical companies, and absorbency and control product managers will rush to provide ways to help us.

Of course, there is exercise. The patient can practice by cutting off the flow of urine mid-stream. That strengthens the Kegel muscles (the muscles on the pelvic floor) to help prevent the bladder from pushing down on the urethra. A number of products are available to help us identify the Kegel muscles and gain feedback and control over those muscles.

On the more popular front, bladder-control medications include the alpha-adrenergic agonist family to help the urinary sphincter maintain tone and to contract with greater strength; oxybutynin, calcium-channel blockers, and tricyclic antidepressants relax involuntary contractions.

In postmenopausal women, some doctors may recommend estrogen therapy, but all patients are advised to weigh carefully the risk/benefit ratio of that sort of treatment.

As mentioned before, some trials have involved botulism toxin injections to the detrusor muscle. (10)

Of course, there are always products that help us with damage control. These items include protective undergarments, absorbency pads, and absorbent mattress pads. These products are readily available, no prescription is needed, they are relatively affordable, and they help patients regain a normal lifestyle. However, the pads and undergarments can be uncomfortable, especially if they become soiled.

Pessaries for women help to suspend the bladder into its proper position. Urethral inserts are a sort of a plug and are available by prescription. One type works like a balloon; another works like a tampon. The insert can be removed when the person must urinate and can be replaced after relief is achieved.

Urinary patches have begun to make inroads. These are small foam pads with a gel adhesive that fit over the urethral opening to absorb minor leakage.

Permanent catheters are also available as a solution; however, medical intervention is necessary, and infection sometimes results.

For men there are fewer choices, partly because women make up the larger market and partly because the male urinary system is constructed in such a way that inserts are not an option. Devices for males must be worn externally, and most of them create pressure around the urethra, preventing urine flow. A number of penile rings and clamps are designed to work this way. Catheters tend to be external for men; they work like a sheath that fits over the penis and is connected to an external bag strapped to the upper leg.

None of these options for men or women seems particularly appealing. Unfortunately, the other option is to hide the problem by lurking near known toilets and venturing only to familiar ground.

In summary, symptoms accompanying bladder disease range from embarrassing to unbearable. The psychological distress alone, brought on by myriad awful thoughts about ourselves when we cannot control our bladder, is mind-boggling. If you are or if you know someone who has a bladder condition, do not be silent. Get answers. They are available, and you deserve them.


(1.) The Continence Foundation.

(2.) National Kidney and Urological Disease Foundation.

(3.) Arnot Ogden Medical Center, Elmira, N.Y., 1998.

(4.) Interstitial Cystitis Network.

(5.) Urology Channel

(6.) Neurogenic bladder. Merck Manual of Diagnosis and Therapy. Merck Research Labs, N.J., 2000.

(7.) University of Maryland Medicine. Cystole (fallen bladder).

(8.) National Cancer Institute.

(9.) The Cleveland Clinic

(10.) Bladder Advisory Council of the American Foundation for Urologic Disease, Inc.

Urinary Tract Infections May Be Foodborne Illnesses

Urinary tract infections (UTIs) in women are common and can be quite painful in some instances.

UTIs are not considered contagious epidemic diseases, but recent breakthroughs in sophisticated genotyping methods have found suprising patterns in UTI pathogens.

One such surprise is the discovery of a unique drug-resistant Escherichia coli clone in UTIs in women from geographically distant communities in the United States.

To answer the question of whether these UTIs might have a common source--such as meat containing drug-resistant uropathogenie E. coli--researchers examined 495 animal and environmental strains of E. coli submitted between 1965 and 2002. They looked for similarities to the clone found in the human infections.

Analyses showed that several of the bacterial strains were similar to the human strain in deoxyribonucleic acid (DNA) and protein structure as well as in antibiotic resistance.

The study did not result in any concrete link between UTIs and tainted meat, but further research could influence the practice of feeding cattle food mixed with antibiotics.

(Source: Clinical Infectious Diseases, 2005;40:251-257, 258-259.)
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Author:Gorman, Gail
Publication:Nutrition Health Review
Date:Jun 22, 2004
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