URINE INFECTIONS (CYSTITIS)
Approximately 1 in 4 women of child-bearing age will suffer a urinary tract infection (UTI) and of these a quarter will have problems with repeated infections. This causes pain and discomfort and often needs several trips to the GP for antibiotics. The job of the urologist is to ensure that there is no underlying reason for the UTI to have occurred such as a stone or a problem with bladder emptying.
Women who are prone to UTIs can often reduce the risk of these occurring by taking simple precautions eg maintaining a high fluid intake, emptying the bladder regularly - especially after intercourse, avoiding things which might upset the normal vaginal bacteria and correct toileting technique and hygiene. Cranberry juice or capsules and even lactobacillus-containing yoghurts or drinks may help but the evidence is weak. In older, post-menopusal women topical oestrogen replacement therapy may be indicated. Sometimes despite all these measures women continue to suffer recurrent UTIs and antibiotcs are required. There are several different ways of using antibiotics and we can discuss with you which approach is best for your situation.
Women with particularly persistent problems who do not respond to the measures listed above may be offered treatment with bladder instillations eg Cystistat or Ialuril. These are designed to replenish the protective surface coating of the bladder known as the GAG layer. They make it more difficult for bacteria to stick on to the bladder wall and set up an infection.
Urinary leakage is a common but distressing problem that can affect anyone at any stage of their life. It is, however, more common in women and tends to become more prevalent as they get older. There are several different types of urinary incontinence but the 2 most common are: stress incontinence – leaking when you cough, sneeze or exert yourself and urge incontinence – not getting enough warning to make it to the toilet.
Stress incontinence is usually due to a weakness of the pelvic floor and is more common in women who have had children. Treatment is aimed at trying to improve muscle strength through pelvic floor exercises. A supervised, structured programme is usually more effective than self-taught exercises. If this fails, then surgery may be offered in the form of a “tape” or “mid-urethral sling”. There are different types of tape including TVT (tension free vaginal tape) and TOT (trans obturator tape) but they are all effective at curing or reducing stress urinary incontinence in 90% of women. Sometimes a tape is not the right operation and other procedures may be considered such as bladder neck bulking injections. Your surgeon will help you decide which approach is right for you.
URGE INCONTINENCE (OVERACTIVE BLADDER SYNDROME)
Urge urinary incontinence, also known as an overactive bladder or overactive bladder syndrome, is a very distressing condition as it is so unpredictable.
The initial approach is to try to avoid things that irritate the bladder and try to establish better urinary control. This normally involves avoiding caffeinated drinks, keeping your bowels regular and practicing pelvic floor exercises and bladder drill. Bladder drill is a method of gradually increasing the amount of urine that the bladder can hold over a period of time with the aim of reducing the urgency symptoms and controlling the number of times that you have to go to the toilet to pass urine.
Sometimes these simple measures will be enough to regain control over your bladder but often a little extra help from medication is needed. There are 2 main groups of drugs that are used – anticholinergics (eg tolterodine, solifenacin) and a new class of drug called a beta-3-agonist (mirabegron). Once you have regained control of your bladder then you may well be able to stop the medication.
Well over 90% of patients with urge symptoms will respond to these treatments but there are other options for those who do not get sufficient relief. Other options include PTNS (Peripheral Tibial Nerve Stimulation), Botox injections into the bladder, Sacral Neuromodulation and more complex surgical options. We can discuss the advantages and disadvantages of each approach with you and help you decide what is best for you.
Pain in the bladder is usually due to a specific problem like an infection or sometimes a stone. However, in some cases there is no obvious explanation and the pain persists and is then referred to as Painful Bladder Syndrome. Usually this is felt as pain low down in the abdomen over the bladder and is associated with a frequent need to urinate to try to alleviate the discomfort. It can be exacerbated by certain foods or drinks and can be affected by other things such as constipation, cyclical hormone changes and sexual activity. This condition used to be referred to as Interstitial Cystitis and there are various theories as to why it might occur but no-one really knows for sure why some people develop it. It us more common in women but can affect men in 10% of cases.
The first thing a urologist will do is to exclude a specific cause for the pain usually by performing various tests and scans. They will normally need to examine the lining of the bladder with a telescope - a procedure known as a cystoscopy. If the bladder lining looks very inflamed or abnormal then a biopsy may be taken to examine under the microscope.
Treatment usually starts with medication eg. Cimetidine or amitriptyline. If this does not work than bladder instillation therapy may be used. There have been a wide variety of substances used to treat bladder pain including DMSO (RIMSO), heparin and, most commonly nowadays, Cystistat or Ialuril.
FEMALE UROLOGICAL CANCERS
Renal (Kidney) cancer is an increasingly common problem. It affects both men and women but is more common in men. Often early kidney cancer has no symptoms and is discovered by chance on scans done for other reasons. Kidney cancer can also cause blood loss in the urine or a lump in the abdomen.
Bladder cancer is one of the most common cancer causes for blood in the urine. Tests including examination of the bladder under local-anaesthetic with a telescope may be needed to make a diagnosis. It may be treated by day / overnight surgery via the urethra (water pipe) with no external cuts to take samples. This is often curative but more complex surgery or chemo/radiotherapy might be needed in more severe cases.
Haematuria is defined as the presence of blood in the urine. It is either visible (frank) or non-visible (microscopic). It has many causes including: infection in the bladder, or kidneys or prostate (often associated with pain or discomfort on passing urine), stones in the urinary tract, bursting of a small blood vessel or, a tumour (cancer) in the bladder, kidneys or ureters.
Sometimes non-visible haematuria can be caused by some disorders of the kidney usually investigated by a nephrologist.
Most people who pee blood would probably think that this was a little worrying. Sometimes blood in the urine can be the first sign of a really important problem such as a bladder or kidney cancer. These problems are more common in current or ex-smokers but even people with a healthy lifestyle may have them. For many people however it is not associated with any major illness and may go away on its own. Because you as a patient can’t tell if blood in your pee is important or not you are encouraged to report it to your doctor urgently. If you see your GP with this problem they are likely to do a urine test to check for infection and antibiotic treatment may be needed if this is the cause.
A urine test and blood tests are usually required to rule out infection and ensure that the kidneys are functioning is normally. The kidneys are examined with ultrasound and CT scans if required and a flexible camera is used to examine the bladder under a local anaesthetic (called a flexible cystoscopy). These tests will usually demonstrate the cause of the bleeding and your treatment options will be discussed with you after these tests. Occasionally, further tests are required.
Often the ‘all clear’ is given and no long term follow up is needed, but if a serious condition is diagnosed then keyhole surgery for kidney and bladder problems can be offered and laser vaporisation of kidney stones can be performed if required.
Kidney stones make up the majority of stone disease in the UK but bladder stones still occur, usually in men whose bladders empty incompletely of urine do not empty of urine completely. Stones occur most commonly in the 20-50 age range, but can affect any age group. Men are affected more commonly than women and stones occur more frequently in the summer. In the UK 1 in 10 will suffer with a kidney stone by the age of 70. Most stones are formed of calcium combined with other chemicals, most commonly phosphate and oxalate. There is a high risk of forming further stones, once one has occurred.
Risk factors for stones include:
Low fluid intake, high protein diet, Low calcium diet (Calcium in the diet binds to oxalate and phosphate preventing absorption), Diabetes, Obesity, Rare genetic conditions e.g. Cystinuria
Stones form in the kidney and if they pass out of the kidney into the tube connecting the kidney to the bladder (ureter) pain usually occurs. This is known as “Renal Colic”. The pain is often agonising and comes in waves and patients often cannot get comfortable. Most small stones will pass on their own given some time, but others will not. Many stones may will not cause symptoms if they remain in the kidney
Most stones are visible on a plain x-ray, known as a KUB. The use of CT scans is becoming more common as it is very good at detecting stones and does not require an injection. We have recently adopted the use of “ultra-low dose” CT scans designed to minimise the dose of radiation received, whilst still being able to visualise stones.
The majority of stones that cause symptoms by passing down the ureter, do not require surgical treatment. 85% of stones less than 4mm will pass spontaneously. Medicines can be given to relieve pain and help with the passage of the stone. Stones within the kidney, can be treated with shockwaves generated by a machine. This is known as Extracorporeal Shock Wave Lithotripsy (ESWL). The patient lies on a couch and the machine is placed against the back. Treatments may last for up to 1 hour, patients may require pain killers during the procedure. The number of treatments required depend on the size, type and number of stones. Some patients require the placement of a ureteric stent before treatment, this is a plastic tube running from the kidney to the bladder placed under a short general anaesthetic.
Stones may require surgical removal. This is usually performed endoscopically, using a rigid or flexible camera passed via the bladder to the stone (Ureteroscopy). Stones may then be removed intact with a basket or broken up into fragments with a laser or shockwave machine. Larger stones in the kidney may need to be removed by a “keyhole” technique with a direct puncture into the kidney, this is known as Percutaneous Nephrolithotomy (PCNL).
We have access to all state of the art treatments for stones including laser treatment to vapourise stones and shock wave therapy (Extracorporeal shock wave lithotripsy: ESWL)
Support information from the British Association of Urological Surgeons.