Bladder problems in women

Townsend Letter for Doctors and Patients, Nov, 2006 by Jule Klotter

Women are more likely to have problems with urine storage (urgency, frequency, discomfort, and/or incontinence) than men. While these problems are not life-threatening, they can be embarrassing and burdensome, and they can negatively affect a woman's quality of life. The May/June 2006 Journal of Midwifery & Women's Health has an excellent article by Katharine K. O'Dell, CNM, and Lisa C. Labin, MD, on overactive bladder, urge incontinence, and stress incontinence. Overactive bladder refers to a sudden, painless urgency to void urine that is unrelated to infection or other pathology. Frequency (voiding at less than two-hour intervals) and nocturia (voiding more than two times at night) are also signs of an overactive bladder. When involuntary urine loss accompanies this feeling of urgency, it is called urge incontinence. Urinary urgency and frequency have been associated with thyroid abnormalities, diabetes, and estrogen depletion. Stress urinary incontinence is the involuntary loss of urine with exertion, such as coughing, sneezing, laughing, lifting, or exercise.

The article includes several treatments for overactive bladder and urge incontinence. Using a voiding diary to keep track of consumed liquids and a schedule to help retrain the bladder improves symptoms in at least 50% of women, according to a Cochrane evidence review. Bladder control can be affected by drinking too much, too little, and/or by certain foods or drinks that irritate the bladder. O'Dell and Labin recommend drinking six to eight cups of liquid evenly spaced throughout the day. They refer readers to the Interstitial Cystitis Association website (www.ichelp. org) for information about foods and drinks that irritate the bladder. Retraining the bladder involves regular, timed voids, gradually increased by 15 to 30-minute increments, to teach the bladder to hold increasing amounts of urine. Herbalist Kathleen Maier suggests beginning with a scheduled void every 60-90 minutes, then gradually lengthening the time between voids until reaching every four hours. O'Dell and Labin emphasize that women need to understand that retraining takes time so that they do not become discouraged.

The authors offer some strategies for dealing with sudden urges to urinate. Self-distraction, such as counting backward from 100 by sevens or thinking about something else, and self-talk (e.g., "Calm down. I can wait.") may help a woman defer voiding until the urgency has passed and/or her scheduled time to void occurs. Also, relaxing and breathing while squeezing the pelvic muscles five times may stimulate reflex bladder relaxation. Pelvic muscle exercises can also help women with overactive bladder and/or urge incontinence. The authors say, "One regimen involves a goal of ten pelvic muscle contractions, held for five seconds, pulsed for five seconds, and followed by full perineal rest for 20 seconds between contractions." Pharmaceuticals that target muscarinic cholinergic receptors of the parasympathetic nervous system can be prescribed for women who do not respond to these measures. However, the authors note, "Medication alone is not enough: in one study, only 18% of patients continued bladder medication for more than six months." These drugs have several common side effects, including dry mouth, constipation, digestive upset, tachycardia, blurred vision, headache, sleep disturbances, and cognitive effects.

Stress incontinence occurs when pelvic floor muscles that support the urethra or the urethra itself are not strong enough to counteract pressure from the abdomen and bladder. For those with weak pelvic floor muscles, exercising the muscles using voluntary contractions is an effective way to decrease stress incontinence. Losing excess weight may also be helpful. Both urge and stress incontinence improved by up to 60% in overweight women who lost five percent to 15% of their weight, according to a study by L.L. Subak and colleagues (J Urol. 2005;174:190-5). Intravaginal support devices, such as tampons and vaginal pessaries, provide support for the urethra and decrease stress incontinence. A urethral insert, such as Femsoft, is another option. Women using any of these inserts must watch for signs of irritation and infection that may occur with their use. Oral estrogen has no effect on stress urinary incontinence. One pharmaceutical may provide relief for stress incontinence: duloxetine (Cymbalta), a serotonin and norepinephrine reuptake inhibitor that has already been approved for use in the treatment of depression and diabetic neuropathic pain. Duloxetine reduced stress incontinence episodes by 50%, compared to a 27% reduction in the placebo group. However, side effects led 24% of the duloxetine group to stop taking the medication (compared to four percent in the placebo group).

Maier K. "Menopause Naturally." (Lecture at SE Women's Herbal Conference, Black Mountain, NC; September 2005).

O'Dell KK, Labin LL. Common problems of urination in nonpregnant women: Causes, current management, and prevention strategies. Journal of Midwifery & Women's Health. 2006; 51: 159-173.