Dr. Dale Peterson, urinary retention, incontinence, stress incontinence, urge incontinence, BPH, benign prostatic hypertrophy, saw palmetto, Kegel exercises, African pygeum, zinc

Urinary Difficulties

Urinary Difficulties

© 2011 Dr. Dale Peterson & drdalepeterson.com

As we go through life we rarely think about how smoothly our bodies perform their many functions. Rarely do we consciously think about the fact that we are breathing, we are generally unaware of our heart’s rhythmic beat, and until we reach a critical age we don’t realize how hard our eyes are working to keep things in focus. It is only when routine functions go awry that we become aware of their complex nature.

The ability to retain urine in the bladder until an appropriate time and place and then release it without difficulty is a skill that, once acquired, is considered routine and taken for granted. Its contribution to one’s quality of life goes unappreciated until the day bladder control is lost. When urinary difficulties develop they can be annoying at best and life-threatening at worst. They can range from an occasional loss of a small amount of urine to a complete inability to start urine flow. When certain anatomic abnormalities are present surgery may be the only answer, but much can be done to prevent urinary challenges and to improve conditions that lead to urinary difficulty.

Urinary challenges tend to differ between men and women. Women are likely to wrestle with incontinence, an unintended loss of urine, while men are more likely to encounter difficulty in starting and maintaining urine flow. The difference is explained by anatomy.

Blood passes through the kidneys where it is filtered. The filtrate is called urine. Urine passes from the kidneys to the bladder through tubes called ureters. It is stored there until the bladder is emptied through another tube called the urethra.

In women the urethra is approximately two inches in length. It passes directly from the bladder to the skin surface without encountering any obstacles along the way. Urine is kept in the bladder solely by muscle tightness. The chief muscle controlling urine retention or flow is called the urinary sphincter. It is located at the outlet of the bladder and can be consciously tightened or relaxed depending upon whether one wishes to retain or release urine. Pelvic muscles support the bladder and prevent it from sagging. A well-supported bladder outlet remains narrow and capable of being closed by the sphincter. If the pelvic muscles become weak and allow the bladder to sag or fall the bladder outlet will stretch and the urinary sphincter will no longer be able to contract tightly enough to prevent the bladder from leaking.

In men the urethra is in excess of six inches in length. As it runs from the bladder to the tip of the penis it passes through the prostate gland, which produces the fluid that carries sperm out of the body. Any swelling or enlargement of the prostate is capable of slowing or blocking urine flow.

Women are at risk of developing several types of incontinence. Girls and young women may experience incontinence due to an infection. Bladder infections are often characterized by frequent, sudden, and uncontrollable urges to urinate. Treatment of the infection quickly eases the urgency and frequency and bladder control is restored. If bladder infections tend to recur it may be helpful to take a teaspoon of d-mannose daily. D-mannose is a sugar that is not burned for energy, but is passed unchanged into the urine. There it coats the arm-like structures that bacteria use to attach themselves to the bladder wall. The coated bacteria are unable to cause an infection and are washed harmlessly out of the body when the bladder is emptied.

The most common form of incontinence experienced by women is called stress incontinence. Stress incontinence is a loss of urine due to coughing, laughing, sneezing, or exercising. The cause of stress incontinence is weakness in the pelvic muscles that support the bladder. When the pelvic muscles are too weak to withstand the extra intra-abdominal pressure created by coughing, sneezing, or lifting, urine is squeezed out of the bladder.

Stress incontinence can often be improved by strengthening the pelvic muscles. This is accomplished by performing a set of exercises that are often referred to as Kegel exercises. They were developed in 1948 by Dr. Arnold Kegel, a professor of gynecology at the University of Southern California, as a means of tightening and strengthening the pelvic muscles without surgery. Kegel exercises are performed by alternately tightening and relaxing the muscles that are used to stop urination. It is generally recommended to start with 3 seconds of contraction followed by 3 seconds of relaxation and progress to contracting and relaxing the muscles for 10 seconds as strength improves. The sequence is repeated ten times and three sets are done daily. Use of a device called a progressive resistance vaginal exerciser is required to achieve optimum results. When Kegel exercises are done correctly and consistently up to 90 % of women note improvement in stress incontinence.

Urge incontinence is another type of urinary difficulty. In this type of incontinence it is difficult to reach a restroom in time when the urge to urinate appears. Some urine leakage generally occurs before the bladder can be emptied. Urge incontinence can often be improved by bladder training. This is done be determining the approximate interval between urinary episodes. Using a timer, an alert is set for fifteen minutes before the next urge is expected to occur. As consistent dryness is achieved the time interval is increased by 5 – 10 minutes. As dryness is achieved at the new interval the time is once again lengthened. If urge incontinence returns, the interval that maintained dryness is resumed. Most people with urge incontinence can successfully achieve and maintain a 2 – 3 hour dry interval with bladder training.

A diagnosis that has become popular over the past decade is “overactive bladder.” Overactive bladder is defined as "urgency, with or without urge incontinence, usually with frequency and nocturia." Urgency means a need to empty the bladder immediately, frequency is defined as needing to empty the bladder 8 or more times daily, and nocturia is the need to empty the bladder two or more times during sleep.

The diagnosis of “overactive bladder” did not exist prior to 2001. It has been popularized by pharmaceutical companies that market drugs to relax the bladder and prevent it from contracting normally. Some of the drugs commonly promoted and prescribed for “overactive bladder” include oxybutinin, which is sold generically and under several brand names, Detrol and Detrol LA, Vesicare, Enablex, and Toviaz.

It is important to recognize that “overactive bladder” is simply a collection of symptoms, not a specific disease. If you have heard me speak on various health topics you know that symptoms are the body’s dashboard warning lights. I use the example of a person who is driving down the highway when a red light that says “oil” appears on the dashboard. The driver tries to go on, but the red light is too annoying. Having pulled off on the shoulder of the road several options are available. The engine oil level can be checked and oil added if it is confirmed to be low. A road service can be called and the vehicle towed to a service station where the cause of the low oil level can be determined and corrected. Another option is to find a pair of pliers, identify the wire that is leading to the annoying red light, and clip it. The driver can then get back into the car, start up the engine, and, since the red light is no longer present, continue blissfully on to his or her destination.

When I give that example everyone agrees that the clipping the wire option is ridiculous and that serious engine damage is likely to result somewhere down the road. This is true, but that is exactly what is being done every time a drug is used to eliminate a symptom without identifying and correcting its underlying cause.

Many medical conditions can cause urinary urgency, frequency, and nocturia. Most are as potentially damaging to the body if unidentified and untreated as failing to address the cause of a lack of engine oil is to an automobile. A thorough search for the cause of overactive bladder symptoms should be undertaken before a medication that prevents the bladder from contracting is taken.

Some causes of overactive bladder symptoms are bladder infections, bladder tumors, diuretics (water pills), diabetes, drinking caffeinated beverages, neurologic disorders such as multiple sclerosis, and tumors of the uterus or ovaries. It is even possible to misdiagnose a pregnancy as an overactive bladder since enlargement of the uterus early in pregnancy can reduce the size of the bladder and trigger urinary frequency and nocturia.

One often overlooked cause of overactive bladder symptoms is a condition called interstitial cystitis. It is an inflammation of the bladder wall, the cause of which is usually unknown. It has been my experience that many causes of interstitial cystitis are due to a low grade yeast infection of the bladder. This can generally be treated successfully with a combination of pau d’arco (extracted from a South American tree bark), Undecyn (a combination of several substances that inhibit the growth of yeast in the body), and a probiotic. Two capsules of each are taken twice daily for seven weeks (two 100 count bottles of each). When the cause of interstitial cystitis remains elusive it will often improve with the use of anti-inflammatory supports such as omega-3 oils and systemic enzymes.

Overactive bladder symptoms also occur with a fallen bladder. When the bladder has dropped due to weakness of the pelvic muscles the outlet may no longer be located at the lowest point of the bladder. This means that the bladder will not empty completely. Since one is starting with a partially filled bladder after urination its capacity to hold more urine is limited. Therefore, the urge to urinate will return much more quickly. Leaning forward while urinating can raise the bladder and facilitate a more complete emptying. The Kegel exercises described above may be helpful. Another option is the use of a pessary, a device that is placed in the vagina to support and elevate the bladder. Surgery may be needed to restore bladder support.

The most common cause of urinary difficulty in men is enlargement of the prostate gland, which impedes the free flow of urine through the urethra. In young men prostatic swelling is generally due to prostatitis, and infection of the gland. Treatment of the infection should result in a return of the prostate to normal size and restoration of normal urine flow.

Older men may develop a condition called benign prostatic hypertrophy (BPH). BPH is a non-cancerous enlargement of the prostate gland. I have seen the condition in men as young as 50, but it becomes more common with increasing age. Developing BPH is not inevitable, however, as many men live into their 80s and 90s without experiencing any of its symptoms.

BPH develops gradually. Symptoms may include a weakening of the urinary stream, difficulty starting or stopping the urinary stream, increasing urinary frequency, a need to urinate several times during the night, and a need to empty the bladder quickly when the urge to urinate presents itself. A man with BPH may find his urine flow starting and stopping several times as he attempts to empty his bladder and he may have a sensation of not having completely emptied the bladder upon finishing urination.

A valuable tool in diagnosing and monitoring the progress of BPH is the International Prostate Symptoms Score (IPSS). The IPSS questionnaire contains seven questions about symptom severity and one question about quality of life as it relates to urinary challenges. It was created by the American Urological Association in 1992. A copy of the questionnaire is available from several online sources. If one suspects that BPH is present it is quite helpful to complete a baseline IPSS. This can be used as a basis for judging the effectiveness of supports or medications.

The primary cause of prostatic hypertrophy is believed to be the accumulation of the hormone dihydrotestosterone (DHT) in the gland. DHT is derived from and more potent than testosterone. When it is present it causes each cell of the prostate gland to grow larger. This results in an overall enlargement of the gland.

Several nutritional substances are helpful in reducing prostatic enlargement. Plant sterols are the primary supports used in managing BPH. Plant sterols work by reducing receptor sites for estrogen and progesterone in the prostate gland. When estrogen is present excess water tends to accumulate causing swelling of the gland. More importantly, estrogen interferes with the removal of DHT from the gland. Reducing estrogen levels in the prostate allows DHT to be neutralized and eliminated efficiently. Improvement of BPH symptoms is generally seen within 2 – 3 months of the start of sterol use.

The most commonly used source of sterols is the saw palmetto berry. The amount of saw palmetto berry extract that is generally effective is 160 mg. twice daily. When purchasing saw palmetto products it is important to read the label carefully. I have seen several saw palmetto products that do not contain the sterol-rich berry extract. Unsuspecting consumers are often tricked into purchasing them because they list a much higher saw palmetto content than the sterol-containing products. It is a natural impulse to choose a product that is said to contain 750 mg. over a product containing 160 mg. Unfortunately, the higher mg. product is often void of sterols and is therefore of no benefit in relieving BPH.

Another beneficial substance is African pygeum extract. Prostate cells should have a prism shape, but they tend to be flat in BPH. When they flatten the cells are not able to produce and release their secretions normally. As a result they become congested and swollen. Pygeum works not by inhibiting the action of estrogen, but by causing prostate cells to regain and retain their normal shape.

Zinc is a critical nutrient for the prostate gland. Levels of zinc in the gland are typically 10 times greater than in other tissues. Zinc is needed to prevent testosterone from being converted to DHT. Since the typical U.S. diet is low in zinc, supplementation is required to maintain normal levels in the prostate. This is why men who take a nutritional supplement that contains zinc are less likely to develop BPH as they grow older. When BPH is already present zinc supplementation in the amount of 30 mg. daily is often effective in shrinking the gland over time.

Two classes of drugs are commonly prescribed for treatment of BPH. Alpha blockers are drugs that prevent smooth muscles from contracting effectively. They are used to relax the internal urethral sphincter near the prostate gland. This will immediately improve urine flow in many cases, but it does nothing to address the underlying problem, which is the enlargement of the prostate gland. Some alpha blockers are alfuzosin (Uroxatral), doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin), and tamsulosin (Flomax). Because the drugs cause smooth muscles to relax throughout the body, including in arteries, they can cause a substantial drop in blood pressure leading to dizziness or even fainting.

The other class of drugs used to treat BPH are 5-alpha-reductase inhibitors. 5-alpha-reductase is an enzyme that facilitates the conversion of testosterone to DHT. The most commonly prescribed are finasteride (Proscar and others) and dutasteride (Avodart). The drugs work slowly and often need to be taken for 6 – 12 months before improvement is noted. The drugs can cause a loss of libido (interest in sex) and an inability to achieve an erection.

I have had many men change from 5-alpha-reductase inhibitors to combinations of saw palmetto, pygeum, and zinc over the years. Nearly all have been much happier with the non-prescription formulations than with the drugs.

If BPH symptoms are mild I generally suggest that a man begin a formulation such as Prostazyme, which contains saw palmetto, pygeum, and zinc in amounts that have been shown to be effective in reducing the size of the prostate gland. If the symptoms are moderate to severe I will prescribe an alpha blocker to hopefully provide some immediate short-term improvement until the size of the prostate gland is reduced enough to bring about lasting results.

As in the case of urinary incontinence, conditions that are too advanced to respond to nutritional supports or medications may require surgical intervention. Several options are available, so it is important to review them before committing to a specific procedure. Several major medical centers offer information about surgical treatments for BPH on their websites.

Urinary difficulties can significantly lower one’s quality of life. Fortunately, issues such as urinary incontinence and obstruction of urine flow can often be successfully addressed without resorting to drugs or surgery. Because early intervention has a significantly greater chance of success than waiting until the challenge is advanced I encourage you to address urinary challenges when they first appear rather than attempting to live with them. Life is too short to compromise its quality.

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