How to beat health problems when your plumbing goes wrong

Problems with our personal plumbing are incredibly common - from cystitis to incontinence after childbirth, or prostate troubles. We look at what can go wrong with your waterworks - and what can be done to help. Although rarely talked about, urinary incontinence affects many. And it seems many are too embarrassed even to talk to their doctor about it. But just putting up with it means you miss out on treatment that can improve the situation.

Stress that’s no laughing matter

Small leakages of urine when you cough or laugh is known as stress incontinence. It happens when the bladder neck cannot remain closed under physical stress. ‘In women, this can happen after childbirth, when the neck gets stretched during delivery, or because the pelvic floor muscles are weakened, causing the neck to sag,’ says Mike Bowen, a consultant gynaecologist based at Nuffield Health Oxford Hospital.

In men, removal of the prostate gland (prostatectomy) ‘is the principal cause for stress urinary leakage’, says Giles Hellawell, a consultant urological surgeon at The London Clinic. This may only be temporary - though men may have to wear pads while it settles down. Pelvic floor exercises are very effective at helping to alleviate stress incontinence. A review of studies published in 2010 found up to a 70 per cent improvement in symptoms of stress incontinence in women after appropriately performed exercises. For stress incontinence that persists, and seriously affects quality of life, there are surgical options.

When you can't hold on

If you feel a near-constant need to urinate, or feel as though you can’t ‘ hold on’ when you do need to go, this is likely to be urge incontinence. This differs from stress incontinence, when the pelvic floor muscles are too weak to prevent urination. Urge incontinence is twice as common among women as men and is caused by damage to nerves in the bladder or muscle, bladder stones, infection or bladder inflammation. Leakage occurs because the bladder muscles squeeze or contract at the wrong times, not just when your bladder is full.

Overactive bladder, when the bladder muscles contract too often, is one cause of urge incontinence. It creates an uncomfortable feeling of wanting to urinate all the time. Some men suffer overactive bladder and flow problems because of an enlarging prostate, which can block the urethra - the tube which carries urine from the body. Unlike with stress incontinence, there are drug treatments for urge incontinence and an overactive bladder. It can be stabilised with anticholinergic drugs, which work by dulling the autonomic, or involuntary, nervous system which controls the functioning of organs such as the bladder and genitals.

‘But the side-effects of these medications are not great,’ says Mr. Hellawell. ‘Not only will they lessen the bladder contractions, they will also lessen bowel contractions, leading to constipation.’ Anticholinergic drugs will also affect the lacrimal glands behind the eyes and the salivary glands, leaving patients complaining of dry eyes and dry mouth. They take 12 weeks to take full effect - and while the idea is to take the drugs for life, patients are unlikely to want to take them long term. But there’s a new prescription drug available called mirabegron, marketed as Betmiga, which works by relaxing muscles in the bladder.

Constant trickle linked to prostate

Overflow incontinence is caused when the bladder never fully empties and small amounts dribble out all the time, rather than only when the bladder is under stress. People with this type of incontinence may not always sense that their bladder is full. It is more common in older men and is often due to an enlarged prostate. Women can suffer from this type of incontinence too, when the urethra is blocked by prolapsed organs or kidney stones. It is often diagnosed when someone has frequent bladder infections caused by a back- up of urine, which grows bacteria.

Men with an enlarged prostate may be helped by drugs called alpha adrenergic agonists, such as clonidine, which reduce contractions of the bladder and the urge to pass water. Medicines, such as the ‘alpha blockers’ tamsulosin and alfuzosin, can also be prescribed to relax the muscle in the prostate, taking the pres- sure off the urethra. Leakages can be controlled by absorbent pads or men can use a urinary sheath, worn like a condom with a tube leading to a bag.

Going to the loo at night

For men and women over 50, getting up to pee once a night is normal, and twice a night over 65. In men, an enlarged prostate or prostate cancer can be a cause. But because it happens to men and women, all the blame for ‘nocturia’ - needing to go at night - can’t be laid on the prostate: disturbed sleep patterns and medications including blood pressure drugs can play a part. It is important to check that the issue isn’t an undiscovered cardiac problem, which can cause fluid retention.

Lifestyle can play a part. ‘ I have patients who have a couple of strong coffees or teas last thing.’ Caffeine encourages urination, and ‘is also known to cause bladder instability’ - triggering a need for frequent or urgent weeing.

Painful urine infections

Cystitis, or inflammation of the bladder, is one of the most common types of urinary tract infection (UTI) and affects more than 90 per cent of women.

It is typically caused by bacteria invading the bladder wall, explains Con Kelleher, an obstetrician and gynaecologist based at Guy’s and St Thomas’ NHS Foundation Trust. Pain when urinating or passing frequent, small amounts of urine are signs of cystitis. It’s more common in women than men. ‘The anus is closer to the urethra [the tract that carries urine from the bladder out of the body] in women and the urethra is shorter,’ explains Mr. Kelleher. "This makes it more likely that bacteria will invade." "UTIs should not be ignored since they can lead to more serious complications such as kidney infection as the bacteria travel up from the bladder," says Emma Soos, a nurse with a special interest in urology and director of the Women’s Health Clinic.

For mild cystitis, drinking plenty of water can help flush out bacteria. The antibiotic trimethoprim (Monotrim) is the main treatment and works in 80 per cent of infections. Adults with UTIs which are not responding to treatment should have their urine tested to identify the bacteria causing the problem so they can be targeted with the most effective drugs. To prevent UTIs, wearing clean cotton underwear, avoiding perfumed products and wet wipes, which can be irritating, and wiping front-to-back are effective. Always passing urine at bedtime and after sex - during which bacteria can transfer to the urethra - can also help.

‘Male Cystitis’

Although men can get cystitis, more common is prostatitis - inflammation of the prostate gland and is sometimes called ‘male cystitis’. Symptoms include pain when urinating, frequent urination and the urgent need to pass water, cloudiness or blood in the urine and pain in the abdomen, groin or lower back. Sometimes it causes sexual problems such as low libido and erectile dysfunction. In about 10 per cent of prostatitis cases it can be down to bacterial infection. "This type comes on quickly and can cause a high fever, chills, muscle aches and joint pain, as well as pain in the perineum and around the base of the penis and difficulty passing urine," says Professor Roger Kirby, from the Prostate Centre.

Treatment is with antibiotics. ‘ In severe cases, a man may need antibiotics for four to six weeks,’ says Professor Kirby. Professor Christopher Eden, a urological surgeon at Royal Surrey County Hospital, says the quinolone class of antibiotics are most effective at entering the prostate gland. The most common type of prostatitis is not caused by bacteria at all. Chronic prostatitis without bacterial infection, also known as chronic pelvic pain syndrome ( CPPS) is diagnosed when men complain of pain around their back passage and discomfort passing urine. ‘Most experts believe this is caused by scar tissue left after a bacterial infection has resolved - this can stimulate nerves which continue to send sig- nals to the brain that there is inflammation,’ says Professor Eden.

Treatment for CPPS includes alpha blockers, which can help by relaxing the bladder neck and the muscle fibres within the prostate. Some patients seem to benefit from Cialis, used to treat erectile dysfunction, in doses of 5mg per day which can also improve sexual function. Frequent sex and masturbation are sometimes cited as ways to reduce the pain of prostatitis, but Professor Eden says that this is probably a myth. ‘But some men do say that it helps.’

Prolapse: What really does work?

The worst cases of prolapse can make women feel as if their insides are literally falling out. ‘The ligaments and muscles that make up the pelvic floor start to stretch, and the organs in the abdomen slip down,’ says Dr. Philip Owen, a consultant obstetrician and gynaecologist at the Princess Royal Maternity Hospital in Glasgow. Stretching can occur during pregnancy and childbirth. Being overweight and ageing are risk factors. According to the Royal College of Obstetricians and Gynaecologists, half of women over 50 will have some degree of prolapse. ‘Menopausal women are at risk as muscle tone deteriorates and oestrogen levels fall, which cause the wall of the vagina to become thin and less able to support itself,’ says Dr Owen.

Prostates: What men need to know

When it comes to men’s ‘ plumbing’ issues, the culprit in many cases is the prostate, the gland which produces the fluid that mixes with sperm to create semen. The walnut-sized prostate, which is positioned below the bladder, is wrapped around the urethra, the tube that carries urine out of the body through the penis. That arrangement works just fine when men are in their prime. But as men grow older, the prostate gradually enlarges, placing increasing pressure on the urethra and interfering with the flow of urine. Most men who go to see their GP have been spooked by symptoms caused by a harmlessly enlarged prostate. They might have poor flow of urine - what once was a river in flood becomes a mere stream. Or, if they have tolerated poor flow for a number of years, as many men do, they may have started to experience secondary effects on the bladder.

Any lump, swelling, change in firmness or texture of the testicles, or a feeling of heaviness or pain in the testicles or scrotum should be checked out by a doctor.