When your plumbing goes WRONG

PROBLEMS with our personal plumbing are incredibly common — from cystitis to incontinence after childbirth, or prostate troubles. In the final part of our series we look at what can go wrong with your waterworks — and what can be done to help . . .

AlTHOUGH rarely talked about, urinary incontinence affects millions of people in the UK.

and it seems many are too embarrassed even to talk to their doctor about it — one survey found that 60 per cent of women with incontinence problems would not go to their GP for help.

But just putting up with it means you miss out on treatment that can improve the situation. There are various types of incontinence, which have different causes and therefore require different solutions. But the key thing is you don’t have to live with it. 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 the 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, and at Imperial College Healthcare NHS Trust. This may only be temporary — though men may have to wear pads while it settles down.

To diagnose stress incontinence, a GP can perform a bladder stress test, which is usually done lying down: fluid is inserted into the bladder using a thin tube — you’ll be asked to cough and the doctor will check for fluid loss. The test may be repeated standing up.

There is also a pad test when you will wear an absorbent pad for a period of time. It will be weighed afterwards to work out how much urine you have lost without going to the loo.

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 (see overleaf for how to do these, as well as gadgets that can help).

For stress incontinence that persists, and seriously affects quality of life, there are surgical options. Over the past decade or so, women have been given synthetic mesh slings, also known as transvaginal slings or tensionfree vaginal tape (TVT), which support internal organs and ‘lift’ the bladder neck and urethra.

However, recently there have been concerns about the material in these shredding and cutting into the bladder and nearby tissue. more than 92,000 women had vaginal mesh implants from 2007 to 2015 in england, and a 2012 Government report found that around 15 per cent experienced complications.

Campaigners, including doctors and women who have been affected, are calling for a return to older sling techniques, including the open Burch colposuspension, which used the woman’s own tissues to recreate a stable pelvic floor.

There is a newer sling procedure known as a trans-obturator tape (or TOT) — available on the NHS and privately — which supports the urethra using a tension-free tape slung between the two obturator foramens (holes in the pubis bones of the pelvis which allow passage of nerves and blood vessels). Unlike the TVT operation, the tape does not go close to the bladder to keep it in its correct position. ‘Trans- obturator sling procedures have a success rate of 85 per cent,’ says mr Bowen. ‘research has shown it is much less likely to lead to bladder damage.’ men with stress incontinence after prostate surgery, which hasn’t improved after 18 months, can also opt for a sling procedure, where a synthetic mesh is positioned to give the urethra support.

There isn’t any long-term data for this relatively new operation, but so far about 80 per cent of men are able to stop using pads afterwards or their urinary leakage is halved.

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. But in most cases, no cause can be found.

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. ‘The bladder is having to increase the pressure to maintain flow. Eventually, it becomes unstable, leading to overactivity,’ says Mr Hellawell.

It can be diagnosed through urodyanamic testing, which includes noting if someone can stop urine flow mid-stream, or using sensors to check pressure within the bladder and measuring nerve activity. This can evaluate how well the bladder, sphincters and urethra are storing and releasing urine.

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, heart, lungs 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.

Injecting Botox into the bladder muscle has been found to be effective because it paralyses the muscles for up to two months. It is available in a few centres on the NHS, but it is not currently licensed to treat urge incontinence so doctors need to go through all the risks before a patient can decide to go ahead.

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.

To diagnose it, you may be asked to go to the loo and completely empty your bladder before a doctor inserts a catheter to see if more urine comes out — if more urine is produced it could indicate overflow incontinence.

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 pressure off the urethra. Many herbal and other alternative treatments can be found online, but there is no evidence to show any is effective at countering an enlarged prostate.

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.

For treatments for overflow incontinence in womenw caused by prolapse, see panel, right.

WHEN GOING TO THE LOO AT NIGHT IS A PROBLEM

FOR both 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 (more rarely) 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 all play a part.

It is, says Mr Hellawell, 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.