Disorders, Conditions,
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Urology Treatments

Bladder Disorders

The role of the bladder is to store and to empty urine. It should store urine at low pressures allowing for passage of urine easily out of the kidneys, down the ureters into the bladder. It should keep the urine without leaking or bothersome bladder sensations.

When it is a convenient time to urinate, bladder emptying should occur as an easy command from the brain to the bladder. The bladder muscle should contract, the pelvic floor should relax, and the bladder should empty fully.

Interruption of the bladder's functions can lead to irritation, fear of urine loss, poor quality of life, kidney failure, or infection. This article examines several types of bladder disorder along with their symptoms, diagnosis, and treatment.

Urinary Incontinence

Urinary incontinence - the loss of bladder control - is a common and often embarrassing problem. The severity of urinary incontinence ranges from occasionally leaking urine when you cough or sneeze to having sudden, unpredictable episodes of strong urinary urgency.

There are different types of urinary incontinence. These include:

Urge Urinary Incontinence
This is involuntary leakage with a sudden strong urge to urinate (for example, putting the key in the door on arrival home). This condition may cause you to have to urinate often. We recommend the following treatments, depending the patient's individual preferences and needs and based on prior attempts at treatment.

• Biofeedback - pelvic floor muscle exercises are used to manipulate the nerve pathways from the bladder to the spinal cord
• Medication - relaxes the bladder muscle by attaching to the bladder lining
• Botulinum toxin - is injected into the bladder muscle to relax it for 6-9 months at a time
• Sacral Neuromodulation - a bladder "pacemaker" can be used to treat urinary symptoms by manipulating the nerve pathways from the bladder to the spinal cord.

Stress Urinary Incontinence
This is the involuntary leakage on effort or exertion, such as coughing, sneezing or lifting. Stress incontinence occurs when the sphincter muscle at the bladder is weakened. The problem is especially noticeable when you let your bladder get too full. Most treatments are surgical, but all options are tailored to the patient's preferences, the severity of incontinence, as well as other physical exam findings such as prolapse (a relaxed bladder or rectum). Minimally invasive options are usually possible, so a fear of surgery should not prevent one from seeking treatment.

• Kegal exercises are designed to strengthen the urethral sphincter (bladder closing) muscle. These are no-risk exercises that can reduce leakage for as long as they are performed.
• Injection therapy to bulk up the urethral sphincter (bladder closing) muscle. There is no incision for this surgery. It is performed by telescope from inside the urethra.
• Minimally invasive surgeries (e.g. the transobturator tape sling, tiny hidden vaginal incision). These are very successful and well tolerated surgeries.
• Traditional anti-incontinence surgeries (e.g. the pubovaginal sling, a smiley-face incision with the lower abdominal curve). These surgeries work well for very heavy leakage.
• Specially designed surgeries for people who have had prior unsuccessful treatments (for example we sometimes use an adjustable sling, or sometimes identify a "fistula" or hole from the bladder to the urethra or vagina that need to be repaired).

Mixed Urinary Incontinence
This is a combination of stress urinary incontinence and urge urinary incontinence.Treatment is tailored to symptoms and diagnostic testing, but basically a combination of the therapies mentioned for stress and urge urinary incontinence.

Overflow Incontinence
This is the over-stretching of the bladder and poor emptying leading to overflow of urine when the bladder reaches maximum capacity. If you frequently or constantly dribble urine, you may have overflow incontinence. With overflow incontinence, sometimes you may feel as if you never completely empty your bladder. When you try to urinate, you may produce only a weak stream of urine.

Non-emptying of the bladder can occur when the bladder muscle does not contract, or with a blockage of the bladder due to "cystocele", a muscle spasm of the sphincter muscle, or other causes. Treatment involves correction of bad voiding habits, correction of anatomy to its natural location (fixing prolapse or hernias) or teaching people how to empty their own bladder with a catheter placed in for two minutes to drain.

Lower Urinary Tract Symptoms or "Overactive Bladder"

Overactive bladder is a condition that results from sudden, involuntary contraction of the muscle in the wall of the urinary bladder. Overactive bladder is also referred to as urge incontinence. Symptoms include:

• Frequency - voiding more frequently than is normal
• Urgency - sudden compelling urge to void
• Nighttime voids - waking up from sleep to urinate
• Feeling of incomplete emptying

Sometimes these symptoms respond to simple treatments. When the simple treatments fail, there are newer technologies that can markedly improve quality of life. In order of simplest to most complex, treatments are

• Lifestyle changes (for example reducing fluid or caffeine intake)
• Biofeedback - pelvic floor muscle exercises are used to manipulate the nerve pathways from the bladder to the spinal cord
• Medication - relaxes the bladder muscle by attaching to the bladder lining
• Botulinum toxin
• Sacral Neuromodulation - a bladder "pacemaker" can be used to treat urinary symptoms by manipulating the nerve pathways from the bladder to the spinal cord

Neurogenic Bladder

The normal function of the urinary bladder is to store and expel urine in a coordinated, controlled fashion. This coordinated activity is regulated by the central and peripheral nervous systems. Neurogenic bladder is when the spinal cord, brain, or bladder nerves are not functioning properly and the bladder fails to store and empty urine as it should.

The treatment depends heavily on diagnostic testing (urodynamics) and patient preference. The primary concern is making sure the kidneys can drain urine safely into the bladder to prevent kidney damage. The second goal is to address quality of life issues, such as preventing unwanted leakage or wetting of urine.

Diagnostic Testing

• Cystoscopy - This test is performed to look at the inner lining of the bladder, to detect stones or tumors. It involves using a small thin telescope (smaller than a drinking straw) to enter the bladder through the urethra (the urinary tube). This is usually well tolerated. Special concerns or fears about the procedure should be voiced to the nursing staff prior to the procedure.
• Urodynamic Testing - This test is performed to see how strong the bladder contraction is, to measure how easily leakage occurs, to determine how much the bladder will safely hold, and to see how well it empties. It involves placement of two tiny catheters (tubes) and some sticky patches on the genital region. It is an essential part of the decision making in many cases.

Center for Voiding Dysfunction

Our Center for Voiding Dysfunction, Directed by Dr. Elise De, offers state-of-the-art diagnostic testing, treatment, and surgery for simple and complex urinary problems, including robotic-assisted surgery, multi-channel urodynamic testing, minimally invasive vaginal surgeries, and diagnostic cystoscopy.

The problems treated include urinary incontinence (unintentional wetting or loss of urine) after childbirth, aging, or prostate surgery, inability to empty urine, bothersome urinary frequency and urgency, nighttime urination, and neurogenic bladder.

Related problems such as prolapse of female organs (relaxation of the bladder, rectum, or uterus into the vagina), pelvic floor muscle spasm, or recurrent urinary tract infections are also diagnosed and treated.

"Prolapse" or "Falling" of Female Organs

Prolapse is a condition where organs fall down or slip out of place. There are several types of prolapse, which can be felt as pressure or even a bulge or ball at the vaginal opening. These include:

• Cystocele - a relaxation, falling, or hernia of the bladder backward into the vagina
• Rectocele - a relaxation, falling, or hernia of the rectum forward into the vagina
• Uterine Prolapse - a relaxation, falling, or hernia of the uterus downward into the vagina
• Vault Prolapse (Post-Hysterectomy) - a relaxation, falling, or hernia of the top of the vagina downward into the vagina

Treatment of these conditions is either surgical correction or support with a pessary (a plastic disc). Most women choose surgery if they are in good health. Sometimes prolapse is mild and does not require surgery.

All options are tailored to the patient's exact diagnosis. Robotic-assisted surgeries or minimally invasive vaginal incisions are usually possible.

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