What is bladder dysfunction?
Bladder dysfunction is a collective term for abnormalities of bladder urine filling, storage and emptying.
Parameters of normal bladder function
- A residual urine volume of less than 50ml.
- The first desire to void occurs when there is between 150-200ml of urine in the bladder.
- A functional bladder capacity between 400-600ml.
- No rise in bladder pressure during bladder filling or when standing.
- There are no unprovoked spasms of the detrusor muscle of the bladder.
- No leakage of urine during activities such as coughing, sneezing and laughing.
- The amount of urine voided should be at least 150ml.
- The peak flow rate during voiding should be greater than 15ml/sec.
What are symptoms and signs?
Any departure from the normal in structure, function, or sensation, experienced by the woman and indicative of disease or a health problem.
Any abnormality indicative of disease or a health problem, discoverable on examination of the patient; an objective indication of disease or a health problem.
Bladder Problems and the gynaecologist
Gynaecologists with a special interest in female urology deal with problems of the lower urinary tract:
- Distal ureter
Bladder and urethra
This section will be limited to the abnormal function of the bladder and it’s outlet, the urethra
Urinary incontinence symptoms
Involuntary loss of urine.
Urinary leakage associated with different types of physical exertion (coughing, laughing, walking, gym, standing up, intercourse etc).
Urinary leakage associated with urinary urgency.
Involuntary loss of urine associated with change of body position, for example, rising from a seated or lying position.
Involuntary urine loss which occurs during sleep.
Involuntary urine loss associated with urgency and also with physical exertion or on coughing or sneezing.
Continuous involuntary loss of urine.
Urinary incontinence where the woman has been unaware of how it occurred.
Urinary incontinence during coitus (penetration &/or orgasm).
Bladder storage symptoms
Complaint that micturition (voiding) occurs more frequently during waking hours than previously deemed normal by the woman.
Interruption of sleep one or more times because of the need to micturate. Each void is preceded and followed by sleep.
Sudden, compelling desire to pass urine which is difficult to defer.
Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or obvious pathology.
Lower urinary tract pain
Suprapubic or retropubic pain, pressure or discomfort, related to the bladder, and usually increasing with bladder filling. It may persist or be relieved after voiding.
Pain felt in the urethra and the woman indicates the urethra as the site.
Lower urinary tract infection
Microbiological evidence of significant bacteriuria and pyuria usually accompanied by symptoms such as increased bladder sensation, urgency, frequency, dysuria, urgency urinary incontinence, and/or pain in the lower urinary tract.
At least 3 symptomatic and medically diagnosed UTIs in the previous 12 months. The previous UTIs should have resolved prior to a further UTI being diagnosed.
The desire to void during bladder filling occurs earlier or is more persistent to that previously experienced.
Complaint that the definite desire to void occurs later to that previously experienced despite an awareness that the bladder is filling.
Complaint of both the absence of the sensation of bladder filling and a definite desire to void.
Voiding and postmicturition symptoms
Delay in initiating micturition.
Urinary stream perceived as slower compared to previous performance or in comparison with others.
Complaint of urine flow that stops and starts on one or more occasions during voiding.
The impression of the need to make an intensive effort (by abdominal straining, Valsalva or suprapubic pressure) to either initiate, maintain, or improve the urinary stream.
Complaint that the urine passage is a spray or split rather than a single discrete stream.
Bladder does not feel empty after micturition.
Having to take up specific positions to be able to micturate spontaneously or to improve bladder empyting.
The inability to pass urine despite persistent effort.
Complaint of burning or other discomfort during micturition. Discomfort may be intrinsic to the lower urinary tract or external (vulvar dysuria).
Urinary incontinence signs
Involuntary loss of urine.
Urinary leakage associated with different types of exertion.
Observation of involuntary leakage from the urethra synchronous with the sensation of a sudden, compelling desire to void that is difficult to defer.
Observation of urine leakage through channels other than the urethral meatus; for example, a fistula.
Stress incontinence only observed after reduction of the co-existent prolapse.
The management of bladder dysfunction
Like any medical complaint, are tailored to the specific problems of the patient.
Should always include:
- Bladder diary
- Residual bladder volume
May need to include:
- Ultrasound – bladder/ureters/kidneys/pelvis/abdomen
- Bladder biopsy
- Micturating cystogram
Are tailored to the specific problems and circumstances of the individual patient.
- Lifestyle modifications
- Pelvic floor muscle training
- Bladder training
- ß-adrenoceptor agonists
- Tricyclic antidepressants
- Percutaneous tibial nerve stimulation
- Magnetic chair
- TVT (sling) procedures
- Paraurethral & transurethral injections
- Botox injections
- Bladder augmentation
Unless we have a problem with our bladder function we remain largely unaware of the multiple, complex, interacting systems that work to maintain subconscious control and allow effortless voluntary oversight. We are not born with these systems working effectively but during early childhood the appropriate neural networks become established and increasing cortical control allows the transition from functioning as a baby to developing control over when and where to void.
It should come as no surprise that many women who seek help for their incontinence do so because of a fear of returning to this childhood state as they get older. This fear may be exacerbated by an experience of seeing their mother or another female relative devolve into a situation of incontinence with its’ myriad social and hygienic sequelae.