It's well known for its cosmetic uses, but doctors say Botox may also be the key to helping millions of Americans who suffer from overactive bladders. It's ranked among the 10 most common chronic medical conditions and impacts nearly 34 million people. More than half don't find relief through traditional treatments, so one woman turned to an experimental injection for help.
"If you're going to the restroom a couple times a day you don't really notice it, but when the numbers start adding up to where it's 40, 50, 60 times a day… the pain you get from it, the physical pain is not fun at all," said 29-year-old Claudia Angel, who has an overactive bladder.
It's a painful and annoying problem that's plagued Angel for the past six years. She tried medications, pelvic exercises, even an implant, but nothing relieved her overactive bladder.
"I didn't know what to do anymore. I thought 'oh my god, this is going to be the rest of my life?'" said Angel.
Angel became a test patient for an experimental treatment. Under a local anesthetic, University of Miami Urologist Dr. Angelo Gousse threads a needle through a scope with a camera mounted on it. As it passes through the urethra, Gousse injects Botox, the same treatment for wrinkles, directly into the bladder.
"What it does is it tends to kind of numb, if you would, not only the muscle but also the nerves that are located within the wall of the urinary bladder, and so for this reason it also helps significantly with the sense of urgency," said Gousse.
Doctors familiar with the procedure say 75 percent of patients report significant improvement in symptoms and in their quality of life.
Claudia felt the difference after her first treatment.
"Awesome. I was very excited the first day that I noticed it. I called my husband and I said, 'do you know I haven't gone to the bathroom in like eight hours?'" said Angel.
For the first time in years, Angel feels like she's in control.
The Botox procedure is done on an outpatient basis and patients can return to work the same day. Each treatment lasts four to six months. Angel says her Botox injections were not covered by insurance, and the cost is about $1,000 per treatment. Though the Botox is given in non-toxic amounts, some patients may suffer retention problems from the injections.
Background: An overactive bladder is the result of a sudden and involuntary contraction of the bladder muscle, causing an unstoppable need to urinate. An overactive bladder is most common in adults, affecting one in 11 adults in the United States. According to the National Association for Continence, an overactive bladder is a widespread problem that affects people of all ages.
An overactive bladder often causes an uncomfortable quality of life for those who suffer from it. Sufferers may have the need to urinate more than eight times a day. In these severe cases, a normal lifestyle is prevented. Research has indicated that people often believe an overactive bladder is a normal part of aging, so symptoms can be overlooked. Less than half of sufferers actually consult a doctor about their symptoms.
Overactive bladder treatment: According to the National Association for Continence, anticholinergic and bladder muscle relaxant drugs are often prescribed for treating an overactive bladder. Several side effects are associated with these drugs, such as dry-mouth, constipation, blurred vision, gastroesophageal reflux and urinary retention. Because of these negative side effects, other treatments are being investigated to improve the lifestyle of those with OAB.
Botox as OAB treatment: Gousse is experimenting with using Botox as a treatment for overactive bladder. Botox would be used to relax the muscles of the urinary bladder and deplete the sensation of the bladder. Urologists from UK Guy’s Hospital and King’s College London have carried out a double-blind, placebo-controlled trial involving 34 patients using Botox as a treatment for OAB. The study involved 20 injections (of 1 ml each) of Botox totaling 20 ml (200 Units) into several areas of the bladder. Results of the study were measured using a zero to 100 scale. On average, severity of the participant’s symptoms decreased by 33 points and the overall impact on their incontinence decreased by 35 points. Gousse says according to his research, Botox injections are the simplest solution for an overactive bladder. Botox as a treatment for overactive bladder is expected to be approved by the FDA within the next two years.
What is Overactive Bladder?
Overactive bladder (OAB), also known as overactive bladder syndrome, is a condition where there is a frequent feeling of needing to void to a degree that it negatively affects a person's quality of life. The frequent need to urinate may occur during the day, at night, or both. Frequent urination at night is called nocturia. When there is loss of bladder control associated with a strong and compelling urge to urinate it is known as urge incontinence OAB wet. Other patients only have urinary urgency and frequency but do not experience leakage (OAB dry). More than 40% of patients with overactive bladder have incontinence. The condition is chronic. Therefore, most patients have this problem for the remaining of their life.
Mild Electrical Pulses Can Help Bladder Control
If you suffer from any of the symptoms of overactive bladder, you’re not alone. It is estimated that more than 33 million Americans suffer from OAB. If you are not responding to the oral medications (antimuscarinics) or having side effects from them sacral neurostimulation (Interstim) may be an option to help you regain bladder control.
How is Interstim Unique?
The uniqueness of Interstim is that it offers a trial period before the device is implanted. The trial assessment takes 3 to 7 days and lets you try neurostimulation to see if it is right for you without making a long-term commitment. Dr Gousse will help you determine whether neurostimulation is right for you. The treatment is designed to minimize the symptoms of overactive bladder.
How does it Work?
The exact mechanism by which Interstim works is not known. The first stage of the procedure (called peripheral sacral nerve evaluation (PNE) may be performed in the office or the operating room, depending on the case. Dr Gousse will numb a small skin area and insert a thin, flexible wire in your sacral nerves (near your tailbone).
During the PNE, you will be awake in order the guide proper placement. You will be asked where you feel the nerve stimulation in your body. Dr Gousse will also note some muscle contractions in your body to guide proper placement. Typically, you will be in the prone position (lying on your stomach). This position allows access to the tail bone and anal area.
Once proper placement is confirmed, the electrical wire is taped to your skin and connected to a small external stimulator (resembling a large beeper) which you’ll wear on your waistband.
The external stimulator sends mild electrical pulses through the wire to a sacral nerve. Electrical shock or severe nerve damage associated with the therapy has virtually never been reported. The stimulation may help improve your bladder function or get it working the way it’s supposed to.
During the trial assessment, you can continue many of your daily activities with caution. You can usually continue to work throughout your trial assessment if your job doesn’t require strenuous movement. You’ll be asked to document your urinary symptoms which led to the implant. If your symptoms are significantly reduced or eliminated during the trial, you and Dr Gousse can discuss long-term neurostimulation therapy. Dr Gousse or nurse will give you information about operating the test stimulator. He or she will also tell you about any precautions or activity restrictions related to the trial assessment.
Long-term sacral nerve stimulation therapy involves placement of an implantable pulse generator-battery (the size of stop watch) under the fatty tissues of the upper buttock area. Typically this step (step 2, battery implant), done only after the trial test (step 1) is shown to be successful, is performed in the operating room under local or general anesthesia. The half life of the battery varies according to usage and type and may last 3 to 8 years. Once the entire system is in place, there are no visible wires or batteries outside of the body. One can regain a normal life without limitations. A few patients may experience discomfort at the battery implant site.
Do not Suffer in Silence after Prostate Surgery: Consider the “Gold Standard Treatment for Urinary Incontinence.
It is estimated that approximately 56% of patients will suffer from urinary incontinence in the peri-operative period following catheter removal after a radical prostatectomy is performed for prostate cancer. This decreases to 21% at three months, and up to 14% at one year. While the initial management of post-prostatectomy incontinence consists of emotional support and reassurance, it is expected that, in most cases, steady improvement will be noted. Pelvic floor exercises (Kegel), the use of incontinence pads, as well as a trial of oral antimuscarinic medications can be initiated in the early postoperative stages. In severe cases, ongoing skin irritation due to urine bathing the skin and difficulty with pads may necessitate the use of condom catheters, penile clamps and even indwelling Foley urinary catheters to improve control.
Surgical therapy should be considered in men with post-prostatectomy stress urinary incontinence that persists beyond the first postoperative year, or even earlier in men with severe symptoms. Surgical devices aim to prevent involuntary urinary leakage during storage by increasing bladder outlet resistance while allowing unimpeded flow during voluntary urination. The “Gold Standard” surgical treatment, to date, is the artificial urinary sphincter.
The artificial urinary sphincter (AUS) is a surgically implantable device used to restore urinary control in men. Most commonly, the device is implanted in men who have sphincter or valve muscle damage following prostate surgery. The entire device is implanted inside the body in a brief surgical procedure lasting approximately one hour. With appropriate evaluation for the proper selection of candidates for the AUS, the long-term results in experienced hands are excellent.
Components and Function
The AUS consists of three components: the cuff, which goes around the urethra, the pump, which goes inside the scrotum, and the balloon, which holds the fluid for the device (see figure). The balloon is available in different pressure ranges and is filled with a fluid that is very safe even if it leaks. The device works hydraulically, with the cuff around the urethra staying closed at all times. When the person wants to urinate, the pump is squeezed and the cuff opens. Automatically, in 3-5 minutes, the cuff closes again. The refilling of the cuff is controlled by a resistor mechanism inside the pump.
Indications for Use
The most common indication for implanting the AUS is sphincter damage following prostate surgery (especially radical prostatectomy for prostate cancer). It is essential that the exact cause of urine leakage be defined by special bladder and sphincter function tests, called urodynamics, before any surgery is performed. In order for the AUS to be successful, the bladder must be able to store a normal amount of urine at low pressure and to empty normally.
This ability of the bladder to function normally is examined during the urodynamic tests.
Technique of Implantation In the Male
Insertion of the AUS is performed in a hospital operating room under either a general or a spinal anesthetic. Two small incisions are made: one in the groin area and the other between the scrotum and the rectum. The proper size cuff is placed around the urethra and the tubing from the cuff is passed up to the groin area. The small pressure-regulating balloon, which is about the size of a golf ball, is placed beneath the abdominal muscles and the pump that controls the device is tunneled down into the scrotum, just beneath the skin. All connections between the three components are made in the groin area and the incisions are closed. At the conclusion of the operation, the cuff is locked open for 4-6 weeks until healing is complete.
Usually only an overnight hospital stay is required and there is minimal postoperative pain. Some patients can be discharged on the day of the procedure. Most men return to work 2-3 weeks after surgery. About 4-6 weeks after surgery, the AUS is activated in the office (no surgery is required) to allow urinary control to be restored.
An Excellent Track Record
More than 100,000 men worldwide have received the AMS 800 Urinary Control System. For almost 35 years, physicians worldwide have been implanting the AMS 800 as an effective treatment for stress urinary incontinence in men. The AMS 800 has been proven to be effective in the treatment of male incontinence following prostate surgery, and is considered the gold standard by most urologists. When using this device, most men are dry, with only minor leaks or dribbles of urine, usually with strenuous exercise or exertion. Most men use one pad or less per day to manage these minor leaks. As with any medical procedure, the AMS 800 is not 100% effective in all patients. Some men may require additional protection.
Recently, the male synthetic sling called Advance has become available. Although long-term outcome data is currently being accumulated, the procedure appears to be most effective for mild to moderate male urinary incontinence. Urethral Bulking agents (Collagen and Durasphere, Teflon) for male incontinence have basically fallen by the way-side for lack of efficacy.
Benign diseases of the urethra which affect urine flow and/or blaldder emptying very often require surgical intervention. Urethral strictures and urethral narrowing (stenoses) are treated by various techniques. The treatment for urethral strictures include numerous options, such as dilation with sounds or plastic dilators, urethrotomy (cutting scar tissue with a knife by going through the penis), stent and open reconstructive surgical techniques. The treatment choice will be dictated by the specific urethral condition or the surgeon’s preference. Although less effective long-term, urethral dilation and direct visual urethrotomy (DVIU) continue to be the most commonly used techniques. They have a high failure rate with recurrence in at least 50% of patients. Most patients who undergo these procedures require repeated interventions for recurrences. Often the patients progress to surgical repair. Persistent use of dilation or urethrotomy for the treatment of urethral strictures may be the result of the urologist unfamiliarity with the published literature and inexperience with urethroplasty surgical techniques. Open urethral reconstruction(Urethroplasty) is the international gold standard treatment for urethral strictures.  Urethroplasty is not a routine operation and a lack of the necessary skills should prompt a referral to a specialist skilled in urethroplasty.
There are two types of Urethroplasty. Many surgical techniques with or without grafts have been developed to allow the aesthetic reconstruction of the glans and the penis while repairing the strictured areas. Basically, the surgical technique for urethral reconstruction is selected according to the cause and location of the urethral stricture disease. The choice between an anastomotic versus a tissue transfer technique is aided by a radiograph (retrograde urethrogram), surgeon experience and preference.
The choice must, in addition be based on the proper anatomic characteristics of the penile tissues to ensure flap or graft take and survival. Urethroplasty is a open surgical procedure for urethral reconstruction to treat urethral stricture. Urethroplasty can be performed by 2 basic methods; Excision and anasmotomis (primary repair) which involves complete excision of the narrowed part of the urethra and the subsequent rejoining of the proximal and distal patent luminal segments. The second method of Urethroplasty utilizes tissue transfer (flaps) or graft technique. In this method, tissue is grafted from penile foreskin, or buccal (inner lining of the mouth) mucosa and is used to enlarge the caliber of the strictured (narrowed) segment of the urethra. Dr Gousse prefers buccal mucosa graft as his tissue transfer(graft technique) because the graft material is abundant, well tolerated, cosmetic, and successful in most cases. Urethroplasty is typically performed under general or spinal anesthesia.
Selected patients may be discharged home on the day of the surgery. Many others will be in the hospital for a day or two. The patients typically wears an indwelling urethral Foley catheter for 2- 3 weeks to allow the repair to heal. After catheter removal, the patients are followed with clinical symptoms, urine flow rate, and post void residual volumes to ensure bladder emptying. Many patients will be able to enjoy baseline sexual function and father children after surgery.
Like all surgical procedures, the results of urethroplasty are not 100%. A recurrence urethral stricture rate of 10 % can be expected long-term. Patients with pelvic fracture associated urethral stricture and prostate involvement associated strictures have the highest recurrence rate. Erectile dysfunction is also most commonly seen in this sub-category of patients.
Stress urinary incontinence (SUI) is leakage with physical activity. Here the word “stress” refers to physical stress or exertion, not “emotional stress”. In many instances of SUI, the pelvic floor, which supports the bladder, bladder neck and urethra, becomes weak due to pregnancy, childbirth, hormonal changes, aging, and/or prior pelvic surgery. This may lead to excessive movement of the urethra, i.e. hyper mobility, with physical stress maneuvers. Another cause of SUI is a weakened urethral sphincter, known as intrinsic sphincteric deficiency (ISD), in which the urethral sphincter becomes incapable of sealing the flow of urine during physical exercise.
Many experts believe that women with SUI and concomitant ISD should undergo either a sling-type procedure or an injection of bulking agents (collagen, carbon particles (Durasphere), Teflon, fat, silicon, copatite) around the bladder neck and proximal urethra. Patients with concomitant ISD and significant urethral hyper mobility may respond less favorably to bulking agents and are best treated with sling procedures.
Three categories of surgical techniques used to treat SUI are: retro pubic suspensions (more invasive); transvaginal bladder neck suspensions (less efficacious) ; and sling procedures to create hammock-like support of the urethra using synthetic material or abdominal fascia, thigh fascia or similar tissue derived from carefully processed cadaveric tissue. One of the most novel and exciting procedures is the use of a synthetic mesh made out of prolene to treat SUI. The technique is similar to other sub urethral “sling” devices. A supportive hammock of Prolene (a synthetic mesh) is placed under the mid portion of the urethra in a “tension-free” manner. The mesh is placed vaginally using minimal tissue dissection. A small puncture incision is placed below the pubic hair line on either side.
Frequently Asked Questions after Stress Incontinence Surgery
How long will the surgery last?
Typically the procedure will last 30 minutes to one hour. You might be in the operating longer to account for preparations
What can I expect during recovery?
You will likely have some vaginal spotting and drainage for 3-4 weeks. Heavy bleeding with large blood clots is not normal.
You may experience some (usually minimal) vaginal and suprpubic discomfort for 7 days. You may experience some burning on urination. If your catheter has been removed and you can't empty your bladder, you should call the office. Approximately 5% of patients may experience this problem. You should not experience much change in your bowel function.
When will I be discharged?
The same day of the surgery or the following morning.
Will my diet change?
When can I go back to work?
When you feel you are ready. (Usually 3 days after surgery)
When can I resume physical activity?
You should avoid lifting anything heavier than 10 lbs for 6 weeks. You may resume driving in 24-48 hours if you feel up to it and if you are not taking narcotic pain pills.
When can I resume sexual activity?
6 weeks after surgery
When Do I follow-up with you?
2-3 weeks after surgery
What are the 5 most common complications?
Urinary retention (5%), bleeding (<1%), bowel injury (<1%), injury to adjacent structures (1%), development of new urge related incontinence (7%), extrusion of the mesh in the vaginal canal (1-5 %).
What is the Cure Rate for SUI?
80-90%. Note that if you have mixed incontinence (ie both stress and urge incontinence), you may have persistent urge incontinence in at least 50% of the cases.
Pelvic organ prolapse (POP) is a common condition affecting many adult women today. The exact prevalence of pelvic organ prolapse is difficult to determine. However, the lifetime risk of requiring at least 1 operation to correct incontinence or prolapse is estimated at approximately 11%. About 200,000 inpatient procedures are performed annually in the United States.
In Pelvic organ prolapse, the vagina and the organs surrounding and supporting it descend from their normal position. When the descent involves the bladder it is termed cystocele. Likewise, when the descent involves the rectum and the intestines it is termed rectocele and enterocele respectively. The descent of the uterus (uterine prolapse) through the vagina is not uncommon. The severity of the condition is based on the degree of the descent. Patients can present with isolated or a combination of the aforementioned conditions.
An intense network of muscles, ligaments and connective tissue collectively support and hold the pelvic organs in their normal position. Weakening or collapse the support leads to prolapse of the pelvic organs namely: vagina, bladder, rectum and the uterus. Childbirth may lead to weakening of the pelvic support. Pregnancy itself, without vaginal birth has also been cited for weakening the support structures. Menopause and lack of estrogen are predisposing factors for POP.
The common symptoms relating to POP are pressure in the vagina, lump or bulge at the vaginal opening, urinary and bowel incontinence and sexual dysfunction. Urinary retention or hydronephrosis (kidney dilation) can also be noted in severe cases. Diagnostic evaluationcan include physical and pelvic examination, ultrasonogram, video-urodynamics, MRI and/or cytoscopy. Surgery is often essential to treat symptomatic POP. Prolapse surgery may be performed with or without synthetic mesh implant. Dr. Gousse prefers to repair prolapses without synthetic mesh. He prefers to use porcine or cadaveric tissue to repair the weakness of the pelvic floor. There have been some reports of synthetic mesh extrusion in thevaginal canal or erosion into the urinary tract. Therefore, patients must be very carefully selected. In some cases, pelvic floor strengthening exercises and vaginal pessaries are good alternative options. Pelvic muscle exercises can improve pelvic floor muscle tone and urinary incontinence. Pessaries are manufactured from medical-grade silicone and are safe, cost-effective, and minimally invasive options for treating patients with pelvic organ prolapse. The pessaries can be inserted in the vagina to reduce the prolapse and changed once a month to every 3 months. Surgery may not beindicated for women with minimal or no symptoms or who are unable to undergo surgery because of medical reasons. For those patients requiring surgery, it is usually performed under general or regional anesthesia. Patients may be hospitalized for 2-4 days and are instructed to avoid sexual activity and heavy lifting for approximately 6 weeks. Another option is endoscopic surgery such as laparoscopy or robotic. Dr. Gousse believes that a vaginal approach is the least invasive one in most cases.
Reconstructive Urology: Dr Angelo Gousse is fellowship trained training in upper and lower urinary tract reconstruction:
Procedures can include:
1- Ureteral reconstruction and Reimplantation. The procedure is typically indicated after ureteral trauma or injury of the ureter by cancer or other disease processes. The ureter can be refashioned, reconstructed, and then re-implanted into the urinary bladder On occasion, the urinary bladder has to be reconstructed or moved prior to the reimplantation / reconstruction (Psoas Hitch Procedure or Boari Flap). A typical hospital stay is 3-4 days with a Foley catheter in the bladder for 1 or 2 weeks.
2- Bladder augmentation using intestinal segments such as colon or small intestines to enlarge the urinary bladder. This procedure is usually performed in patients with neurogenic bladder after spinal cord injury, spina bifida or multiple sclerosis. Urodynamic (bladder testing) may indicate a very high bladder pressure that is dangerous to the kidneys or leakage per urethra (incontinence). The findings are caused by high bladder pressures or involuntary (spastic) contractions. Making the bladder larger by patching a segment (10-20 cm) of intestine into the bladder will decrease the bladder pressure and help protect the kidneys and achieve urinary continence.
On occasion, it is not possible to catheterize per urethra and a catheterizable tube (channel) has to be constructed using intestinal segments or the appendix (Mitrofanoff). An anti-incontinence valve is created using intestines and special surgical techniques to allow the catheter to go in the augmented bladder very readily without allowing urine to leak out. Dr Gousse has performed more than 250 bladder augmentation procedures. The average hospital stay is 7 days after this procedure.
3- Urethral reconstruction.
Benign diseases of the urethra which affect urine flow and/or blaldder emptying very often require surgical intervention. Urethral strictures and urethral narrowing (stenoses) are treated by various techniques. The treatment for urethral strictures include numerous options, such as dilation with sounds or plastic dilators, urethrotomy (cutting scar tissue with a knife by going through the penis), stent and open reconstructive surgical techniques. The treatment choice will be dictated by the specific urethral condition or the surgeon’s preference. Although less effective long-term, urethral dilation and direct visual urethrotomy (DVIU) continue to be the most commonly used techniques.
They have a high failure rate with recurrence in at least 50% of patients. Most patients who undergo these procedures require repeated interventions for recurrences. Often the patients progress to surgical repair. Persistent use of dilation or urethrotomy for the treatment of urethral strictures may be the result of the urologist unfamiliarity with the published literature and inexperience with urethroplasty surgical techniques. Open urethral reconstruction (Urethroplasty) is the international gold standard treatment for urethral strictures. Urethroplasty is not a routine operation and a lack of the necessary skills should prompt a referral to a specialist skilled in urethroplasty.
There are two types of Urethroplasty. Many surgical techniques with or without grafts have been developed to allow the aesthetic reconstruction of the glans and the penis while repairing the strictured areas.
Basically, the surgical technique for urethral reconstruction is selected according to the cause and location of the urethral stricture disease. The choice between an anastomotic versus a tissue transfer technique is aided by a radiograph (retrograde urethrogram), surgeon experience and preference. The choice must, in addition be based on the proper anatomic characteristics of the penile tissues to ensure flap or graft take and survival. Urethroplasty is a open surgical procedure for urethral reconstruction to treat urethral stricture. Urethroplasty can be performed by 2 basic methods; Excision and anasmotomis (primary repair) which involves complete excision of the narrowed part of the urethra and the subsequent rejoining of the proximal and distal patent luminal segments. The second method of Urethroplasty utilizes tissue transfer (flaps) or graft technique. In this method, tissue is grafted from penile foreskin, or buccal (inner lining of the mouth) mucosa and is used to enlarge the caliber of the strictured (narrowed) segment of the urethra. Dr Gousse prefers buccal mucosa graft as his tissue transfer(graft technique) because the graft material is abundant, well tolerated, cosmetic, and successful in most cases. Urethroplasty is typically performed under general or spinal anesthesia. Selected patients may be discharged home on the day of the surgery. Many others will be in the hospital for a day or two. The patients typically wears an indwelling urethral Foley catheter for 2- 3 weeks to allow the repair to heal. After catheter removal, the patients are followed with clinical symptoms, urine flow rate, and post void residual volumes to ensure bladder emptying. Many patients will be able to enjoy baseline sexual function and father children after surgery.
Like all surgical procedures, the results of urethroplasty are not 100%. A recurrence urethral stricture rate of 10 % can be expected long-term. Patients with pelvic fracture associated urethral stricture and prostate involvement associated strictures have the highest recurrence rate. Erectile dysfunction is also most commonly seen in this sub-category of patients.
Your Urologist may require Urodynamics to evaluate your urinary symptoms (urinary incontinence, urinary frequency, urgency, difficulty initiating a urinary stream, recurrent UTIs,painful urination etc). Any procedure designed to provide volume and pressure information about a bladder problem can be called urodynamic testing.
Understanding the Bladder and the Voiding Process
The bladder, a hollow muscular organ shaped like a sac located in the human pelvis near the uterus (female) or the prostate (male). The bladder stores urine until you are ready to empty it. It swells into a round shape when it is full and gets smaller as it empties. A healthy bladder can hold up to 16 ounces (2 cups) of urine comfortably. How frequently it fills depends on how much excess water your body is trying to get rid of.
The bladder opens into the urethra, the tube that allows urine to pass outside the body. Circular muscles called sphincters close tightly to keep urine from leaking. The involuntary leakage of urine is called incontinence.
Nerves in the bladder tell you when it is time to empty your bladder. When the bladder begins to fill with urine, you may notice a feeling that you need to urinate. The sensation becomes stronger as the bladder continues to fill and reaches its limit. At that point, nerves in the bladder send a message to the brain, and your urge to urinate intensifies.
When you are ready to urinate, the brain signals the sphincter muscles to relax. At the same time, the brain signals the bladder muscles to squeeze, thus allowing urine to flow through the urethra. When these signals occur in the correct order, normal urination occurs.
Problems in the urinary system can be caused by aging, illness, or injury. The muscles in and around your bladder and urethra tend to become weaker with age. Weak bladder muscles may result in your not being able to empty your bladder completely, leaving you at a higher risk for urinary tract infections. Weak muscles of the sphincters and pelvis can lead to urinary incontinence because the sphincter muscles cannot remain tight enough to hold urine in the bladder, or the bladder does not have enough support from the pelvic muscles to stay in its proper position.
Urodynamics is a study that assesses how the bladder and urethra are performing their job of storing and releasing urine. Urodynamic tests help your doctor or nurse see how well your bladder and sphincter muscles work and can help explain symptoms such as
These tests may be as simple as urinating behind a curtain while a doctor or nurse listens or more complicated, involving imaging equipment that films urination and pressure monitors that record the pressures of the bladder and urethra.
Evaluation prior to testing
The first step inevaluating a urination problem is to tell your doctor exactly what your symptoms are. The doctor will find out important information such as when your symptoms started, if they are constant, what causes them, when they occur, if you have leakage etc.
If leakage is the problem, the doctor or nurse may ask you to do a pad test. This test is a simple way to measure how much urine leaks out. You will be given a number of absorbent pads and plastic bags of a standard weight. You will be told to wear the pad for 1 or 2 hours while in the clinic or to wear a series of pads at home during a specific period of time. The pads are collected and sealed in a plastic bag. Your health care team will then weigh the bags to see how much urine has been caught in the pad. A simpler but less precise method is to change pads as often as you need to and keep track of how many pads you use in a day.
A physical exam will also be performed to rule out other causes of urinary problems. This exam usually includes an assessment of the nerves in the lower part of your body. It will also include a pelvic exam in women to assess the pelvic muscles and the other pelvic organs. In men, a rectal exam is given to assess the prostate. Your doctor will also want to check your urine for evidence of infection or blood.
Preparing for the Test
If the doctor or nurse recommends bladder testing, usually no special preparations are needed, but make sure you understand the instructions you are given. It is not necessary to fast prior to the test.You will be asked to come with a full bladder in order perform a flow rate (uroflownetry). You may continue to take all your medications, unless asked otherwise.
Taking the Test
Be as calm and cooperative as you can. The specific technique used may depend on your problem. Most urodynamic testing focuses on the bladder’s ability to store fluid at steady and low pressureand empty completely whithout excessive bladder pressure. It can also show whether the bladder is having abnormal contractions that cause leakage. Your doctor will want to know whether you have difficulty starting a urine stream, how hard you have to strain to maintain it, whether the stream is interrupted, and whether any urine is left in your bladder when you are done. The remaining urine is called the postvoid residual. Urodynamic tests can range from simple observation to precise measurement using sophisticated instruments.
Uroflowmetry (Measurement of Urine Speed and Volume)
A uroflowmeter automatically measures the amount of urine and the flow rate—that is, how fast the urine comes out of the baldder. You may be asked to urinate privately into a toilet that contains a collection device and scale. This equipment creates a graph that shows changes in flow rate from second to second so the doctor or nurse can see the peak flow rate and how many seconds it took to get there. Results of this test will be abnormal if the bladder muscle is weak or urine flow is blocked..
Measurement of Postvoid Residual
After you have finished, you may still have some urine, usually only an ounce or two, remaining in your bladder. To measure this postvoid residual, the doctor or nurse may use a catheter, a thin tube that can be gently glided into the urethra. He or she can also measure the postvoid residual with ultrasound equipment that uses harmless sound waves to create a picture of the bladder. A postvoid residual of more than 200 mL, about half a pint, may indicate a problem. Even 3 ounces, about half a cup, requires further evaluation. However, the amount of postvoid residual can be different each time you urinate.
Cystometry (Measurement of Bladder Pressure)
A cystometrogram (CMG) measures how much fluidyour bladder can hold, how much pressure builds up inside your bladder as thefluid idis being infused. We will use a tiny catheter to empty your bladder completely prior to the beginning of the study. Then a special small (spaghetti size) catheter with multiple lumenwill be placed in the bladder. This catheter has a pressure-measuring device called a manometer. Another catheter willbe placed in the rectum to record rectal pressure.. Your bladder will be filled slowly with warm saline. During this time you will be asked how your bladder feels and when you feel the need to urinate. The volume offluid and the bladder pressure will be recorded by a computerized system. You may be asked to cough or strain during this procedure. Involuntary bladder contractions may be noted by the computerized tracings. If you are unable to urinate with the catheter in the urethra, youmay be asked to void without the catheter or in the restroom. This does not mean thatyou "failed" the test.
After the test
After the test you may resume your normal activity. It is normal to feel some burning during voiding after the test or experience some mild urethral bleeding or bloody urine. Call your doctor if you experience fever, inability to urinate, or very grossly bloody urine. Your doctor will give you an appointment to discuss the resultsafter the examination with you. The results of the test are often very useful in the long-term management of your urination problem.
The simplest type of prosthesis consists of a pair of malleable (bendable) plastic rods surgically implanted within both erection chambers of the penis. With this type of implant the penis also feels semi-rigid and merely needs to be lifted or adjusted into the erect position to initiate sexual activity. Many men do find the malleable penile prosthesis natural enough.
Currently, most men with ED choose a hydraulic, inflatable penile prosthesis, which allows a man to have an erection whenever he chooses and is much easier to conceal when deflated. Many men feel that the inflatable prosthesis is more natural.
Urologists should advise a penile prosthesis only when there is a clear medical cause for ED and when the problem is unlikely to resolve or improve naturally or with other medical treatments. Rarely a penile prosthesis is implanted during surgery to reconstruct the penis when scarring has caused erections to curve (Peyronie's disease).
The inflatable penile prosthesis consists of two cylinders -- a reservoir and a pump -- which are placed surgically in the body. The two cylinders are inserted in the penis and connected by tubing to a separate reservoir of fluid. The reservoir is implanted under the groin muscles. A pump is also connected to the system and sits under the loose skin of the scrotal sac, between the testicles.
To inflate the prosthesis, the man presses on the pump. The pump transfers fluid from the reservoir to the cylinders in the penis, inflating them and causing an erection. Pressing on a deflation valve at the base of the pump returns the fluid to the reservoir, deflating the penis and returning it to the normal flaccid state.
While men who have had the prosthesis surgery can see the small surgical scar where the bottom of the penis meets the scrotal sac, other people probably will be unable to tell that a man has an inflatable penile prosthesis.
When the penis is inflated, the prosthesis makes the penis stiff and thick, similar to a natural erection. Most men rate the erection as shorter than their normal erection; however, newer models have cylinders that may increase the length, thickness, and stiffness of the penis.
When the penis is inflated by pressing on the scrotal pump, the prosthesis makes the penis stiff and thick, similar to a natural erection. Most men rate the erection as shorter than their normal erection; however, newer models have cylinders that may increase the length, thickness, and even stiffness of the penis.
A penile prosthesis does not change sensation on the skin of the penis or a man's ability to reach orgasm. The sensations associated with ejaculation are not affected either. Once a penile prosthesis is put in, however, it may destroy the natural erection reflex. Men usually cannot get an erection without inflating the implant by pressing on the pump. If the implant is removed, the man may never again have natural erections. That is the reason why the penile prosthesis is used only in cases of irreversible ED. Occasional complications related to infection or malfunction of the prosthesis can occur.
Fortunately, approximately 90%-95% of inflatable prosthesis implants produce erections suitable for intercourse. Satisfaction rates with the prosthesis are extremely high, and typically 80%-90% of men are satisfied with the results and say they would choose the surgery again.
Insurance plans are likely to pay for the penile prosthesis, as long as a medical cause of ED is established. Medicare covers the surgery, but Medicaid does not.
Benign Prostatic Hyperplasia is Different from Prostate Cancer
Not to be confused with prostate cancer, benign prostatic hyperplasia (BPH) is essentially a normal part of male aging. Most men with benign prostatic hyperplasia BPH will never develop clinical prostate cancer. While prostate cancer typically grows in the peripheral zone of the prostate, BPH is found in the transition zone which is more toward the center (the core) of the prostate gland.
After the age of 40 the prostate progressively enlarges (from size 15 grams to approximately 50 grams - rarely up to 250 grams or more) to the point where urination starts becoming more difficult. Typical symptoms include needing to urinate very often (frequency) during the day or during the night (nocturia). Some patients start taking a while to get started (urinary hesitancy). Other patients start to strain or push to urinate (straining). If the prostate grows too large or the tension of the prostate muscles increases, it may constrict the urethra, block the bladder neck (outlet) and impede the flow of urine, making urination difficult and painful. In severe cases, the patient may not be able to urinate at all. The bladder remains full, the patient has the desire to void, yet no urine comes out of the urinary bladder. This condition called acute urination retention is very painful and considered a medical emergency. In cases of urinary retention, a urethral Foley catheter (a straw) is typically inserted to drain the urine out of the urinary bladder. If urinary retention remains untreated, it will cause kidney damage (hydronephrosis) and / or infection or even renal failure.
The cause of urinary retention needs to be determined since other medical and neurologic conditions can cause inability to urinate or adequately empty the urinary bladder. A bladder test (Urodynamics) can determine that the bladder pressure is high while the urine flow is low. Cystoscopy and ultrasound of the prostate may be indicated in select cases.
Once prostate cancer has been ruled out by PSA blood test and digital rectal examination, a treatment plan can be determined.
When is Medication Indicated?
Medication is the most common treatment for mild to moderate symptoms of prostate enlargement. The options include:
When Is Minimally invasive or surgical therapy Indicated?
Minimally invasive or surgical therapy might be recommended if your symptoms are moderate to severe or medication hasn't relieved your symptoms. Other strong indications include
severe urinary tract obstruction, bladder stones, gross blood in your urine or kidney problems. Other patients prefer surgical treatment instead of medications.
Any type of prostate procedure can cause side effects. Depending on the procedure you choose, complications might include:
A lighted rigid scope is inserted into your urethra, and the surgeon removes the central part (transition zone) of the prostate. It is still possible to develop prostate cancer after a TURP. Therefore, the patients need continued monitoring using PSA and rectal examination. TURP generally relieves symptoms quickly, and most men have a stronger urine flow soon after the procedure. After TURP you might temporarily need a catheter to drain your bladder, and you'll be able to do only light activity until you've healed. Usually erectile dysfunction is not noted after a TURP. Transurethral microwave thermotherapy (TUMT)
Your doctor inserts a special electrode through your urethra into your prostate area. Microwave energy from the electrode destroys the inner portion of the enlarged prostate gland, shrinking it and easing urine flow. This surgery is generally used only on small prostates in special circumstances because re-treatment might be necessary.
Transurethral needle ablation (TUNA)
In this outpatient procedure, a scope is passed into your urethra, allowing your doctor to place needles into your prostate gland. Radio waves pass through the needles, heating and destroying excess prostate tissue that's blocking urine flow.
This procedure might be a good choice if you bleed easily or have certain other health problems. However, like TUMT, TUNA might only partially relieve your symptoms and it might take some time before you notice results.
A high-energy laser destroys or removes overgrown prostate tissue. Laser therapy generally relieves symptoms right away and has a lower risk of side effects than does nonlaser surgery. Laser therapy might be used in men who shouldn't have other prostate procedures because they take blood-thinning medications. There is no evidence that Laser prostate surgery is superior to TURP.
In this newly FDA approved transurethral procedure, special tags (like staples) are deployed through the urethra to compress the sides of the prostate to increase the flow of urine by retracting the lateral obstructing lobes of the prostate. Long-term data on the effectiveness of this procedure aren't yet available.
When the prostate is very large, usually much greater than 100 grams as measured by a prostate ultrasound and the patient needs surgery, many urologists prefer an open or robotically assisted prostatectomy because it is safer and more effective. In this surgery the core(Transition Zone) of the prostate is removed after opening the bladder and/ or prostate. The peripheral zone is left behind. The recovery and bladder catheterization is typically much longer than TURP. It is important not to confuse this surgery with complete removal of the prostate performed for prostate cancer. In other words -Open prostatectomy is performed for benign prostatic hyperplasia (BPH) while Radical Prostatectomy is only recommended for prostate Cancer.