by Dr. Shreya Patel
Bladder and urinary symptoms are extremely common, and as physicians we see women with a variety of problems related to these sorts of symptoms on a daily basis. The statistics illustrate just how common these symptoms are: in a study of women aged 40 years and above, 76.3% reported having at least one urinary tract symptom sometimes, 52.5% reported having at least one urinary tract symptom often, and 75.8% reported waking at least once during the night to pass urine.1
Bladder and urinary symptoms can be divided into four groups: storage symptoms, voiding symptoms, post micturition symptoms, and infective symptoms.
Storage symptoms include urinary frequency, waking up at night to urinate, urinary urgency (the urge of having to pass urine very often), and urinary incontinence (not being able to hold urine, or leakage of urine on coughing/sneezing). Voiding symptoms include slow stream, hesitancy, and straining, post micturition symptoms include the feeling of incomplete emptying and dribbling after urinating, and infective symptoms include pain on urination, strong smelling urine, and blood in the urine. The most common troubling symptom that women experience is urinary urgency.2
The questions doctors ask when taking a history can be personal, and some women feel embarrassed or uncomfortable disclosing certain information. Some patients have the idea that their symptoms are unique to them and that we may have not heard of it before, but this is simply not true. Whatever symptoms you report have definitely been brought up by other women, and you are not alone.
When you attend your appointment you will need to go armed with certain bits of information about your medical history, and information about your symptoms, and when they occur. Your doctor will also ask you certain questions to help them gauge a bit more about what might be going on, so it is worth having an idea of these in your head to prepare you if you are feeling nervous or embarrassed.
Questions your doctor may ask you
How long have your symptoms been present, are they painful, and are they getting worse?
Your doctor is likely to ask you how long your symptoms have been present, whether or not you are experiencing any pain, and whether your symptoms are worsening, improving or fluctuating. The duration of symptoms is important to know as short-term symptoms can signal an infection or a sudden variation due to a change in medications or fluid intake.
Pain on urination can indicate a urine infection, as can pain felt just above the pubic bone or in the back. All of the symptoms detailed above can worsen over time, and worsening or bothersome symptoms require intervention, and as doctors we want to know if the problem is affecting your quality of life. The symptoms and condition itself will guides us to opt for either conservative management, or medical or surgical treatment. Finally, storage symptoms can fluctuate depending on the time of day, and can be affected by lifestyle changes.
Do symptoms affect you during the day or night, what makes them worse, and have you changed your lifestyle or diet recently?
Urinary symptoms generally occur during the day when you are most active. However, nocturia (the urge to pass urine which wakes you up in the night) can signal a few other things. Unless you have always woken at night to pass urine, it is unusual to suddenly have nocturia, as your body usually produces lower amounts of urine at night. Therefore, it could mean you are drinking a lot prior to going to bed, or it could be due to an infection, or pregnancy (because of increased pressure on the bladder from the uterus). Nocturia can also be a symptom of diabetes.
Pinpointing what makes your symptoms worse is a particularly important question if you have incontinence. Coughing and sneezing can cause leakage of urine in those who have stress incontinence. Drinking caffeinated drinks can make symptoms such as frequency, urgency, and nocturia worse. In some women, sexual intercourse can increase their susceptibility to urinary tract infections.
Changes in your lifestyle can have a big effect on your bladder. Caffeine and alcohol particularly can affect how often and how much you urinate. New medications (prescribed or over the counter), particularly blood pressure and heart failure medications, can affect urination as they try to get rid of excess fluid. Some blood pressure medications can increase coughing which can worsen stress incontinence symptoms. Some antidepressants and sedatives can cause urinary retention. Chronic constipation (also a side effect of opioids) can contribute to urinary symptoms as it inhibits proper emptying of the bladder, which can cause retention of urine. Stagnant urine in the bladder creates an environment for infection to develop.
How many children have you had? Did you have a vaginal delivery or a caesarean section?
The pelvic floor can weaken after a pregnancy resulting in urinary incontinence and urgency, so we like to ask the number of pregnancies as well as the mode of delivery. Those who have had a prolonged labour, normal vaginal delivery, or an instrumental vaginal delivery are more likely to suffer from stress incontinence compared with those who have had a caesarean section.
Have you tried any treatments yet? If so, which ones?
We want to get an idea of what treatments have worked for you and what haven’t. This also lets us reassess your situation in case an initial diagnosis was wrong, which is why a treatment may not have worked in the first place.
Apart from the above questions, we also need to ask questions about your past medical history, surgical history, sexual history, family history, and smoking/alcohol history. Your past can influence the development of certain urinary conditions in the future. Endocrine conditions, being immunosuppressed, menopause, anxiety, previous surgery for renal stones, or vaginal or bladder prolapse can all influence or increase your susceptibility to urinary problems.
Prior to your appointment with your doctor, it would be beneficial to make very brief notes on the above questions but also keep a bladder diary over the few days before the appointment. A bladder diary involves keeping a record of urinary output, frequency of urination, frequency of incontinent episodes, frequency of pad changes (if you require a pad due to leakage), and the type and volume of fluid intake.
An appointment with your GP regarding bladder issues usually includes an abdominal exam to check for any masses that can put pressure on the bladder. A pelvic exam is also carried out if you have noticed any heaviness or dragging down below which could suggest a prolapse. This can contribute to voiding problems and incontinence. We can also observe for stress incontinence by asking you to cough and check for urine leakage. A vaginal examination can check the tone of the vaginal muscles and the pelvic floor which is important in determining if physical therapy is required. Vaginal discharge can also mimic urinary incontinence and so it is important to determine one from the other.
A urine analysis is the most important first test that we do as it will either exclude or confirm a urine infection, it can detect excess glucose in the urine (a sign of diabetes), and can pick up blood and protein which can either be signs of an infection or a problem further up the urinary tract. A urinary tract infection is an extremely common cause of urinary symptoms, which is why we confirm or exclude its presence first.
Depending on the symptoms and diagnosis, treatment for bladder issues may include lifestyle changes, physiotherapy, medications to reduce frequency or referral to a urogynaecologist. Whatever happens, if you are experiencing problems, it is important to be seen by your doctor.
Featured image is for illustration purposes only and depicts models