Diabetes Mellitus, the condition where the body is resistant to insulin, leading to elevated blood sugars, is a common condition that can lead to many detrimental health issues such as heart disease and stroke. Often, if diabetes is poorly controlled, patients will notice they have more urine, and urinate more frequently. The extra sugar in the blood spills into the urine through the kidneys and draws more water into the urine, increasing urinary volume.
This is a somewhat oversimplified look at diabetes, but diabetes can lead to muscle and nerve deterioration of the pelvic organs as well. This I will discuss further below.
Ask yourself, what can happen if you’re constantly making more urinate and have to void every hour? Well, drip, drip, gush sometimes. Controlling diabetes is one very simple and reversible way to treat urinary incontinence.
The number of people with diabetes is rising worldwide, which itself is contributed by increasing obesity rates and an aging population. As an aside, obesity and aging are themselves correlated to urinary incontinence rates as well. I posted a blog entry not too long ago, that weight reduction by 18 lbs showed a significant reduction in urinary incontinence. Aging, simply put, is unavoidable and many women will experience urinary incontinence, whether stress related (exercise-induced) or urge related (overactive bladder), and often times both together.
Women with urinary incontinence are known to experience social or sexual isolation, whether from friends, lovers, or even self-imposed. This adds to psychosocial stress and diminished quality of life. It is important when evaluating diabetes to include all co-morbid conditions that can be associated with it, when eye, kidney, heart or bladder related.
It is believed that the same damage that diabetes causes to small blood vessels and nerves that leads to poor circulation and numbness, also occurs with the bladder and urethral sphincter. I’m sure most of us have a relative with diabetes with “bad feet”. They can’t feel their toes, or they have bad circulation with foot, pain, or non-healing ulcers. Similarly, poor blood flow and nerve injury can lead to incontinence. Bladder muscle injury and bladder nerve injury can lead to overactive bladder. A “numb” bladder may not sense it’s full till it’s “too late”, leading to urge incontinence. Bladder muscle can lose its elasticity and not fill all the way, leading to frequent urges. Poor muscle function may lead to incomplete bladder emptying (that is not perceived due to nerve injury), leading to the constant sense of urge. Incomplete bladder emptying and bad sugar control are ripe conditions for recurrent urinary tract infections.
Poor muscle function or nerve injury of the urethral sphincter can lead to stress incontinence, but diabetes can lead to obesity which itself is a risk for stress incontinence anyway.
A recent large study from Turkey compared groups of women with and without diabetes and found a 2.5 fold increased risk of urinary incontinence with diabetes. Age and BMI were also weakly related to incontinence as well. Among diabetics, 41% had urinary incontinence, while only 22% of non-diabetics had urinary incontinence. This is an astounding set of figures. Other researchers suggest that nearly 50% of severe incontinence could be avoided by preventing diabetes. Where does this lead us? Lifestyle changes, diet regimen and exercise are all important interventions. Since diabetes is an independent risk factor for urinary incontinence, all diabetics should be questioned about it for overall health promotion.
Monday, November 9, 2009
Thursday, October 29, 2009
Can Marijuana Potentially Treat Overactive Bladder?
First, a disclaimer. This blog post does not endorse the use of marijuana as it is illegal; however I recently read several studies of interest on this topic.
THC, tretrahydrocannabinol, is the major active ingredient in the marijuana and well known for inducing euphoria and relaxation, as well as sedation and drowsiness. It has been used for treating nerve pain, or neuropathic pain, cancer pain and even convulsions seen with multiple sclerosis.
AJA, Ajulemic acid, is the synthetic equivalent to THC, and is a strong pain reliever an anti-inflammatory but does not have the mind altering effects the THC has. In lab studies, it mimics many of the same properties as the popular anti-inflammatories known as NSAIDs, such a motrin or naproxen. In studies on neuropathic pain and volunteers, AJA did not cause dependency after withdrawal at the end of a one-week treatment period.
So, how would AJA potentially treat overactive bladder? A recent study on rats showed that AJA was able to suppress normal bladder activity and urinary frequency induced by bladder irritants. The researchers believe that AJA blocks the outgoing pain signal from the bladder by one of the receptors it and THC can bind to in the bladder. In the experiment, two different bladder irritants were administered to rats. Bladder pressure and contractions were measured. After injection of AJA, the bladder muscle contraction intervals and bladder pressures were blocked reversing the effect of the irritants.
So what does this mean? AJA is a promising compound that can have potentially broad application in treating the pain and overactivity symptoms that occur in many bladder conditions such as overactive bladder, interstitial cystitis, and perhaps even the bladder pain after surgery or urinary tract infections. One wonders if it many also be effective in not only treating the pain or symptoms after they occur but also given before to prevent them as well. Hmm….
THC, tretrahydrocannabinol, is the major active ingredient in the marijuana and well known for inducing euphoria and relaxation, as well as sedation and drowsiness. It has been used for treating nerve pain, or neuropathic pain, cancer pain and even convulsions seen with multiple sclerosis.
AJA, Ajulemic acid, is the synthetic equivalent to THC, and is a strong pain reliever an anti-inflammatory but does not have the mind altering effects the THC has. In lab studies, it mimics many of the same properties as the popular anti-inflammatories known as NSAIDs, such a motrin or naproxen. In studies on neuropathic pain and volunteers, AJA did not cause dependency after withdrawal at the end of a one-week treatment period.
So, how would AJA potentially treat overactive bladder? A recent study on rats showed that AJA was able to suppress normal bladder activity and urinary frequency induced by bladder irritants. The researchers believe that AJA blocks the outgoing pain signal from the bladder by one of the receptors it and THC can bind to in the bladder. In the experiment, two different bladder irritants were administered to rats. Bladder pressure and contractions were measured. After injection of AJA, the bladder muscle contraction intervals and bladder pressures were blocked reversing the effect of the irritants.
So what does this mean? AJA is a promising compound that can have potentially broad application in treating the pain and overactivity symptoms that occur in many bladder conditions such as overactive bladder, interstitial cystitis, and perhaps even the bladder pain after surgery or urinary tract infections. One wonders if it many also be effective in not only treating the pain or symptoms after they occur but also given before to prevent them as well. Hmm….
Saturday, October 17, 2009
Are Women with Pelvic Organ Prolapse at Risk for Other Hernias Elsewhere in Their Bodies?
This is such as interesting question, because when I see patients who present with a cystocele, vaginal vault prolapse or rectocele, I will often help describe it as a “bladder hernia” or “rectum hernia”. In essence it is, since a hernia is a defect in muscle or fascia (connective tissue) that when sufficiently weak will allow another organ usually to push out or through. We think classically of a male groin hernia, after lifting a heavy box. The fascia in the groin will tear or become weak, allowing the small intestine to push through creating pain and a bulge.
The same can be said of pelvic organ prolapse. Muscle weakness and fascia injury from hysterectomy, childbirth or age/menopause develop and will allow the pelvic organs to push down on the various vaginal walls creating a bulge. The more severe the hernia/prolapse, the more bulge/pain and symptoms are created, whether urinary, defecatory, or with sex.
The next question is: if hernias are more common in women with POP (pelvic organ prolapse), where in the body should we look out for it, and why is this happening in the first place?
A recently published study addresses at least the first question, but a lot of research in the past 5 years has addressed the second question. Researchers in Israel performed quite a simple chart review of 60 patients they had treated surgically for POP and compared them to 60 controls. They found that the total prevalence of hernias in the POP group was significantly higher vs. those without POP. Nearly 32% in the POP had hernias elsewhere in the body vs. only 5% in controls. This was a huge difference! Women with POP were more likely to have hiatal hernias (16.6% vs. 1.6%), as well as inguinal (groin) hernias (15% vs. 3.3%). [Hiatial hernias can lead to gastric reflux).
Collagen is the substance of connective tissue in the body and there are many collagen types. Some are stronger than others. There is mounting evidence that certain proteins which degrade collagen faster or at higher levels in women with POP. These proteins are often regulated by estrogen which can affect the balance of destruction of old collagen and production of new collagen. Add childbirth, menopause, and hysterectomy and you’ve got a “golden recipe” for POP (and stress incontinence). This logically suggests that weaker collagen is not just a pelvic problem but a problem of collagen throughout the body wherever collagen is relied upon to confer strength to an organ or tissue.
Of course most women do not undergo surgery for POP or incontinence, in fact just over 10% do over the course of their lifetime. However, POP and incontinence do run in families and now we are finding out why. So now you ask your mother, aunt or grandmother if they have pelvic floor problems to see what your risk factors are, but also ask them about other hernias as well.
The same can be said of pelvic organ prolapse. Muscle weakness and fascia injury from hysterectomy, childbirth or age/menopause develop and will allow the pelvic organs to push down on the various vaginal walls creating a bulge. The more severe the hernia/prolapse, the more bulge/pain and symptoms are created, whether urinary, defecatory, or with sex.
The next question is: if hernias are more common in women with POP (pelvic organ prolapse), where in the body should we look out for it, and why is this happening in the first place?
A recently published study addresses at least the first question, but a lot of research in the past 5 years has addressed the second question. Researchers in Israel performed quite a simple chart review of 60 patients they had treated surgically for POP and compared them to 60 controls. They found that the total prevalence of hernias in the POP group was significantly higher vs. those without POP. Nearly 32% in the POP had hernias elsewhere in the body vs. only 5% in controls. This was a huge difference! Women with POP were more likely to have hiatal hernias (16.6% vs. 1.6%), as well as inguinal (groin) hernias (15% vs. 3.3%). [Hiatial hernias can lead to gastric reflux).
Collagen is the substance of connective tissue in the body and there are many collagen types. Some are stronger than others. There is mounting evidence that certain proteins which degrade collagen faster or at higher levels in women with POP. These proteins are often regulated by estrogen which can affect the balance of destruction of old collagen and production of new collagen. Add childbirth, menopause, and hysterectomy and you’ve got a “golden recipe” for POP (and stress incontinence). This logically suggests that weaker collagen is not just a pelvic problem but a problem of collagen throughout the body wherever collagen is relied upon to confer strength to an organ or tissue.
Of course most women do not undergo surgery for POP or incontinence, in fact just over 10% do over the course of their lifetime. However, POP and incontinence do run in families and now we are finding out why. So now you ask your mother, aunt or grandmother if they have pelvic floor problems to see what your risk factors are, but also ask them about other hernias as well.
Monday, October 12, 2009
What Else Can Lead to Pelvic Organ Prolapse Besides Childbirth?
It is widely known and accepted that even just one vaginal birth is the most common risk factor for pelvic organ prolapse (POP) such as cystocele, rectocele, uterine prolapse and urinary incontinence. There are some women who can develop POP even in the absence of vaginal birth. POP is usually blamed on torn or stretched connective tissue (fascia) that invests/supports the pelvic floor muscles (levator ani), in addition to injury to nerves r blood supply to the organs in question. Are there other concomitant conditions that may call attention to the risk of developing POP?
Interestingly, and per common sense, POP conditions and urinary incontinence often co-exist in women. A huge study from Kaiser in 2008 surveyed more than 4000 women, with a mean age of 56, to see what kind of pelvic floor disorders they have. The prevalence is as follows:
Stress Incontinence 15%
Overactive Bladder 13%
Pelvic Organ Prolapse 6%
Anal Incontinence 25%
Not surprisingly, 48-80% of women with one disorder reported having at least another disorder. 60% of women had at least something.
An even larger population based study of women from Stockholm of 8000 recently reported their findings of the non-obstetric risks for developing POP. They are:
Age
Obesity
History of conditions suggesting connective tissue defects (hernia, varicose veins, hemmorhoids)
Family history of POP
Heavy lifting at work
Constipation
Interestingly, and per common sense, POP conditions and urinary incontinence often co-exist in women. A huge study from Kaiser in 2008 surveyed more than 4000 women, with a mean age of 56, to see what kind of pelvic floor disorders they have. The prevalence is as follows:
Stress Incontinence 15%
Overactive Bladder 13%
Pelvic Organ Prolapse 6%
Anal Incontinence 25%
Not surprisingly, 48-80% of women with one disorder reported having at least another disorder. 60% of women had at least something.
An even larger population based study of women from Stockholm of 8000 recently reported their findings of the non-obstetric risks for developing POP. They are:
Age
Obesity
History of conditions suggesting connective tissue defects (hernia, varicose veins, hemmorhoids)
Family history of POP
Heavy lifting at work
Constipation
Saturday, October 3, 2009
Vaccine for Urinary Tract Infections?
For several decades, scientists have been attempting to develop a vaccine for the common UTI. The only problem is, that UTIs are caused by more than one type of bacteria and there are many risk factors for developing UTIs. UITs affect more than 50% of women at least once in their lives. This leads to a lot of medical costs, lost work days and emergency room visits.
Escherchia coli (E. coli) is the most common pathogen leading to UTIs. There are many types of E coli that exist. Certain bacteria express certain proteins that act as anchors that allow them to easily attach to urogenital mucosa and creep into the urethra and bladder. Recently, researchers at Univ. Michigan developed a vaccine against E coli using certain iron receptors on the bacteria against which the patient’s immune system can react. The vaccine is administered in the nose and is currently in phase 1 trials.
Escherchia coli (E. coli) is the most common pathogen leading to UTIs. There are many types of E coli that exist. Certain bacteria express certain proteins that act as anchors that allow them to easily attach to urogenital mucosa and creep into the urethra and bladder. Recently, researchers at Univ. Michigan developed a vaccine against E coli using certain iron receptors on the bacteria against which the patient’s immune system can react. The vaccine is administered in the nose and is currently in phase 1 trials.
Friday, September 25, 2009
Interstitial Cystitis can mimic other common female pelvic conditions
Interstitial Cystitis (IC) is a chronic pain syndrome of the bladder that is often now included within Painful Bladder Syndrome (PBS). IC is noted for symptoms of pelvic pain, urgency, frequency, nocturia in the absence of bacterial infection.
Some surveys show that it may be present in up to 2% of all women. The chronic nature of the symptoms can be debilitating and have a profound negative impact on quality of life.
What causes IC is not well understood, but it may be secondary to defective bladder lining that then allows acid/other toxins to permeate into the bladder wall and lead to pain. Pain nerves are stimulated but perhaps maintain an “on” state where pain is perceived in the absence of the bad stimulus.
After a bladder infection is cleared with antibiotics, the pain and symptoms resolve. In IC the nerves that send pain signals may continue to be active despite the fact that no toxin/bacteria are present any longer.
So what can common diagnoses can IC mimic? In other words, most or all of the following conditions are often diagnosed first, while IC becomes a diagnosis of exclusion once these common problems have been ruled out.
Recurrent UTIs- a simple culture can verify the presence of bacteria, but if recurrent UTIs really occur, a search for why bacteria persist or recurs must be sought after.
Endometriosis- this could lead to pelvic pain and bladder symptoms, as well as pain with sex. Pain with endometriosis will mimic the menstrual cycle and laparoscopy with a gynecologist can make the diagnosis.
Chronic Pelvic Pain- this is usually defined as pain for at least 6 months with unclear etiology. It can be from the back, buttocks, abdominal wall muscles, and the pain leads to functional impairment. Common causes are: adhesions, pelvic inflammatory disease, ovarian pain, radiation pain, and so on…)
Vulvodynia- this is pain emanating from the opening of the vagina in the absence of any clear pathology. The vulva and the bladder share nerve endings and are derived from similar structures in development and there is likely some crossover in perception of symptoms. Often IC and vulvodynia will be diagnosis together in about half of all IC cases.
Overactive Bladder (OAB)- This is a common constellation of symptoms of urgency, frequency, and urge incontinence, with or without nocturia. It does not involve chronic pain. Often, OAB can be managed with fluid/diet/caffeine control, and of more severe, medication.
Bladder cancer- This usually presents with blood in the urine. It’s higher risk in those over 50, or smokers. Gross blood in the urine should always be evaluated, but microscopic blood in this age and risk group should also be evaluated. Bladder cancer usually doesn’t cause pain, but can lead to OAB-type bladder symptoms.
Some surveys show that it may be present in up to 2% of all women. The chronic nature of the symptoms can be debilitating and have a profound negative impact on quality of life.
What causes IC is not well understood, but it may be secondary to defective bladder lining that then allows acid/other toxins to permeate into the bladder wall and lead to pain. Pain nerves are stimulated but perhaps maintain an “on” state where pain is perceived in the absence of the bad stimulus.
After a bladder infection is cleared with antibiotics, the pain and symptoms resolve. In IC the nerves that send pain signals may continue to be active despite the fact that no toxin/bacteria are present any longer.
So what can common diagnoses can IC mimic? In other words, most or all of the following conditions are often diagnosed first, while IC becomes a diagnosis of exclusion once these common problems have been ruled out.
Recurrent UTIs- a simple culture can verify the presence of bacteria, but if recurrent UTIs really occur, a search for why bacteria persist or recurs must be sought after.
Endometriosis- this could lead to pelvic pain and bladder symptoms, as well as pain with sex. Pain with endometriosis will mimic the menstrual cycle and laparoscopy with a gynecologist can make the diagnosis.
Chronic Pelvic Pain- this is usually defined as pain for at least 6 months with unclear etiology. It can be from the back, buttocks, abdominal wall muscles, and the pain leads to functional impairment. Common causes are: adhesions, pelvic inflammatory disease, ovarian pain, radiation pain, and so on…)
Vulvodynia- this is pain emanating from the opening of the vagina in the absence of any clear pathology. The vulva and the bladder share nerve endings and are derived from similar structures in development and there is likely some crossover in perception of symptoms. Often IC and vulvodynia will be diagnosis together in about half of all IC cases.
Overactive Bladder (OAB)- This is a common constellation of symptoms of urgency, frequency, and urge incontinence, with or without nocturia. It does not involve chronic pain. Often, OAB can be managed with fluid/diet/caffeine control, and of more severe, medication.
Bladder cancer- This usually presents with blood in the urine. It’s higher risk in those over 50, or smokers. Gross blood in the urine should always be evaluated, but microscopic blood in this age and risk group should also be evaluated. Bladder cancer usually doesn’t cause pain, but can lead to OAB-type bladder symptoms.
Friday, September 18, 2009
Persistent Gential Arousal Disorder
Recently I saw a patient with an interesting and peculiar complaint: she felt constant clitoral arousal that lead to pressure that she could not relieve. It was leading to anxiety and disrupting her life and activities. Even after achieving orgasm from masturbation, she would still sense the clitoris to be stimulated.
It was fortuitous that I read about this condition about 3 months before I saw the patient in the office. It is a little known condition that was first described in 2001. It is a problem of genital arousal not sexual arousal. Patients will experience tingling, pressure, irritation, congestion, throbbing, pain or vaginal contractions. Only sometimes can sexual intercourse or masturbating alleviate the sensation. In a recent Dutch study, there appears to be a correlation between PGAD, overactive bladder and anxiety.
In my patient’s case, as is described for PGAD, the patient felt genital/clitoral arousal the entire day; it was unwanted and intrusive to her life; it was triggered by non-sexual activity (she had a UTI that preceded it); it lead to distress; it was not associated with a psychological condition. Because of the problem, her anxiety level is raised which leads to a vicious cycle of worsening the condition.
What are considered to be the triggers for PGAD?
Sexual stimulation
Masturbation
Stress
Anxiety
Loss
Menses
What can exacerbate the condition?
Pressure against the genitals
Visual arousal
Vibration (car, motor)
Stimulation by partner
Intercourse
PMS
Genitals becoming too hot
Riding a bicycle/horse
There is no specific treatment since the cause remains vague. Psychosocial support and defining the condition helps to create some knowledge that such a condition exists. Intercourse or orgasm may bring some temporary relief. Ice or topical anesthetics can help reduce swelling and sensation. Pelvic massage or stretching exercises may help. Mood stabilizing medication is empiric and may or may not help, especially if there is underlying anxiety or depression. Anxiety-reducing coping skills and activities can lead to distraction and may be useful.
Thus far, topical anesthetics have brought my patient some relief.
It was fortuitous that I read about this condition about 3 months before I saw the patient in the office. It is a little known condition that was first described in 2001. It is a problem of genital arousal not sexual arousal. Patients will experience tingling, pressure, irritation, congestion, throbbing, pain or vaginal contractions. Only sometimes can sexual intercourse or masturbating alleviate the sensation. In a recent Dutch study, there appears to be a correlation between PGAD, overactive bladder and anxiety.
In my patient’s case, as is described for PGAD, the patient felt genital/clitoral arousal the entire day; it was unwanted and intrusive to her life; it was triggered by non-sexual activity (she had a UTI that preceded it); it lead to distress; it was not associated with a psychological condition. Because of the problem, her anxiety level is raised which leads to a vicious cycle of worsening the condition.
What are considered to be the triggers for PGAD?
Sexual stimulation
Masturbation
Stress
Anxiety
Loss
Menses
What can exacerbate the condition?
Pressure against the genitals
Visual arousal
Vibration (car, motor)
Stimulation by partner
Intercourse
PMS
Genitals becoming too hot
Riding a bicycle/horse
There is no specific treatment since the cause remains vague. Psychosocial support and defining the condition helps to create some knowledge that such a condition exists. Intercourse or orgasm may bring some temporary relief. Ice or topical anesthetics can help reduce swelling and sensation. Pelvic massage or stretching exercises may help. Mood stabilizing medication is empiric and may or may not help, especially if there is underlying anxiety or depression. Anxiety-reducing coping skills and activities can lead to distraction and may be useful.
Thus far, topical anesthetics have brought my patient some relief.
Subscribe to:
Posts (Atom)
