Advice for self-management of lower urinary tract symptoms in men July 2012

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1 Advice for self-management of lower urinary tract symptoms in men July 2012 When you have problems passing urine The upper urinary tract is the kidneys and the ureters, which take urine from the kidneys to the bladder. The lower urinary tract is the bladder, prostate and urethra (which takes urine from the bladder out of the body). Problems with passing urine are also known as lower urinary tract symptoms. Many people with lower urinary tract symptoms are able to reduce these by modifying their drinking or other daily habits. We discuss some of these in this leaflet. Your GP will be able to explain which of these are more likely to be helpful for you, depending on what your specific problems are. The urinary tract Image from: Urine is produced by your kidneys and is then stored in your bladder until it is convenient for you to empty it. Your bladder is a muscular bag which needs to shrink and expand to allow you to store and pass urine when you wish to. To allow this to happen you need a good blood supply to your bladder muscle and a functioning nervous system. Your bladder has to store enough urine, between 250 and 500mls, to allow you to undertake daily activities and 1

2 have enough sleep. At night it is normal to pass urine once and this usually increases over the age of 60 years so that it is normal to pass urine four times at night by the age of 90. If you make your bladder hold too much urine on a regular basis (more than about 600mls), this can damage your bladder so that it can be difficult to empty the bladder properly. Your bladder empties best when you are standing or sitting and you should not need to strain to pass urine. You should empty your bladder completely and regularly every 3 to 4 hours during the day. Some bacteria will get into your bladder and this is normal. Regular and complete emptying of your bladder will prevent you developing a urinary tract infection by flushing out these bacteria. Your urine contains waste products and chemicals not required by your body. They can be toxic such as nicotine (smoking) which may affect bladder health in the long term (increased risk of bladder cancer). Your urine is acidic and this creates a bladder environment where bacteria are less likely to survive. You need a good urinary flow to flush out bacteria and this needs to be over 200mls each time you pass urine to be effective. What should I drink? Ensure you drink about 1.5 litres of different fluids daily (about 8 cups). You will need more fluid in hot weather, or if you are doing strenuous exercise (which makes you sweat). It is best to keep the urine a light yellow colour. Caffeine (in coffee, tea, cola and chocolate) can irritate the bladder in some people, and if rushing to the toilet is a problem for you, then you should try cutting out coffee and other caffeinated drinks. Fizzy drinks can cause similar problems, so you should also reduce these. Alcohol can dehydrate you by making the kidneys produce more urine (this is why you feel very thirsty if you have drunk too much alcohol). Some people find that drinking small volume alcoholic drinks (e.g. spirits such as whisky) can reduce the number of times they need to go to the toilet compared to large volume drinks such as beer or cider. It can be very helpful to fill out a bladder diary where you record how much you drink (and what it is), and how much urine you pass over 3 different 24 hour periods. There is a bladder diary at the end of this advice sheet. Can I reduce the amount I drink to avoid going to the toilet? It can be useful at times to restrict the amount you drink e.g. before going on a long journey, attending a meeting or going to the cinema. However, you should try to drink plenty at another time of day when it will be convenient to go to the toilet. If you reduce your drinking the urine that you produce will look darker, and will be more concentrated. Sometimes this concentrated urine can irritate the bladder and make you feel that you need to rush to the toilet even though there is only a small amount to pass. 2

3 Problems emptying your bladder properly There are different reasons why a person might not empty their bladder properly each time they go to the toilet. These include: Constipation Being in a rush and not allowing enough time to empty your bladder Feeling inhibited when passing urine in public toilets Not having enough privacy to pass urine Passing urine often (less than 3-4 hourly) so your bladder never has enough pressure to have a good flow Your bladder muscle does not push out your urine effectively (detrusor failure) Enlargement of the prostate gland or scarring of the waterpipe (urethra) in men causing outflow obstruction Nerve damage to the bladder such as in Multiple Sclerosis, Parkinson s and strokes Following pelvic or spinal surgery which can damage the nerves which supply the bladder Taking very strong pain killers causing you to lose bladder sensation A combination of the above reasons The effects of poor bladder emptying may include: Frequent visits to the toilet to pass urine (less than 3-4 hourly, frequency) Getting up more at night to pass urine (nocturia, more than once) Feeling tired due to lack of sleep Dribbling after passing urine (post micturition dribble) Your urinary stream/flow is poor When passing urine you stop and start (intermittency) Taking longer to pass urine (poor flow) Straining to pass urine Difficulty in starting the flow of urine (hesitancy) Always feeling uncomfortable because your bladder is never empty Urinary leakage during the day and night (incontinence) Need to use pads because of urinary leakage Increased risk of having urinary tract infections (UTI) and cystitis Swollen tummy, abdominal bloating, lower abdominal discomfort Kidney problems and permanent damage to the kidneys in some cases Disruption to your daily activities and life style 3

4 General advice which may help Keep your bowels working and avoid constipation (you may need to consider a laxative) Running water or putting your hands in water may stimulate you to pass urine Allow time to empty your bladder, avoid being in a rush Find a quiet zone, with maximum privacy to pass urine with no-one waiting outside the door Try to reduce the amount of times you go to the toilet. This will increase the pressure in your bladder and it may empty better Cutting down your drinks for about two hours before going to bed may reduce the number of times you get up during the night. Please make sure though that you drink enough (11/2 litres mixed fluid) during the day Try to pass urine in a relaxed and unhurried way. When you feel you have finished passing urine, stop for about two minutes then try to pass some more, again remain relaxed. You may find that leaning forwards or standing up walking round and sitting down again helps when you pass urine for the second time. This is called double voiding. Getting up at night to pass urine If you wake with the need to pass urine, this is called nocturia. About a third of adults get up once at night to pass urine. As you get older this can increase. By 70 years of age you can get up twice, by 80 three times and by 90 four times. This is typical night time activity. It is also usual to pass most of your urine during the day and little at night. Reasons caused by your bladder There are four main reasons why you may need to pass urine at night that are directly caused by your bladder: A bladder that doesn t stretch easily (low compliance) If your bladder capacity is smaller than average it may be unable to store enough urine to get through the night so you will need to get up to pass urine more often. Common causes include diabetes and radiotherapy that has affected the bladder. Poor bladder emptying If your bladder does not empty properly (and contains residual urine after you have tried to empty it) you are likely to have to get up to pass urine more often. Common causes include: constipation, enlarged prostate gland, multiple sclerosis and diabetes. What can I do about poor bladder emptying? Check the side effects of any medication you take as some may cause bladder emptying problems Limit your fluid intake for two hours before going to bed and during the night. Treat constipation 4

5 Medication for men with prostatic enlargement may help to shrink the gland. Using a catheter (fine tube which goes into your bladder to drain urine) may empty your bladder and reduce your symptoms In some men a Urologist may need to do an operation to deal with the prostatic obstruction An overactive bladder Before your bladder is full it starts to contract and you get sudden urges to pass urine. This can disturb your sleep as you will have to keep getting up to pass urine. The cause is unclear in some people; it increases with age and is common in multiple sclerosis. What can I do about an overactive bladder? Cut down or stop your caffeine intake as it increases over activity of the bladder Try to avoid caffeine based drinks (e.g. coffee, tea, cola) for about five hours before bedtime Medication may help; for example Oxybutynin which reduces the urge to pass urine. (Note the side effects and contraindications) Bladder retraining may help to expand your bladder capacity and reduce the times you go to the toilet during the day and night. When combined with medication (Oxybutynin) the results can be better Nocturnal polyuria If you produce more than a third of your urine during the night, this is called nocturnal polyuria. Common causes include: heart disease, high blood pressure, circulation problems and swollen legs and feet. If you are awake at night for other reasons and decide to go to the toilet, this is called secondary nocturnal voiding. Common causes include: snoring, stress, worry, smoking, noise, pain, uncomfortable bed, too hot, taking naps during the day, insomnia (not being able to sleep) and high fluid intake at night. What can I do about nocturnal polyuria? Restrict your fluid intake for two hours before going to bed and during the night. Try to cut your salt intake down as this can cause you to retain fluid. Each day during the afternoon lie down with your feet higher than your heart for at least one hour. This improves the blood supply to your heart and kidneys. It may increase your urine output during the afternoon and evening. In some cases your doctor may prescribe a diuretic (water pill) to increase your daytime urinary output and reduce the night time output. One cup of nettle tea taken late afternoon may have the same effect as a diuretic. Nettle tea is not advised if you have blood pressure problems. If you use nettle tea or a diuretic you must have your blood checked to ensure you do not lose too much potassium on a regular basis. If you have swollen legs, support stockings may help. 5

6 Secondary nocturnal voiding If you are awake at night for other reasons and decide to go to the toilet, this is called secondary nocturnal voiding. Common causes include: snoring, stress, worry, smoking, noise, pain, uncomfortable bed, too hot, taking naps during the day, insomnia (not being able to sleep) and high fluid intake at night. What can I do about secondary nocturnal voiding? Consider what may be disturbing your sleep. Try to change this by self-help measures or talk to your doctor. An irritated bladder If you have a urinary tract infection, cystitis or bladder stones, this can cause your bladder to be sore and cause you to pass urine more often. What can I do about an irritated bladder? Drink extra water to dilute your urine and the irritation it causes Get a course of antibiotics to treat urinary infection Try self-help remedies for cystitis A Urologist will advise on the treatment of bladder stones Bladder retraining for an overactive bladder What is an overactive bladder? Three factors make up the diagnosis of an overactive bladder. You can have all three, just one or various combinations or degrees: 1. Urinary frequency: Going to the toilet often 2. Urinary urgency: Urgency to pass urine which is abnormal to you 3. Urge incontinence: Leaking urine if you don t get to the toilet on time A diagnosis of an overactive bladder is usually made from symptoms as above, from a bladder chart or diary or following investigations such as ultrasound, urinalysis and urodynamics. What is bladder retraining? Bladder retraining is a behavioural (self-help) treatment for people with overactive bladders. It aims to increase the gaps between visits to the toilet and increase the amount of urine you pass each time. The treatment has no side effects and when combined with medication research has shown it can be very effective. Bladder retraining may not be as effective for the elderly, or those with lifelong bladder problems. 6

7 The bladder and caffeine Caffeine can affect your bladder by: Slightly increasing the amount of urine you produce Reducing the length and depth of your sleep, so indirectly increasing the number of times you might pass urine at night Increasing urinary urgency, frequency and getting up to the toilet at night (nocturia) if you have an overactive bladder Slightly reducing pelvic muscle tone which may mean you leak urine more We recommend that all patients trying a bladder retraining programme try to cut out caffeine to see if their bladder symptoms improve. If you stop taking caffeine do it gradually over two weeks to avoid the following withdrawal symptoms: Headache Drowsiness Stomach upsets or irritability Muscle pains Sweating Runny nose What causes an overactive bladder? Increases with advancing age Sometimes the cause is not known, but is more common in women Prostate enlargement in men Anxiety of not reaching the toilet in time, so going more often to reduce the risk of incontinence People whose nervous system is affected which can be caused by a number of reasons including, dementia, stroke, spina bifida, Parkinson s disease, multiple sclerosis, diabetes or spinal cord injury What can bladder retraining achieve? Reduce the total daytime visits you make to the toilet to under eight each day Increase the time between toilet visits to about three hours Reduce severe urgency to pass urine and make it more controllable Make your bladder hold more urine When you pass urine it should be over 250mls and under 600mls at a time Reduce the number of times you pass urine at night Reduce or stop urinary leakage that you get when you don t make it to the toilet in time Reduce your anxiety about your bladder and increase your confidence 7

8 Methods for bladder retraining: Bladder retraining requires you to hold on and not go to the toilet so often. You may need to do pelvic muscle exercises to help you hold on. If you wake up at night with a strong urge to pass urine, then use the toilet. Start to avoid going just in case or every time you are near a toilet. Start to miss the occasional toilet stop. When you have an urge to pass urine, sitting down on something hard often helps. Be prepared that leakage may be a little worse when you start bladder retraining. Watching the television, counting back from 100, read a book or do some pelvic floor exercises may take your mind off thinking about the toilet. Always try to avoid going to the toilet on a strong urge. You want to control your bladder, not have it control you. Medication A range of drugs called anticholinergics are available to help with overactive bladders. These drugs work by reducing urgency and increasing the volume of urine your bladder holds. Research has shown that combining bladder retraining with anticholinergics is more successful. Anticholinergic medication will not cure your bladder problem, but can relieve your symptoms. Anticholinergics should be stopped every three months for a few days to see if they are still having any effect. Please read the leaflet that comes with your medication carefully as anticholinergic drugs have a number of side-effects. Post micturition dribble What is post micturition dribble (PMD)? When you have finished passing urine a small amount may leak out onto your underpants. This after dribble is called post micturition dribble and is a normal occurrence in men of all ages. Why does post micturition dribble happen? If you consider your anatomy in your lower urinary tract, this will explain why it happens. Your urethra (tube) passes from your bladder to the tip of your penis and allows your urine to be passed. Your urethra is between 18 to 22cm long (about two thirds of a twelve inch ruler). At the bladder end of your urethra are your sphincters which control the passing of urine. At the end of passing urine (micturition), your urethra may be left with a few drops of urine in it after your sphincters have closed. As you move about in the toilet after you have finished, this urine may leak out. This is called post micturition dribble. Again ask your GP to show you a diagram/model of the anatomy of the urethra in men to explain PMD further. Can I do anything to reduce it? Remember that post micturition dribble is a normal occurrence in all men of various ages. Some self-help measures may minimise it but it will still happen to some degree from time to time. There are no specific drugs or operations that will help the situation. Here are five self-help measures that you can try. 8

9 1. At the end of passing urine leave a few moments for those last drops to be passed, be patient. 2. At the end of passing urine lean slightly forward and pull your penis slightly downwards. Shake it gently and allow those last few drops to pass. 3. When you feel you have finished passing urine, lean slightly forward and try to pass more urine. You may pass a few more drops. This technique is called double voiding. 4. When you have finished passing urine, using your fingers, press your perineal area under your scrotum to expel those last few drops (milking). Your GP will demonstrate how to do this. 5. Sometimes if post micturition dribble is a considerable problem, a course of pelvic muscle exercises may improve it. Does smoking have any effect on my bladder function? This answer is yes. Smoking causes urinary urgency, it can cause coughing which may result in urinary leakage. Smoking also increases your risk of developing bladder cancer. 9

10 None 1 time 2 times 3 times 4 times 5 times or more Your score Not at all Less than 1 time in Less than half the About half the More than half Almost always Your score International Prostate Symptom Score (IPSS) Name: Date: Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? Urgency Over the last month, how difficult have you found it to postpone urination? Weak stream Over the past month, how often have you had a weak urinary stream? Straining Over the past month, how often have you had to push or strain to begin urination? Nocturia Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? Total IPSS score 10

11 Delighted Pleased Mostly satisfied Mixed about equally satisfied Mostly dissatisfied Unhappy Terrible Quality of life due to urinary symptoms If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? Total score: 0-7 mildly symptomatic; 8-19 moderately symptomatic; severely symptomatic. 11

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13 DATE: DAY 1 DATE: DAY 2 DATE: DAY 3 Time Amount drunk Urine passed Leak? Activity during leak urgency? Time Amount drunk Urine passed Leak? Activity during leak urgency? Time Amount drunk Urine passed Leak? Activity during leak urgency? Total Total Total 13

14 INSTRUCTIONS TO COMPLETE BLADDER DIARY This diary provides important information used to guide your treatment. It is vital that you fill it in accurately. Complete the diary for 3 consecutive days. Start recording on the first line when you wake up. Record all liquids (water, juice, tea, coffee etc) you drink: The time you drank in the time column and the amount you drank in the amount drunk column. Record every time you pass urine: The time you passed urine in the time column and the amount you passed in the urine passed column. Record every time you leak urine: The time that you leaked in the time column and place a tick ( ) in the leak column. Also note the activity you were doing when you leaked in the activity during leak column. Record every time you have urgency: The time that you had urgency in the time column and place a 0=no urgency 1=mild urgency 2=moderate urgency 3=severe urgency in any urgency column. Mayday Healthcare NHS Trust Mayday University Hospital FUTURE APPOINTMENT DATE: BLADDER DIARY MUG=150 ml GLASS=200 ml / / AN EXAMPLE: DATE: 01/01/2010 DAY 1 Time 8:00 AM 10:30 AM 11:45 AM Amount drunk Urine passed Leak? Activity during leak Dog walking urgency 180 doubt phone Lancaster Suite on CLINIC: TIME: APPOINTMENT WITH: PATIENT NAME: DATE OF BIRTH: / / 14