Bladder/Urethra

The bladder is a urine storage organ that receives urine from the kidneys via the ureters. It expels the urine through the urethra, controlled by the urethral sphincter.

Bladder Symptoms+-

The bladder is supposed to store urine but when affected by a number of conditions it fails to do this and people complain of a number of storage symptoms. These include:

  • Frequency – going to pass urine too frequently
  • Urgency – the uncomfortable inability to defer urination
  • Overactive bladder – a combination of these factors
  • Urge incontinence – As above with urine leakage
  • Nocturia – waking at night to pass urine

When the bladder outflow tract is obstructed e.g.by an enlarged prostate, then the bladder may develop voiding symptoms. These include:

  • Hesitancy – delayed start of urination
  • Poor flow
  • Intermittent stream
  • Dribbling at the end of voiding

The bladder may be painful or may bleed due to a tumour or inflammation. Cystitis also gives sufferers a burning pain during urination.

Haematuria (Blood in Urine)+-

Haematuria is the presence of red cells in the urine. It can be visible (pink/rose or red/claret urine) and often termed macroscopic haematuria; or invisible blood, termed microscopic, which is usually detected on a routine urine test (dip test or laboratory microscopy) performed by your nurse or doctor.

Visible haematuria should always be reported to your doctor and will often require further investigations. It is worth noting if you have any other symptoms such as pain on voiding, frequency, urgency or fever which might suggest a urinary tract infection. Many people have no other symptoms and are termed asymptomatic.

Causes of haematuria

The blood may be coming from anywhere in the urinary system and causes include infection, bladder cancer, kidney cancer, prostate cancer and urinary stone disease.

Not everyone with haematuria has cancer, but 20-25% of those with visible haematuria will have a significant finding, compared to 3-5% of those with invisible or dip test haematuria. The chances of cancer increase with age and with risk factors such as smoking.

Should haematuria be investigated?

We recommend investigation of visible haematuria, symptomatic invisible haematuria and persistent asymptomatic invisible haematuria in the over 50’s or over 40’s with risk factors such as smoking. Persistent invisible haematuria is defined as being present on two or more of three tests.

Investigations for haematuria

Investigations are aimed at checking the whole urinary system from kidneys down to the bladder and prostate (in men)

The first step is a detailed history and physical examination. The urine will be tested and some blood tests performed to check kidney function. In men a PSA (prostate) blood test may be indicated after counselling.

Imaging will be required and will consist of an ultrasound scan and / or CT scan.

The vast majority of patients will require a cystoscopy. Most patients will have a flexible cystoscopy, as an outpatient test, usually carried out in endoscopy. A small fibre-optic telescope is passed up the urethra (water pipe) following the instillation of a local anaesthetic gel. The instrument allows us to inspect the urethra and lining of the bladder and prostate (in men). This can all be viewed by both the patient and your surgeon on a television screen.

Bladder Cancer+-

Bladder cancer is the 7th most common cancer with just over 10,000 people diagnosed each year in the United Kingdom. It is approximately twice as common in men compared with women.

The causes of bladder cancer

The majority of bladder cancers are transitional cell cancers and the most common, likely, cause is smoking. Those smoking a greater number and for a longer time are at a greater chance of developing these cancers. Chemicals associated with the paint, dye, rubber and petrochemical industries can also lead to the development of these cancers. Some patients develop these cancers with no obvious cause being identified.

Squamous cell cancer of the bladder is associated with chronic irritation of the bladder. Classically it is associated with a chronic parasitic infection of the bladder called schistosomiasis. In the United Kingdom it is more likely to be secondary to long term urinary catheters or bladder stones. In general, the risk only rises after at least ten years of problems.

The symptoms of bladder cancer

The vast majority of patients develop haematuria (blood in the urine). Most have visible (pink/rose or red/claret urine) but some have invisible blood which is detected on a routine urine test (dip test or laboratory microscopy) performed by your nurse or doctor.

Patients often have no other symptoms but can also develop urinary symptoms, such as pain on voiding, frequency, urgency or recurrent urinary tract infections.

Not everyone with haematuria has cancer, but 20-25% of those with visible haematuria may have, compared to 3-5% of those with invisible or dip test haematuria. The chances of cancer increase with age and with the risk factors above.

The blood may not be coming from the bladder and investigations are also designed to check the kidneys, ureters and, in males, the prostate.

Diagnosis of bladder cancer

The key investigation is the flexible cystoscopy. This is an outpatient test which is usually carried out in endoscopy. A small fibre-optic telescope is passed up the urethra (water pipe) following the instillation of a local anaesthetic gel. The instrument allows us to inspect the urethra and lining of the bladder and prostate. This can all be viewed by both the patient and your surgeon on a television screen.

Almost all patients will have an ultrasound scan of the kidneys and may also require X-ray, CT scan and urine test.

Treatment of bladder cancer

The initial treatment is a formal biopsy or resection of the tumour. This is carried out in the theatre under an anaesthetic by passing a larger telescope up the urethra. This allows the removal of a piece of tumour or the whole tumour using a hot wire loop. This is called a trans urethral resection of bladder tumour (TURBT).

The tissue is examined by a pathologist. They will tell us what type of tumour it is, along with its grade and stage. The grade is the degree of abnormality from 1 to 3, with 1 being relatively low grade or nice tumours and 3 being high grade or aggressive tumours. The stage tells us how deep the tumour has invaded into the bladder wall. Those that have not reached the muscle layer of the bladder are termed superficial and are treated by resection and sometimes chemotherapy or immunotherapy to the bladder. These tumours often recur and therefore the bladder is kept under surveillance with regular cystoscopies every 3 to 6 months and then annually for about 10 years .Those reaching through the muscle cannot, in general, be treated by resection alone and may require more radical surgery or radiotherapy.

Bladder Dysfunction+-

Bladder dysfunction refers to any symptom relating to abnormal function of the bladder. These may be voiding symptoms such as:

  • Hesitancy – delayed start of urination
  • Poor flow
  • Intermittent stream
  • Dribbling at the end of voiding

Or, storage symptoms such as:

  • Frequency – going to pass urine too frequently
  • Urgency – the uncomfortable inability to defer urination
  • Overactive bladder – a combination of these factors
  • Urge incontinence – As above with urine leakage
  • Nocturia – waking at night to pass urine

These symptoms may be secondary to other problems such as urethral stricture, enlargement of the prostate in men(benign or cancerous) or prolapse in women. Neurological conditions can also affect the nerves (or ‘wiring’)to the bladder. These can include nerve compression from slipped discs, diseases of the nerves such as multiple sclerosis or diseases of the brain such as Parkinson’s. The lining of the bladder can be inflamed from urinary tract infection, bladder tumours, interstitial cystitis and none specific conditions where the diagnosis remains obscure. There can also be primary bladder problems when the bladder is either overactive or poorly contractile for no obvious reason.

Painful bladder syndrome/Interstitial cystitis (IC)+-

This is a spectrum of chronic symptoms with varying combinations of problems relating to pain in the pelvic area usually relating to bladder function. The majority of patients are female but men are also affected. There are often storage symptoms, such as frequency, nocturia and urgency, but this is not always the case. The diagnosis is often one of excluding other diagnoses such as infection, cancer or overactive bladder. There is a lot of debate within the urological community regarding the best diagnostic tests and treatments for this condition. All patients will require a urine test and most will require an ultrasound scan and cystoscopy. There are some recognised criteria for diagnosing interstitial cystitis (IC), relating to number and level of symptoms as well as findings at cystoscopy, but patients are generally treated according to the dominating symptoms. This lack of certainty often necessitates a trial and error approach which can be a source of frustration for patients. Your surgeon will always talk you through the options.

Bladder Infection/UTI+-

UTI’s are more common in women than in men. They often cause frequency, stinging or burning when passing urine, lower abdominal pain and occasionally visible blood in the urine. Most settle quickly with simple antibiotics from your doctor.

Investigation is usually recommmended in children and men. The need for investigation in women is more variable. Unfortunately, some women are prone to UTIs. A UTI in a middle age woman who has not previously had UTIs may be significant. A woman who has suffered all her life may not need investigations, but we need to be aware of new issues such We often recommend investigation if a women gets recurrent UTIs (eg more than 2 in 6 months or 3 in a year) or if the infection is severe and/or affects the kidneys.

The most common investigation required is an ultrasound. Some women require cystoscopy (telescopic inspection of the bladder), usually performed under local anaesthetic in endoscopy. Occasionally further imaging such as CT is required.

The mainstay of treatment is antibiotics. Some patients may require long term preventitive or prophylactic antibiotics, in addition to general advice such as maintaining a good fluid input. Very occasionally patients may benefit from a course of bladder installations. These are designed to replenish the protective lining of the bladder. Any treatments will always be based on discussions between the patient and the surgeon.

Bladder Stones+-

Bladder stones form within the bladder and can cause urine infections, haematuria (blood in the urine) or difficulty/pain while passing urine.

The most common cause is not being able to empty the bladder completely resulting in crystals in the urine aggregating to form stones. The commonest cause is in people the obstructed urine flow from an enlarged prostate, or those with long term catheters or neurogenic (nerve related) bladder dysfunction. Occasionally it might be related to a poor diet intake or a kidney stone that has grown in the bladder.

Treatment of bladder stones varies from washing the stones off the bladder (for small stones) to cystolitholapaxy (breaking/crushing the stone using a special telescope) or using a laser to break it. Rarely for a very large stone percutaneous or open surgery may be necessary. All these procedures need a general or regional anaesthetic and patients might need to have a temporary catheter afterwards.

Tests For Bladder Problems+-

Cystoscopy

A cystoscopy is a telescopic inspection of the bladder. Most patients will have a flexible cystoscopy, as an outpatient test, usually carried out in endoscopy. A small fibre-optic telescope is passed up the urethra (water pipe) following the instillation of a local anaesthetic gel. The instrument allows us to inspect the urethra and lining of the bladder and prostate (in men). This can all be viewed by both the patient and your surgeon on a television screen. This procedure can also be done under a general anaesthetic (Fast asleep!) although this requires you to starve before hand, you would need somebody to take you home once fully awake several hours later and be unable to drive for at least 24 hours.

Flow Test

This is a fairly simple test to assess bladder function. It is most commonly performed when assessing men to predict whether their bladder is blocked by the prostate or narrowing of the water pipe. You would be asked to arrive at the clinic with a reasonably full bladder. Once you feel ready to pass urine you will be asked to void (wee) into a special funnel that measures the volume passed and the rate at which it came. The test is only valid if you pass over 150mls, hence the need for the full bladder. If you are early for the appointment and desperate for the toilet, don’t hesitate to speak with the receptionist or nurse who will be able to get you to do the test before seeing your surgeon.

Urodynamics

This is a more detailed test of bladder function, which is occasionally required if a flow test is unhelpful, if the clinical situation is more complex or other treatments have not been successful. It allows the pressure within the bladder to be measured while being filled and during voiding.

A catheter (small tube) is placed into the bladder via the urethra (water pipe). This has two lumens and allows filling and pressure measurement. A second probe is placed in the rectum (back passage). This allows the machine to subtract abdominal pressure and calculate the true bladder pressure (without this your abdominal muscles will create erroneous pressure within the bladder).

The bladder is then slowly filled, taking continuous pressure readings, until you are ready to pass urine. You then pass urine, with all the tubes still in place, and the pressures are compared with the flows achieved.

This test takes about 45 mins. It is not painful, but is a little uncomfortable and undignified! Your surgeon will be happy to discuss this in detail if necessary.

Treatments For Bladder Problems+-

As a general rule most treatments start with simple measures where applicable. For bladder problems this may start with advice on fluid intake, caffeine reduction and pelvic floor exercises.

The next step is likely to include drug treatment in the form of tablets. All tablets have side effects and our expert surgeons will discuss the most suitable agents for you, taking into account previous treatments and other medical conditions.

Occasionally bladder problems require drugs to be instilled to the bladder. This allows them to ‘coat’ the bladder wall as a topical treatment to the lining of your bladder. The requires the brief placing of a catheter (tube to bladder) to instil the drug. The drugs themselves can cause side effects and this temporary catheter has a small risk of introducing infection. Your surgeon will be happy to discuss all your treatment options.

    • Drug treatment
    • Botox therapy
    • Blue light cystoscopy
    • BCG/ Mitomycin C
    • Cystectomy

Urethral Stricture+-

The urethra is a tube that transports urine from the bladder to the tip of the penis, or perineum in the female. It is normally widely patent to allow unrestricted flow of urine, but it can become narrowed or blocked due to a scarring process – a condition known as urethral stricture.

Scarring (strictures) are most commonly due to previous trauma, infection or inflammatory processes such as lichen sclerosus, or as a longer-term complication of surgery to correct congenital anomalies of the urethra (hypospadias).

Symptoms of urethral strictures can be poor urinary flow, difficulty emptying the bladder, urinary tract infection (UTI), urinary storage symptoms such as frequency or urgency, and finally it can obstruct the urethra completely and cause acute retention of urine (blockage).

The initial investigation for the symptoms mentioned above is usually a telescopic inspection of the urethra and bladder, known as a cystoscopy. This can be done very quickly and easily under a local anesthetic, but may not be able to see beyond the narrowing.

The best investigation to delineate the problem is an X-ray called an urethrogram. This is done by instilling some x-ray contrast (dye) into the tip of the urethra, and this will provide more accurate information as to the length, location and caliber of the stricture. With this information, the best decision about treatment can be made.

Urethrogram showing a tight narrowing in the bulbar (upper part) of the urethra.

It is common for patients to be offered urethral dilatation or internal urethrotomy (incision of the stricture) in the first instance, but if the stricture is long, or has come back following a previous dilatation / incision, an open repair (urethroplasty) may offer a better result.

Dilatation or urethrotomy carry a 50% long-term success rate at best, whereas urethroplasty in straightforward strictures can offer a 90% + long-term success rate. It is important to discuss these options with your urologist before proceeding with treatment.

The techniques of urethroplasty have advanced considerably in the last 20 years, and for long or complex stricture it is now commonplace to repair the urethra using graft obtained from the inside of the check (buccal mucosa graft). This produces excellent results with minimal side-effects, and has transformed the treatment of urethral strictures.

South Coast Urology can offer the full range of options for the management of urethral strictures, and the pros and cons of each will be discussed with you.

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