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Urology Blog

Pediatric Urology: Children and UTIs

Many adults, especially women, have had at least one urinary tract infection or know someone who has. This infection occurs from an overgrowth of bacteria in urine. Because the urethra, the tube through which urine passes, is shorter in women, we see more cases affecting them than men. In most cases, a UTI affects the bladder. There is a chance that the infection could affect the kidneys. Proper treatment is necessary as quickly as possible to prevent kidney infection and restore comfort. Here, we discuss what parents should know about UTIs and how to spot signs of this infection in a youngster

Symptoms of a UTI

A UTI can develop anywhere within the urinary tract. When the infection enters the bladder, it is called cystitis. Symptoms include:

  • A sensation of urinary urgency
  • Frequent urination
  • Difficult or painful urination
  • Incontinence during the day or bed-wetting
  • Foul-smelling urine
  • Blood in the urine

If infection affects the kidneys (pyelonephritis), a child may develop a fever and chills, fatigue, back or side pain, or nausea and vomiting. Any signs of urinary tract infection warrant a prompt visit to the pediatrician for a full consultation and examination. 

Treating a UTI

No treatment should begin until a doctor has examined the child and run a urine test. Children who are potty trained can usually do a standard urine specimen in a sterile container. A catheter, a thin tube, may be inserted through the urethra to collect a urine specimen from non-potty-trained children. In some cases, a urologist may order imaging of the bladder or kidneys to observe structural anatomy for potential abnormalities that may be involved. In most cases, it is not anatomy that causes a UTI but bathroom habits, which can be irregular in children.

Treatment for a UTI is determined by the diagnosis, which identifies the type of bacteria in the urinary tract. A doctor prescribes antibiotics to eradicate the infection. It is imperative that parents avoid giving a child antibiotics without proper testing. The right antibiotic is needed to properly treat each case. 

Are Pediatric UTIs Preventable?

Barring any anatomical abnormalities, it is possible to reduce the risk of subsequent UTIs with a few simple steps. One is to train a child to use the bathroom frequently. Holding urine too long may allow bacteria to accumulate. Children who struggle with constipation may benefit from a fiber supplement or foods that are high in fiber, remembering that it is imperative to drink plenty of water when taking fiber. 

If your child experiences recurring urinary tract infections, they may benefit from a consultation with a board-certified urologist. To schedule a visit at one of our Chattanooga offices, contact us today.

Are You Getting the Right Help for Urinary Incontinence?

Millions of women are affected by urinary incontinence at some point in their lives. This problem seems to most commonly affect women over the age of 50. Research has discovered several interesting facts about urinary incontinence. Perhaps the most fascinating one is that most women who experience symptoms of this condition never see a doctor to find out why or what they can do about it. Here, we discuss what urinary incontinence may look like, what women typically do to help themselves, and what they might do instead.

Symptoms of Urinary Incontinence

It’s easy to assume that urinary incontinence causes a single symptom: accidental urine leakage. This is true in the bigger picture but there are nuances depending on the type of urinary incontinence a woman has.

  • A woman with stress urinary incontinence will accidentally leak urine when she tries to exercise or when she laughs, coughs, sneezes, or performs any activity that may exert pressure on the abdomen.
  • A woman with overflow incontinence may experience frequent dribbling of small amounts of urine. This happens because the bladder does not fully empty during urination.
  • A woman with urge incontinence will feel a strong and sudden urge to urinate. She will leak urine before she makes it to the bathroom.
  • Functional incontinence occurs when a person has a mental or physical impairment.
  • A woman may also have mixed incontinence, which carries symptoms of more than one of the types we’ve mentioned here.

Common Approaches to Urinary Incontinence

Researchers at the University of Michigan Institute for Healthcare Policy and Innovation conducted a poll of over 1, 000 women aged 50 to 80. They discovered that:

  • Less than half of all women who were living with urinary incontinence had seen a doctor to discuss their symptoms.
  • Over 40% of women described their urinary leakage as a major problem.
  • More than half of the women over age 65 had experienced urinary incontinence.
  • 43% of women aged 50 to 65 had experienced symptoms.
  • More than half of the women experiencing urinary incontinence managed their symptoms by wearing special pads or undergarments.
  • 15% were strategic in how they dressed so accidental leaks could be hidden.

A Urologist Can Help

Urinary incontinence is not a simple matter of aging, vaginal atrophy, muscle weakness or weight. There may be several factors contributing to urine leakage. A urologist can help uncover the cause of urinary incontinence and find the right solution to improve quality of life. Learn more about treatments for urinary incontinence. Call our Chattanooga office at (423) 778-5910.

Sleep Apnea and Frequent Night Urination

Many people blame their frequent visits to the bathroom every night on an overactive bladder (OAB) or, for men, an enlarged prostate. While these may be frequent causes of nocturia (waking up to urinate more than one time per night), an often overlooked cause is obstructive sleep apnea. If you wonder how sleep apnea could cause you get up multiple times at night to urinate, a recent study by Miyauchi et al  confirms both the relationship between nocturia and sleep apnea as well as the improvement seen with treatment.
Sleep Apnea and Frequent Night Urination | Chattanooga TNWe begin by noting that many patients who get up frequently at night do so because they make too much urine at night. The bladder is simply filling up more quickly than it should. Normally for young people, no more than 20% of your daily urine production should come while you are asleep. In older patients, less than 33% is more normal. Patients who exceed this are said to have nocturnal polyuria, meaning they make too much urine at night. This is easily diagnosed by having patients keep a diary for several nights to measure how much urine they make during the night compared to the day.

While there are several causes of nocturnal polyuria, an often overlooked one is obstructive sleep apnea. Blockage of your airway in sleep apnea results in a lot of negative pressure in the chest as you try to breathe (try closing your throat and taking a breath).  This causes more blood to return to the heart. When this part of the heart expands from the extra blood, it releases a hormone (atrial natriuretic peptide) that makes you make more urine. It’s as if the body thinks there is too much blood volume (maybe you drank a lot of fluid) and tries to get rid of the excess fluid. So, patients with obstructive sleep apnea make too much urine at night.

The encouraging news is that treatment of the sleep apnea such as with a mask providing continuous airway pressure (CPAP) not only treats the sleep apnea but also will reduce the urine production and the nocturia. So next time you find yourself getting up that 3rd or 4th time at night, consider having an evaluation of whether you are making too much urine at night. If so, a test for sleep apnea may be in order.

Colin M. Goudelocke, M.D.

Does caffeine REALLY cause overactive bladder?

If you are a coffee drinker and you suffer from symptoms of overactive bladder (OAB) such as frequent urination or urgent urination, it is a very safe bet that someone (very often your health care provider) has told you to cut out the caffeine. Caffeine can serve as both a stimulant, an irritant, and a diuretic so it should follow that it must lead to overactive bladder, right? That has been the conventional wisdom for years, though we should always be careful to check that our wisdom is really based on facts.

Does caffeine REALLY cause overactive bladder? | Chattanooga TNA recent review article by Palma and Staak provides an overview of the most recent studies about the effects of caffeine on the bladder. When taken together, these studies demonstrate that drinking more than 2 cups of coffee per day (>200mg caffeine) is associated with worsening symptoms of overactive bladder. The effect does depend on the dose and more than 4 cups of coffee per day may result in developing symptoms of OAB even in patients with no symptoms before.

One bit of good news is that the small amount of caffeine found in decaffeinated coffee does not appear to have a negative effect on OAB symptoms.

In this case, the conventional wisdom, dispensed for years by friends, family and even your health care provider appears to be spot on. You may want to skip that extra cup of coffee tomorrow if you have a long meeting in the morning.

Colin M. Goudelocke, M.D.

Urodynamic Testing can Help Identify Types of Incontinence

People of all ages suffer an immense toll when faced with urinary incontinence. The condition tends to be especially problematic for post-menopausal women as well as those who take certain medications. Whatever the cause, whatever the type, urinary incontinence can be disruptive to daily living. Worried about an embarrassing accident, a person may avoid going out unless absolutely necessary. Because urinary incontinence is not often talked about and may be very embarrassing, many patients simply live with their condition. At UT Urology, solutions can be found in a compassionate environment.

In order to understand the potential treatments that may be recommended, it is beneficial to know how the bladder functions. For most patients with overactive bladder (OAB), questions about bladder function are answered simply by obtaining you medical history and performing a physical exam.  However, if a small percentage of patients who may have a more complicated problem or who don’t seem to improve with therapy, urodynamic testing may be appropriate.

Male Urinary LeakageSome of the situations in which urodynamic testing may be recommended include:

  • Frequent urination
  • Accidental urine leakage, or literal incontinence
  • Urge incontinence or the strong, sudden urge to urinate
  • Painful urination
  • Difficulty provoking urination
  • Incomplete urination
  • Chronic bladder infections

Our team offers the full-spectrum care you need with a great deal of compassion. We understand that urinary incontinence can be a confusing, difficult condition, and we perform diagnostic testing that will allow us to reach an accurate diagnosis in your case.

Urodynamic testing is not a singular diagnostic assessment. It includes precise analysis based on the suspected type of incontinence and the specifics of the individual case. One form of testing may measure residual urine in the bladder after urination using a catheter. Another may slowly fill the bladder with water to measure how much it can hold. Each assessment gathers necessary data that will be used to formulate the most appropriate treatment plan.

There are various types of incontinence, and we can identify which is present and, most importantly, how to treat the problem so you can continue a full, quality life. Don’t live with urinary incontinence. Call UT Urology at (423) 778-8765.

 

How a Care Pathway Improves OAB Treatment

Historically, management of overactive bladder (OAB) can be seen to have failed to fully address the needs of patients. A majority of patients with OAB report their symptoms have a significant impact on daily living and seek medical help. Yet in at least one study (which, is, admittedly, more than 15 years old) only about 1/4 of those patients were receiving treatment at the time evaluated. Half of those patients who did not seek treatment believed that no treatment was available. Furthermore, we know that a significant number of people will fail to see satisfactory improvement with early therapies including behavioral changes and medications.  Few of these people are treated with more advanced therapies intended for those patients patients with these refractory symptoms.

OABPathway edited

A care pathway is a set of steps designed to effectively manage a patient’s journey from disease to health. It is essentially a “roadmap” of how we believe a patient should be diagnosed and treated for a given problem.

It provides a standard set of instructions as to how we should care for patients and should be based on the most current guidelines and evidence available. It would seem logical that an optimized patient care pathway for OAB should lead to better outcomes. Furthermore, illustrating the care pathway in a way patients can see and understand (we use a “roadmap”) can help patients to see what to expect as they undergo evaluation and treatment.

In developing our OAB Care Pathway, we first sought to define what the initial steps should be in evaluating patients thought to have OAB. The initial evaluation of OAB begins with a thorough, but otherwise simple evaluation including a history of symptoms and other medical problems, as well as a physical exam designed to identify any other conditions that may mimic OAB. It is clear that for most patients with OAB, expensive and invasive tests are not needed for the evaluation.

An OAB Care Pathway should define the appropriate therapies for treating OAB. This includes behavioral changes, oral and dermal medications, percutaneous tibial nerve stimulation, sacral neuromodulation, and botulinum toxin. An optimized pathway considers not just what treatments can be used but the ideal order for those treatments. In the case of OAB, you would not want to begin with a treatment such as sacral neuromodulation before trying a more conservative therapy such as behavioral changes or medications. Again, consultation with available guidelines is helpful in defining which therapies are appropriate and when they should be used.

It is important for patients to have an idea of how long they should expect before a treatment begins to work. We use “mile markers” along the way so that patients can anticipate how long before they may see improvement.

A care pathway does little good if patients are blocked from making progress by barriers such as treatment side effects, problems with insurance coverage, or need for more advanced testing. In The OAB Clinic, an OAB Navigator assigned to each patient serves as a guide along the journey. She can help patients get back on track by answering questions, helping to facilitate medication changes, or arranging ahead of time for any needed tests. This helps to decrease the need for frequent visits, eliminating many of the “stops” along the way.

In The OAB Clinic, a part of UT Erlanger Urology in Chattanooga, Tennessee, our use of an optimized Patient Care Pathway has helped to significantly reduce those patients who leave the road to bladder health because of confusion or frustration. We have seen the number of patients “lost” plummet from about 70% to about 7%. This means that more patients are able to reach their bladder goals. With our care pathway, we hope to continue to change the history of OAB for all.

Colin M. Goudelocke M.D.  FPMRS

What is an OAB Navigator?

The OAB Navigator at The OAB Clinic in Chattanooga, Tennessee, serves a very unique and important role in the care of our incontinence patients. But before we describe that role, it may be helpful to first describe the obstacles many of our Overactive Bladder (OAB) patients faced before the arrival of our navigator. Only by seeing how far we have come are we able to appreciate how critical a role the OAB Navigator plays in the success of our patients.

Not so long ago, the majority of our OAB patients were frustrated by the obstacles they faced in seeking and receiving treatment for their bladder symptoms. One example I use frequently is the patient who might come back to clinic several weeks after starting a new medication. Some of those patients might return to tell us that they had stopped the new treatment due to side effects – sometimes only days after starting it. Think of the frustration of sitting at home for weeks without any treatment, waiting for your appointment so that you can tell us that the treatment we prescribed made you worse, not better. And for this privilege you often paid yet another co-pay! This kind of wasteful back and forth was standard before our OAB Navigator.

Today, that patient with intolerable side effects (and every other patient) receives a phone call about a week later from the navigator. If a different medication is needed or questions about side effects need to be answered, this is usually handled over the phone without the need for another visit (and another co-pay!). After 3-4 weeks, another phone call assesses how patients are responding to therapy. If changes need to be made, this can be done, again, by phone. It also allows us to anticipate your needs at the next visit, scheduling additional time or testing as needed.

The use of an OAB Navigator, has allowed us at The OAB Clinic to minimize the number of visits needed for you to reach your bladder goals. Through the navigator, we try to answer your questions when you have them, not weeks later at your next visit. OAB patients calling in with questions or concerns can directly reach the navigator, their own personal “concierge” through the journey to bladder health. Finally, the navigator allows us to anticipate your needs before your visit, so we can be prepared before you come. In one phrase: it allows us to be proactive not reactive.

Our OAB Navigator is one of the many ways we are striving at The OAB Clinic to provide the very best care for urinary incontinence. As a part of UT Erlanger Urology in Chattanooga, Tennessee, we are able to provide all of the resources that may be needed to care for urinary incontinence, no matter how complex. Please visit us or call at (423) 778-4OAB (4622) if we can help.

Colin M. Goudelocke, M.D.  FPMRS

3 Simple Incontinence Questions

These three simple and quick incontinence questions, based on the 3IQ incontinence questionnaire, can be very useful in helping you determine what type of incontinence you may be experiencing.

1. During the last 3 months, have you leaked urine (even a small amount)?

Urinary incontinence can be determined by simply asking someone if they ever experience urine leakage that is unintentional. Yet this ignores the fact that it is possible to experience occasional urinary leakage that may be infrequent enough that it is not bothersome. It may be more helpful to describe urinary incontinence as “the involuntary loss of urine” that poses a “social or hygienic problem”. For many patients with urine leakage, incontinence does represent a severe and bothersome stress that has social, financial and psychological consequences.

2. During what kinds of situations did you leak urine?

Beyond simply determining if urine leakage is bothersome, it is important to determine what type of incontinence you are experiencing. Urine leakage can occur in association with physical activity including coughing, sneezing, laughing, exercise or bending over. This is often referred to as Stress Incontinence. The “stress” refers to the increase in the pressure in your abdomen that results in the leakage.

In other patients, a sense of urgency (a sudden urge to urinate that is difficult to postpone) accompanies urinary leakage. Patients with Urgency Incontinence will often urinate frequently and urgently as well, trying to prevent urinary leakage.

Finally, patients may also experience loss of urine without either any exertion or sense of urgency.

3. During what kinds of situations did you leak urine most often?

While we generally describe urinary incontinence as being either Stress Incontinence or Urgency Incontinence, this does not mean that all patients will have either Urgency Incontinence OR Stress Incontinence. In fact, about 40% of patients (and the number may be much higher) with incontinence will experience both Stress Incontinence AND Urgency Incontinence to some degree. This is usually referred to as Mixed Incontinence.

But for many patients, it is useful to determine if either Stress Incontinence or Urgency Incontinence predominates, even if they experience both types. This allows us to focus on what is the more bothersome form of incontinence. It is not unusual for a patient to see improvement in one type of incontinence, only to realize that they have relatively little bother from the other type and do not need further therapy.

In those patients who do not find a connection between urine leakage and either coughing, sneezing, etc, or urgency, there may be another cause of incontinence (neurologic injury, fistula, etc) that needs to be investigated by a specialist in the field.

With three simple questions, patients can often, reliably, identify they type of incontinence they are experiencing. This is useful in guiding both an evaluation of the urine leakage as well as possible therapies available.

At The Overactive Bladder Clinic a part of UT Erlanger Urology in Chattanooga, Tennessee, we specialize in the evaluation and treatment of all forms of urinary incontinence. For more information, contact us at 423-778-4OAB (4622).

Colin M. Goudelocke, M.D.  FPMRS

5 Common Myths About Incontinence

Urinary incontinence affects millions of men and women. Unfortunately, this is not often openly discussed, leading to common misconceptions that stand in the way of people seeking and receiving treatment. We explore and hopefully dispel some of these common incontinence myths.

1. Urinary Incontinence only happens to older women.

Urinary incontinence certainly becomes more common in older populations, with over one-half of women aged over 65 reporting at least one episode of incontinence. But even younger women still experience urinary leakage at fairly significant rates. Nearly 1 in 5 women aged 20-25 also report urinary incontinence, proving this is not simply a disease of older women. In addition, younger women seek treatment for urine leakage at much lower rates than they report symptoms, suggesting that this myth may be creating barriers to younger women asking for help for their incontinence.

2. Urinary Incontinence is a normal part of getting older.

While incontinence is more likely to occur as men and women age, that does not make it a “normal” part of aging. We see many diseases (heart disease, diabetes, high blood pressure) that are more common as we get older but do not then conclude that it is something to just be accepted and accommodated. Not only does urine leakage have immense impact on the lives of men and women but there are so many treatments that can provide real benefits. This myth, unfortunately, seems to keep many people from talking to their health care provider about diagnosis and treatment of their urine leakage.

3. Men never experience Urinary Incontinence.

While men certainly experience incontinence less often than women, it is still fairly common in men. As many as 11% of men overall report incontinence, with much higher rates than this in older men. Men with urinary incontinence most often report urgency incontinence. Unlike women, men report stress incontinence much less frequently and this is often related to prior surgeries or treatments for the prostate (such as for prostate cancer).

4. Surgery is the only treatment for Urinary Incontinence.

Not only is surgery not the only treatment for urinary incontinence, it is not even the most common treatment for incontinence. Stress incontinence may be treated with surgery (such as a mid-urethral sling) in men and women who have failed to see improvement with more conservative therapy such as pelvic floor exercises (Kegel exercises). However, urgency incontinence, is treated first with behavioral changes (such as dietary modification and bladder training) and medications (such as oxybutynin, VESIcare or Toviaz). Only patients with moderate to severe symptoms of urgency who cannot take or do not see improvement with earlier treatments consider more invasive therapies (Interstim, Urgent PC or Botox).

5. Diagnosis of Urinary Incontinence requires expensive and invasive testing.

The vast majority of patients with overactive bladder (OAB) are evaluated very simply in the office with a thorough history and physical exam. At The OAB Clinic, we do find that questionnaires and a voiding diary help us in our evaluation, but even these are not necessarily required. More expensive or invasive tests are reserved for the few patients with difficulty such as failure to improve with prior therapy or complications such previous pelvic surgeries or blood in their urine. Similarly, most patients with stress incontinence are diagnosed with a history and physical exam and often a questionnaire and voiding diary.

Conclusion

By some estimates, only 1/3 of patients reporting symptoms of urinary incontinence may seek treatment. This may be due to relatively mild symptoms, but is likely also influenced by many of the myths that surround the evaluation and treatment of incontinence. By dispelling these myths, we hope to remove barriers to patients who desire treatment for bothersome incontinence.

-Colin M. Goudelocke, MD, FPMRS

5 Treatments for Overactive Bladder

Overactive Bladder (OAB) is a syndrome that is characterized by sudden urges to urinate that are difficult to postpone. This commonly also results in frequent trips to the bathroom (both day and night) and may even cause some patients to leak urine.

Overactive Bladder (OAB) affects millions of men and women of all ages. There is no “typical” person with OAB and so there is no one treatment for this syndrome that is right for all patients. Proper therapy for OAB means tailoring the treatment to the patient not the patient to the treatment.  Today, we discuss some of the various therapies that can be used to treat OAB.

Behavioral Modifications

These should be the first choice in treating overactive bladder and can be undertaken on your own, before you even see a provider. A bladder diary may help you see patterns that may explain your symptoms, such as drinking a lot of fluids at night. It may be helpful to identify and then reduce or eliminate foods or beverages that may be irritating to your bladder. Some of these possible irritants include caffeinated drinks, carbonated drinks, acidic foods (tomatoes, citrus fruits and juices), spicy foods, artificial sweeteners or dyes. Reducing the total fluid intake may improve symptoms for some people. This is best done after reviewing your bladder diary, because excessive fluid intake is not the cause of OAB symptoms for most people. Timed voiding involves urinating on a set schedule (for instance, every two hours) which can then be gradually increased to train the bladder. Finally, pelvic floor exercises can help to control urinary leakage associated with OAB.

Medications

Medications (such as VESIcare, Toviaz, Myrbetriq, etc) are often prescribed for patients who are not improved enough with behavioral changes, though it is not necessarily wrong to try both medications and behavioral changes as initial therapy. Medication therapy will be more effective if combined with behavioral changes as above. Medications can be very effective but may have side effects in some people. In addition, some people with certain diseases (such as glaucoma) or who are taking medications (such as potassium supplements) may have to be cautious with some OAB medications. This is why these should be used only after consulting a care provider familiar with treating OAB.

Percutaneous Tibial Nerve Stimulation (PTNS)

PTNS (Urgent PC) is a form of neuromodulation. In neuromodulation, we use tiny electrical signals to change the way the bladder sends signals to the brain that it is full and even how the brain responds to that message. In PTNS, that signal is sent via a very small needle placed under the skin near the ankle. There is a branch of the nerve to the bladder located there and stimulating this nerve can significantly improve the urinary frequency, urgency and urgency incontinence that occurs with OAB. There are few complications or risks, other than mild irritation at the site of needle placement, so this may be a good option for patients who are not able to undergo any type of surgical therapy for their OAB. The treatment takes place in the office and is usually administered once a week (it takes about 40 minutes) for 12 weeks and then about every 4 weeks thereafter (to maintain the effect).

Sacral Neuromodulation

Another type of neuromodulation stimulates the nerve to the bladder further up the nerve. Again, tiny electrical signals change the way that the bladder and brain communicate. However, in sacral neuromodulation, (Interstim) we are able to place a small wire beneath the skin just above the buttocks. Because the wire is underneath the skin, there is no need to come into the office for treatment. The wire is placed in the operating room under sedation (much like a pacemaker for the heart), so patients should be able to tolerate minor surgery. Also, this type of treatment is appropriate for those patients with moderate or severe symptoms who have not improved on multiple medications or are unable to take medications (because of side effects, for instance). This type of treatment should also be performed by specialists with knowledge and training in how to properly place the wire.

Botulinum Toxin

For some patients, it may be appropriate to use botulinum toxin (Botox) to help to treat OAB symptoms which do not respond to medications and behavioral changes. Small doses of botulinum toxin (Botox) are injected into the wall of the bladder through a small scope. This may be done in the office (though I find that most of my patients prefer this done in the operating room with some sedation). This will typically need to be repeated after 6-9 months to maintain its effectiveness. In some patients, botulinum toxin may make it difficult to empty the bladder completely, something that is very important to discuss before treatment.

Conclusion

Patients with OAB are very diverse often have different symptoms, lifestyles, or other medical problems. An ideal approach to OAB involves finding the best treatment (or even treatments) for that individual patient instead of treating all patients as if they were the same.

At The Overactive Bladder Clinic a part of UT Erlanger Urology in Chattanooga, Tennessee, we specialize in the evaluation and treatment of all forms of urinary incontinence. For more information, contact us at 423-778-4OAB (4622).

-Colin M. Goudelocke MD, FPMRS

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