I know about this. Not only have I have researched and treated incontinence for 35 years, but I was also a bed-wetter at an English Jesuit boarding school and now, at nearly 65, it’s my bowels that cause the trouble, would you believe. But to keep this agreeable we shall put aside my alarming tales of public lavatory queues, locked doors, wrong coins and transport bottlenecks and stick with the urinary system.
Lower urinary tract symptoms are divided into groups, but there is much overlap, so I tend to view them as a whole. Most women know about stress urinary incontinence, occurring in response to coughing, sneezing and other forms of physical stress. The main, but not exclusive, cause is childbirth. First, do not be bullied into perinatal pelvic floor exercises. There is no evidence that they prevent stress incontinence and the published clinical trials imply that they are not so useful anyway. They do strengthen the relevant muscles if done correctly, but any effect on incontinence is unpredictable.
The advent of tension-free vaginal tape (TVT) treatment has been a bigger advance and is well worth exploring. Mesh inserts have garnered adverse press attention in recent years, and rightly so. But, in skilled hands, a TVT procedure is a worthwhile option, irrespective of age.
An overactive bladder shows itself through frequent urination, nocturnal voiding, urgency and urge incontinence. It is de rigueur to advocate bladder-retraining regimes for these symptoms, but this mystifies me. I have spent hours scrutinising the various studies of bladder retraining and I cannot see an effect. Such exercises are usually advocated with ‘persuader’ phrases like ‘it goes without saying’ that conservative methods should be tried first. Fine if there were any evidence of efficacy. Otherwise it is unfairly discouraging for the patient and a waste of money in providing supervision.
There are some good drugs for treating the overactive bladder; most are antimuscarinic agents, but more recently beta-3 agonists have arrived on the scene. They are worth studying and, failing those, the injection of Botulinum toxin (Botox) into your bladder may achieve far more than sticking it into your face. It’s almost like a youth drug — you can go dancing again.
Voiding problems involve difficulty in emptying the bladder. Urination may be slow to start, the stream may be reduced, it may stop and start and dribble towards the end, or you might have to strain. Most people think these symptoms are the preserve of men with prostate problems, but they are just as common in women. They can be an important signal that urinary infection is present, and women who experience cystitis will recognise them as a preface to the torment that ensues. We suspect that they may also presage infection in the male, but we have to study that more. You can have a urinary infection without pain or burning on passing urine, which is assumed to be a sine qua non. In fact, you can have a urinary infection without pain.
Now we get to the tests that might be proffered — and here it all gets rather depressing. My profession is seized by a plague of Micawberisms. The old-fashioned habit of listening, examining and assimilating the evidence has been replaced by an insatiable compulsion to test and retest in the hope that ‘something will turn up’. Too often this is an incidental, innocent anomaly that nobody has the courage to call innocent. Thus, the patient is subjected to a series of additional tests that inevitably expose further innocent anomalies, and so the patient enters a cycle of ever more extra-ordinary and unnecessary investigations. I believe it possible to meet your demise through testing the absence of pathology. Investigations of this kind require a clear, plausible hypothesis. Without this, the probability of a false positive is unacceptably high. Nobody will be allowed to test me without very good reason.
The panjandrum of all bladder investigations is the urodynamic study. I spent 20 years of my life studying the biomechanics, physiology and applied clinical science of this test. I never found any of the variables to correlate reliably with the pathology, disease experience or treatment outcome. I stopped using urodynamics ten years ago and wonder at those 20 years of commitment. I confess to being an apostate; others will argue vehemently against these views. However, if you are offered the test, ask about rational justification and have a think about it. While I was studying the procedure I performed it on myself and I can assure you it is not much fun.
A cystoscopy is another common procedure that should not be deployed as routine. The clinicians should be clear about what they are looking for, why, and they should have assessed the probability of finding something. I think that we should all protect our private parts from unwarranted intrusion and insist that this occurs only in the case of a plausible hypothesis. Having a look, just in case, is nosy and again risks the incursion of an innocent anomaly. The same principles apply to renal tract ultrasound, CT or an MRI scan — is there a cogent reason for this investigation?
The checking of urine for infection is another vale of tears. If a doctor or nurse dips a test stick into your urine and it turns positive for leucocytes or nitrites, then the nature of the test means that you definitely have a urinary-tract infection. But if the test is negative, the sensitivity is such that there is no justification for claiming you do not have an infection. If your urine is then sent to the lab for culture and a microbe is isolated, it’s likely that this microbe is contributing to your distress. But if the culture is negative it is again wrong to claim this proves an absence of infection; the culture is too insensitive. For these reasons, negative tests are unhelpful and a cause of terrible suffering. Many women with the appropriate symptoms are dismissed as not suffering from an infection when they do in fact have one. This controversial view is supported by much published literature. I am sorry to record this, because in doing so I identify a worrying deficiency in our diagnostic protocols, but the evidence is out there for everyone to read. Science points to clinical history and examination as the best means of finding a diagnosis.
In writing about miserable symptoms that needlessly blight the lives of too many people, I am critical of the approaches to care that are currently promoted and knowingly risk opprobrium. However, the published evidence persuades me that we should re-evaluate current practices and in many cases replace them.
I am close to retirement now and I do not believe that this critical reappraisal will come easily from the clinical professions or the health service bureaucracies. I am, however, optimistic. The most impressive change in medicine I have seen in my career is the freedom, gifted by the internet, for patients to become well informed about their own conditions. They can form themselves into campaign and support groups of similarly affected peers and these can be an astonishingly powerful force. Thus, if you are suffering from urinary symptoms, I encourage you towards the Cystitis and Overactive Bladder Foundation (COB) website where the various forums provide more wisdom than I can offer.
By banding together like this, informed sufferers can campaign for the right to receive rational care, rooted in the practical wisdom of medicine’s ethical history, with technology deployed only when appropriate and after diligent forethought.
James Malone-Lee MD FRCP is Professor of Medicine at University College London Medical School.