Ask the Pharmacist

Q) I’m a fifty year old male who has suddenly found that my schedule is ruled by my bladder. My doctor checked me out with a number of tests, a physical and an ultrasound but said they all came back “normal” and indicated that the size of my prostate appears to be normal as well. So why do I have to urinate 10 times a day and unable to find a bathroom quick enough?

A) Increased urinary frequency and urgency (best described by the signals your brain tells you about the need to urinate are disproportionately strong relative to the volume of urine you eventually produce) has long been the bane of both of the sexes from middle age on.

In males, the problem has traditionally been attributed to either an infection or the growth of our prostate, a condition known as benign prostatic hyperplasia (or BPH). BPH is by far the most common culprit for these symptoms with incidences ranging wildly depending on the study but most pegging it at about 8% of all males by the 4th decade of life and rising to 50% and 80% by the 6th and 9th decades respectively.

However, as medical knowledge has evolved, the diagnosis of these symptoms and their treatment has become a lot more complex rather than just attributing all male cases to BPH. Many clinicians now like to refer to males presenting with these symptoms as having lower urinary tract symptoms (or LUTS , no one likes a good acronym better than the medical community!) and this term would include those with BPH as well as a number of other medical conditions.

In fact, in a great many of LUTS patients, their symptoms are frequently a result of more than one condition. In other words, a male with the need to frequently urinate may have both BPH as well as another cause such as a stone in the urinary tract, cancer of the bladder or prostate, detrusor muscle (this is the smooth muscle found within the walls of the bladder) weakness and/ or instability, a urinary tract infection, diabetes, a neurological condition (such as multiple sclerosis or a spinal cord injury) and prostatitis.

Symptoms are not just limited to frequency or urgency either, although they are often the two most commonly mentioned in those seeking medical attention. Other possible symptoms include nocturia (the need to urinate at night), difficulty initiating urination, a decreased force of stream, an interruption in the act of urinating or a sense of incomplete bladder emptying.

For the gentleman listed above who has gone through a number of tests, that would essentially rule out causes such as BPH, cancer, an infection and others he might well be diagnosed with overactive bladder (OAB) which is not really a condition in and of itself as it is a collection of symptoms such as the ones we have listed above. The prevailing complaint for those labeled with this condition is a sudden and uncontrollable need to urinate which frequently results in leaks or “full-scale accidents”.

Treatment usually starts with lifestyle recommendations which will be the focus of most of the rest of this article. If these fail to adequately control one’s symptoms there are a number of commonly prescribed medications that are both safe and effective which include mirabegron (Myrbetriq) a beta-3 adrenergic agonist, a group of drugs known as the alpha-adrenergics (such as tamsulosin and alfuzosin among others..) or possibly the anticholinergics such as oxybutynin and tolterodine.

Like many other conditions, the treatment of OAB is a stepwise progression where more expensive/ riskier/ invasive or time consuming treatment options are used after easier solutions have proven inadequate.

In the case of OAB, if the addition of multiple medications has failed to provide adequate relief, interventions that a doctor may prescribe include the injection of Botox into the bladder muscles, neuromodulation therapy (this is where a small device is implanted under the skin and delivers electrical impulses to the nerves that control the bladder in much the same way a pacemaker functions for the heart) or surgery in some cases.

The good news is that many men (and women for whom this diagnosis is even more common) can achieve adequate control of their symptoms by undergoing a number of lifestyle changes.

The first thing tried is weight loss if the patient is overweight as this can help reduce the risk of any number of other conditions that may soon be troubling our prospective patient. Excessive weight presses down on the bladder and urinary tract greatly exacerbating these types of symptoms.

Many patients would also benefit from seeing a physiotherapist who specializes in pelvic floor retraining, who can gradually and systematically teach you as to how to ignore the signals your bladder sends to your brain until your bladder is indeed full. They would also be an expert in recommending the proper pelvic floor exercises to counteract your situation which may involve strengthening the muscles through the famed kegel type exercise or conversely relaxing them if they are too tight.

The other key lifestyle type intervention is to make good food/ drink choices. In this case, we are not necessarily talking about achieving weight loss as we are about avoiding choices that “irritate” the bladder causing it to send unnecessary signals to the brain. The chief culprit for many of us here are unfortunately two of our favourite “chemicals” in the standard North American diet.

I am of course referring to caffeine and alcohol. Minimizing, or substantially better, avoiding these two in all of their forms (i.e. wine, beer, liquors, coffee, tea, colas and, yes, even chocolate) can make a world of difference in a relatively short time. Other foods that can prove problematic include artificial sweeteners, tomato products (which are acidic in nature and can really stimulate the bladder nerves), citrus fruits such as oranges, grapefruits, lemons and limes, any beverage which is carbonated, spicy foods (for some although lots of people do not find eliminating these makes much of a difference so feel free to experiment for a couple of weeks to gauge its impact), onions (mainly raw), processed foods (which are just crappy for you in a hundred other ways as well) and cranberries.

Keep in mind that some lifestyle changes are difficult to endure and we all work hard, are time pressed and just want to eat and drink what we wish. However, peeing all the time and having leaky moments are embarrassing enough to cause us to rethink our choices.

For more information about this or any other health related questions, contact your pharmacist.