Reproductive and Sexual Health Handbook

The bladder (Figure 6.1) forms part of the lower urinary tract and is a hollow viscus which receives urine from the kidneys via the ureters and expels urine via the urethra. The bladder has only two functions, to store and expel urine. However, the mechanisms for these functions are complex.

The outer layer of the bladder wall is comprised of bundles of smooth muscle (detrusor muscle) and an inner urothelium. The smooth muscle layers constantly sample the volume of urine with phasic contractions until the stretch receptors in the muscular walls are stimulated enough to create a conscious awareness of bladder fullness, and then the muscle produces more tonic muscular contractions. A decision is then made to either void or hold on until the sensation to void is stronger. During voiding, the detrusor muscle contracts constantly until the void is complete.

This simple muscle action requires a complex neurology. The bladder is controlled locally by the autonomic nervous system. The sympathetic (hypogastric) nerves allow relaxation of the detrusor muscle for storage of urine, and the parasympathetic (pelvic splanchnic) nerves stimulate the detrusor muscle for voiding to occur. In the brainstem the pontine micturition centre is where the unconscious switching from storage to voiding

Urinary tract infections (UTIs) are common, affecting up to 15 per cent of women each year.⁽¹⁾ More than 25 per cent of women who have had an infection will experience a recurrence.⁽¹⁾

UTIs are a major cause of morbidity, anxiety and loss of productivity in women. Most UTIs (95 per cent) are caused by an ascending infection.⁽²⁾ Urogenic bacteria in the faecal flora may colonise the vaginal and peri-urethral introitus and then ascend the urethra into the bladder. A minority of women with UTIs have an underlying abnormality.

Recurrent UTIs can be defined as two or more UTIs in six months, or three or more UTIs in a year.⁽³⁾ Recurrent UTIs occur because of re-infection or relapse after inadequate treatment.⁽⁷⁾

Asymptomatic bacteria occurs in small number of pregnant women (2-10 per cent), and requires treatment. If left untreated, 20-30 per cent of these women will develop acute pyelonephritis.⁽³⁾ Pyelonephritis is associated with an increased risk of prematurity, a lower birth weight, intrauterine growth retardation and congenital anomalies. It is routine to send an MSU for MCS in the first trimester for all pregnant women. A second MSU may be necessary to confirm a positive result in an asymptomatic woman prior to treatment.

All pregnant women with a symptomatic UTI should be treated and an MSU sent for MCS. For first-line treatments see Table 6.1. If required, modify therapy based on susceptibility results. A urine culture 1-2 weeks post treatment is essential. If bacteriuria is still present, consider antibiotic prophylaxis for the pregnancy (e.g. cephalexin or nitrofurantoin, based on MCS results).

Continue to monitor urines monthly throughout the pregnancy. Avoid the use of tetracyclines and fluoroquinolones. Also note, if group B streptococcus is detected in the urine during pregnancy, prophylaxis during delivery is usually indicated. ⁽³⁾

This is a common transitory condition of little significance. It does not require antibiotic therapy as there is no evidence that treatment reduces the infectious morbidity or mortality, and antibiotic use would lead to increasing resistance in the community.

The only exceptions to this are patients with renal transplants or those who are about to undergo genitourinary tract procedures.⁽⁵⁾ If the patient has urge incontinence, this could be a symptom of the UTI in the absence of other usual UTI symptoms. In this situation, treatment according to sensitivities is appropriate, with a careful review of the response.

Interstitial cystitis, also known as ‘bladder pain syndrome’, refers to the complaint of suprapubic pressure or discomfort perceived to be related to the urinary bladder and accompanied by other lower urinary tract symptoms of more than six weeks duration in the absence of proven urinary infection or other obvious pathology.^{(9, 10)} Symptoms can include dysuria, frequency, nocturia, urgency, haematuria, dyspareunia and perineal discomfort.

Interstitial cystitis is often misdiagnosed as recurrent UTI (without urine culture evidence). The aetiology is poorly understood and various theories propose chronic inflammation, autoimmune dysregulation or epithelial cell dysfunction as possible causes. Treatment options include:

behavioural therapy, such as dietary restrictions, fluid management, stress management, or pelvic floor relaxation with a trained pelvic floor physiotherapist oral therapy, e.g. low dose amitriptyline (for pain), pentosan polysulfate sodium (Elmiron), antihistamine various intravesical installation therapies surgery such as bladder distension

Rarely cystectomy is considered. Referral is recommended if interstitial cystitis is suspected.

Urinary tract infections in men are uncommon and often associated with an underlying urinary tract abnormality. Therefore all males with a suspected urinary tract infection should be examined and investigated.

Risk factors include bladder outlet obstruction, e.g. benign prostatic hyperplasia (BPH) or urethral stricture, urinary tract calculi, indwelling urinary catheter, neurogenic bladder, diabetes, immunosuppression, or very occasionally, bladder tumour. Differential diagnoses include chlamydia and gonorrhoea.

Haematuria, the presence of red blood cells in the urine, may be detected on urinalysis (microscopic or non-visible) or be visible to the naked eye (macroscopic, gross or visible). Guidelines often further differentiate on the basis of whether microscopic haematuria is symptomatic or asymptomatic.

Associated symptoms and signs may give clues to the cause:

lower urinary tract symptoms such as dysuria, frequency, urgency any other pain, e.g. flank, pelvic other indicators of systemic illness, e.g. nausea, oedema, fevers, malaise for gross haematuria, ask the patient whether this has occurred in isolation or on multiple occasions; when during the urine stream is the blood seen; presence of any clots; and if the patient has undergone any recent urological procedures

The pelvic floor is a complex muscle structure which refers to the levator ani or pelvic floor muscle (PFM), the urinary and anal sphincter muscles and the perineal or superficial pelvic floor muscles, along with the organs that sit on this muscular floor (bladder, uterus, rectum) and their outlets which pass through this floor (urethra, vagina and anus).

The levator ani muscle is comprised of two components, the puborectalis and iliococcygeus muscles. However this muscle complex normally acts as a whole. When the PFM actively contracts it pulls forward and upwards to support the organs and close the urethral and vaginal outlets. The anal sphincter muscles can both contract with the PFM to help seal the anus, or act independently. The superficial PFM are more involved in sexual function than support, as they contain erectile tissue and form the muscular part of the clitoris.

For full function of the PFM, these muscles must have strength and endurance, act rapidly in response to changes in abdominal pressure (e.g. cough, sneeze), and also be able to relax fully. PFM weakness may be associated with urinary leakage and vaginal prolapse, and increased tone in the PFM may be associated with pelvic pain and vaginismus.

Increased muscle tone in

Urinary incontinence is a term that describes any accidental or involuntary loss of urine from the bladder.

Urinary incontinence is a largely hidden problem as it is often under-reported due either to embarrassment or the mistaken view that it is a ‘normal’ aspect of childbirth, menopause and ageing. However, it is a very common problem which can often be substantially improved with the correct management.

It is estimated that in Australia there are over four million people with some degree of incontinence. The prevalence in women is estimated to be 37 per cent and in men 13 per cent.⁽¹²⁾

Urinary incontinence can be categorised as:

Stress urinary incontinence⁽¹³⁾ Urge urinary incontinence⁽¹³⁾ Mixed urinary incontinence⁽¹⁴⁾ Incontinence associated with chronic retention or overflow urinary incontinence⁽¹³⁾ Fistula related incontinence⁽¹⁴⁾ Functional incontinence⁽¹³⁾ Continuous incontinence⁽¹³⁾

Patients with concerns regarding urinary incontinence should be assessed with a thorough clinical history and examination. Two to three-day bladder diaries may be useful in patients with both stress and urge urinary incontinence. A urinalysis +/- urine culture and an estimation of post-void residual urine with a bladder scan or dedicated genitourinary ultrasound are sufficient in most patients prior to initiating treatment.

The symptom of stress urinary incontinence (SUI) is the complaint of involuntary leakage of urine with increased intra-abdominal pressure (i.e. on exertion, sneezing, coughing, laughing). ⁽¹²⁾

 

Urge urinary incontinence (UUI) is the complaint of involuntary leakage accompanied by or immediately preceded by urgency (a sudden compelling desire to pass urine which is difficult to defer).⁽¹²⁾ UUI is considered as part of an ‘overactive bladder’ (OAB) which is defined as urgency, with or without urge incontinence, usually with frequency and nocturia.⁽¹²⁾ UUI can be triggered by coughing, changes in posture from sitting or lying to standing, hearing running water or washing hands in cold water, or putting the keys in the door. UUI can have neurogenic causes (e.g. multiple sclerosis, Parkinson’s disease, cerebrovascular accident) or non-neurogenic causes (e.g. bladder outlet obstruction, UTI, bladder tumour).

The diagnosis of UUI can be confirmed by urodynamic study, by demonstrating involuntary detrusor contraction (detrusor overactivity).

It is very common for women to have a combination of stress and urge incontinence. This is a symptom complex, most commonly explained by genuine stress incontinence, but can be due to detrusor overactivity, and occasionally by both dysfunctions. Refer to a qualified physiotherapist in this field or continence nurse for first line treatment of PFMT and bladder training. Treat most bothersome symptoms first.

If considering surgery, the predominant dysfunction(s) should be defined on urodynamics first.

Functional incontinence relates to a physical, intellectual or environmental issues that can be a contributing cause of incontinence in a person with normal bladder function.⁽²²⁾ Continuous urinary incontinence is the complaint of a continuous leakage. This can be caused by urethral sphincter weakness or extra-urethral incontinence. Unconscious urinary incontinence is the complaint of involuntary loss of urine that is unaccompanied by either urge or stress. It may be caused by detrusor overactivity, urethral sphincter weakness or extra-urethral incontinence. Nocturnal enuresis is the complaint of an involuntary loss of urine occurring during sleep. In 1-2 per cent of children with enuresis this persists into adulthood (primary nocturnal enuresis). Treatment options include fluid modulation, bladder volume training, bed wetting alarm system, or medications (e.g. desmopressin, imipramine, anticholinergic therapy). Postmicturition dribble is the complaint of an involuntary loss of urine immediately after passing urine. Causes, such as a urethral diverticulum, urethral obstruction, or vaginal entrapment need to be considered. Overflow incontinence refers to leakage of urine associated with incomplete bladder emptying. This can be as a result of impaired detrusor contractility (e.g. idiopathic, diabetes mellitus, after epidural anaesthesia, after major pelvic surgery) or with bladder outlet obstruction caused by prostatic enlargement, urethral stricture or tumour.

All of the above

Incontinence can have a distressing and detrimental effect on relationships. The precise mechanism may be due to detrusor overactivity or related to mechanical pressure with a weak sphincter. It may occur at time of penetration or orgasm. Twenty-five per cent of incontinent women suffer incontinence during sexual intercourse, typically with penetration.⁽²³⁾ Management includes treating any underlying bladder dysfunction, change of position to alleviate pressure on the bladder, and emptying the bladder prior to and after sexual intercourse.

Thorough clinical history of symptoms and physical examination Bladder diary for at least three days MSU to exclude a UTI Assess post-void residual volume with urinary tract ultrasound unless straightforward uncomplicated SUI.

Pelvic organ prolapse is defined as downward displacement of pelvic organs resulting in herniation of these organs into or through the vagina(uterovaginal prolapse) or anal canal.⁽²⁴⁾

Urological Society of Australia and New Zealand

Interstitial cystitis or painful bladder syndrome information sheet

Therapeutic guidelines

Interstitial Cystitis Association

Family Planning NSW fact sheets:

The pelvic floor  Pelvic floor awareness

Kidney Health Australia fact sheets

Jean Hailes for Women’s Health – many resources including fact sheets, webinars and website information

Royal Women’s Hospital Victoria – fact sheets in different languages on Urinary Incontinence, Urodynamic Bladder Test, Interstitial Cystitis, Bladder Training

Continence Foundation of Australia

Bladder Management Problems and Self-Assessment Questionnaire Bladder Diary

Pelvic floor first

National Continence Helpline – phone: 1800 330 066 (free call) – directory of local services including physiotherapists and continence nurses

Australia Dept of Social Services Bladder and Bowel – useful information for patients and Health Professionals, including information about the Continence Aids Payment Scheme (CAPS), fact sheets in a variety of languages and the national public toilet map

National Institute for Health and Clinical Excellence guide:

Urinary Incontinence and Pelvic Organ Prolapse in Women: Management 

UroGynaecological Society of Australasia – patient resources

Australian Commission on Safety and Quality in Healthcare fact sheets:

Treatment Options for Pelvic Organ Prolapse Treatment options for Stress Urinary Incontinence Transvaginal Mesh

Australian Physiotherapy Association

Telephone interpreter service – phone: 131 450

Car J. Urinary tract infections in women: diagnosis and management in primary care. BMJ. 2006;332(7533):94-7. Imam T. Bacterial Urinary Tract Infections (UTIs). MSD Manual; 2018. eTG Complete [internet]. Therapeutic Guidelines; 2019. Antibiotic. Available from: https://tgldcdp.tg.org.au/guideLine?guidelinePage=Antibiotic&frompage=etgcomplete. Stamm W, McKevitt M, Roberts PL, White NJ. Natural history of recurrent urinary tract infections in women. Review of Infectious Diseases. 1991;13(1):77-84. Orenstein R, Wong ES. Urinary tract infections in adults. American Family Physicians. 1999;59(5):1225-34, 37. Munro R, Chamber I. Common Sense Pathology: Laboratory diagnosis of UTI. 5th edition. Sydney Royal College of Pathologists of Australasia; 2002. Dason S, Dason JT, Kapoor A. Guidelines for the diagnosis and managment of recurrent urinary tract infection in women. Canadian Urological Association Journal 2011;5(5):316-22. Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. The Cochrane Database of Systematic Reviews. 2008;April 16(2):CD005131. Hanno P, Burks DA, Clemens JQ, Dmochowski RR, Erickson D, FitzGerald MP, et al. Diagnosis and Treatment Interstitial Cystitis/Bladder Pain Syndrome (2014). American Urological Association; 2014. Available from: https://www.auanet.org/guidelines/interstitial-cystitis-(ic/bps)-guideline. Interstitial Cystitis Association. Diagnosis of IC [internet]. Interstitial Cystitis Association; 2011 [updated 2016 Mar 28]. Available from: https://www.ichelp.org/diagnosis-treatment/diagnosis-of-ic/. Yeoh M, Kid Lai N, Anderson