The Bladder and Urethra

The bladder is essentially a storage organ that exists in 2 phases, storage and voiding. It is hollow and can inflate like a balloon to store urine. When a normal bladder fills with urine, a patient will be unaware of any sensation until a certain volume is reached. This leads to the sensation of needing to pee, but the bladder will not contract and expel urine until the patient decides to (socially acceptable). At this stage the urethral sphincter relaxes and the bladder contracts leading to the passage of urine down the urethra to the outside.

Bladder Cancer

Every year 10,000 people in the UK are diagnosed with bladder cancer. It increases with age and is associated with smoking. 80% are early at diagnosis and grow on the inside lining of the bladder wall. These are often not dangerous, but if left can progress, invading the bladder wall and spreading to other parts of the body (metastasize).

The most common presentation of bladder cancer is with blood in the urine that is usually seen, but sometimes picked up on a 'dipstick'. If you experience these symptoms you should see a urologist. Occasionally bladder cancer can present with urine infections or a change in urination, such as the need to pee more frequently.

The diagnosis of bladder cancer is usually made with a series of blood and urine tests, some scans (CT or ultrasound), and a cystoscopy. A cystoscopy involves passing a very fine camera down the urethra and into the bladder. Local anaesthetic is used and the procedure only lasts a few minutes.

If a cancer is seen then the next step is to be admitted for a further cystoscopy under anaesthetic, where the cancer is either removed with a biopsy or scrapped away with (trans-urethral resection of a bladder tumour or TURBT). It is normal to put some chemotherapy into the bladder after this procedure (mitomycin), which is helpful in preventing recurrence. This procedure is usually performed under general anaesthesia, and may involve spending a night in hospital. Recovery afterwards is fast, but we advise restraining from physical activity for a couple of weeks afterwards. There are small risks of bleeding and urine infection. Very rarely a perforation is made in the wall of the bladder, which requires a catheter to be left in place for a week whilst the bladder heals.

For most bladder cancer this treatment is all that is required, with the final decision made after a pathologist examines the specimen that was removed. If a cancer has invaded the bladder wall then it might be necessary to have further treatment such as removal of the bladder.

Bladder cancer frequently recurs, and you will need to have regular cystoscopic follow up for up to 10 years.

Overactive Bladder

Overactive bladder syndrome is very common and can affect up to 20% of the population at some stage in their lifetime. It usually presents with needing to go to the toilet more frequently both in the day and nighttime. This can sometimes be very urgent, to the extent that sometimes patients will not make it in time (urge incontinence).

Treatment for this condition involves a number of conservative measures such as pelvic floor exercises, bladder retraining, and fluid management. There are several medications also licensed for this condition. Some of these are poorly tolerated because of side effects. There is a new class of drug available recently (Mirabegron), which may avoid these.

When these measures have failed there are alternative options such as putting Botox into the wall of bladder. This can performed under general or local anaesthesia, and can be up to 70% effective. There is a risk of not being able to pass urine afterwards, and so it is necessary to learn how to self catheterize before embarking on this treatment as a precaution.

Urinary Tract Infection

Urinary tract infections (UTI) are common, and are usually managed with the aid of the GP. Women have a lifetime risk of UTI of 1 in 3, and men 1 in 20. Symptoms include:

Burning when passing urine (dysuria)
Frequency and urgency
Blood in the urine (haemturia)
Abdominal pain

Risk factors include:

Sexual intercourse (honeymoon cystitis)
Being post menopausal
Poor emptying of the bladder
Stones
Diabetes
Urinary tract abnormalities (reflux, prostate enlargement) and / or surgery

Occasionally they can be very frequent causing distressing symptoms. In these situations it can be helpful to see a urologist to rule out any significant underlying cause and advise on further management. Investigations usually include a urine dipstick and culture (mid-stream urine or MSU), ultrasound of the urinary tract, assessment of bladder emptying and occasionally a cystoscopy. Provided pathology has been ruled out (stones etc), there are several ways that can be useful for prevention of recurrent urinary tract infections.

Conservative measures:

Not being overly hygienic (too much cleaning can harm the good protective bacteria in the vagina)
Wiping from front to back
Drinking lots of fluid
Wearing loose fitting cotton underwear
Drinking cranberry juice (this is controversial)
Taking D-mannose (may wash bacteria away)

Medical treatments

Low dose antibiotic prophylaxis involves taking a low dose of an appropriate antibiotic every night for long periods (6 months or more)
Self start antibiotics at home or taking an antibiotic after sex if that is the trigger
Rarely medication can be put directly into the bladder as an outpatient (Cystistat®)