Hypermobility Living with an HMS Bladder and Pelvic Floor Introduction In this article Dr Alan Hakim describes bladder symptoms that are often present in the hypermobility syndromes. It is not clear whether these symptoms are more common in hypermobility than in the general population. However treatments (in particular surgery, and advice of fluid intake) may require modification to account for problems that tend to arise in the hypermobility syndromes. The common tests and medical treatments are highlighted. Claire-Anne Head, Women’s Health Physiotherapist then offers advice and discusses some of the self-help techniques used to regain bladder, bowel, and pelvic floor health. Bladder Symptoms Bladder dysfunction is common in the female general population and manifests as ‘urgency’ (desperate need to pass urine), ‘frequency’ (having to pass urine on a number of occasions throughout the day), and ‘nocturia’ (needing to pass urine at night), very often associated with pelvic discomfort/pain, and with an increased risk of stress or urgency incontinence of urine. An ‘over-active bladder’ (OAB) is common in both men and women and related to neuromuscular instability of the bladder wall and controlling sphincter muscles. There is no clear answer as to whether there is an increased risk of these various bladder disorders in the hypermobility syndromes. Some studies show a modest increased risk and others no more risk that in the general population. Perhaps more important than risk is the mechanism by which these conditions arise and the treatments that can be offered. The causes of urinary tract dysfunction in the hypermobility syndromes may be related to changes in the anatomy of the bladder and pelvis, or may be neurological and affecting the sympathetic nerve autonomic control of the bladder, psychogenic (influenced by things like anxiety and pain), or as a consequence of infection and inflammation of the urinary tract. It is also important to consider the presence of bowel problems too in the hypermobility syndromes as things like chronic constipation may affect bladder function. Pain may not be felt over the bladder. It may be felt in any part of the pelvis or the lower back or buttocks. It might be mistaken for some other cause of pain; equally other causes of pain should always be considered. Tests Assessments and tests that might be undertaken include: A visual examination for prolapse and other anatomical issues Urine tests to exclude inflammation or infection. Often a Dipstix analysis strip or similar test done in clinic will suggest to your doctor or nurse that there is an infection but when the urine is examined further in the lab infection an infection is not found. It may be that the Dipstix test is actually picking up inflammation in the bladder rather than infection; the Dipstix clinic test can look the same in both cases. To add to the complexity, in some cases there may actually be infection even though it was not found in the urine in the lab – this is because the infection lies deep in the bladder wall tissues and might only be found after biopsy or cell samples have been taken during a cystoscopy. A bladder diary, recording daily events – number of times passed urine, time it takes to pass urine, volume of urine etc., Bladder filling and measurement of bladder pressures. This can be performed in clinic, gently filling the bladder after normal voiding of urine. It may be helpful in conjunction with a stress test to see if the bladder leaks due to increased pressure e.g. induced by coughing. Measures of bladder emptying, e.g. volume of urine left after voiding. These tests are called ‘Pressure-flow’ studies and ‘Urodynamics’ Tests of function and mobility of the urethra (the tube that conveys urine from the bladder out of the body) and the pelvic floor A cystoscopy (a telescopic camera passed in to the bladder via the urethra) and a biopsy (tissue sample) of the inner lining on the bladder Perhaps in the not too distant future things called ‘Biomarkers’ may become available for doctors to use.. Biomarkers are chemicals or proteins, or genes, that can be tested from blood and cells and inform doctors of the likely risks or presence of conditions like bladder inflammation. Most of these tests require specialist expertise and treatment will very much depend on the findings. Treatments In most cases conservative (non surgical) treatments will apply. This section highlights some of the more common things that your doctor or a specialist might advise you try. The medications mentioned may not apply to you – it depends on the nature of the problem found. Lifestyle advice is an important aspect of treatment – please see the section below with the title ‘Keeping Your Bladder and Bowels Healthy’. If pain is present on passing urine there may be a tendency to avoid fluids in the hope this reduces urine output. This is not a sensible thing to do. A balanced intake of about 2 litres a day is important to maintain. Patients who are trying to control cardiovascular symptoms such as POTs and Orthostatic Hypotension may be taking in excess of this and this may be upsetting the bladder. A comprehensive assessment and a discussion of fluid balance may be needed. One sign that the balance is about right is the colour of the urine – a pale straw yellow is right – too yellow or orange is too dehydrated, and colourless is too over-hydrated. Pelvic floor muscle training may be effective in individuals with urgency incontinence. A therapist might also introduce a bladder re-education programme with biofeedback and bladder drill. Sometimes manipulation of trigger points on the pelvic floor may help. Again, please see the section below, ‘Keeping Your Bladder and Bowels Healthy’. Drug therapies are available for OAB. The most commonly used ones are oxybutynin, tolterodine or festerodine, propiverine, trospium, solifenacin, darifenacin, and Beta-3 agonists such as Miragegron. Desmopressin is a drug used to treat nocturia (night time passing of urine) and nocturnal enuresis (bed-wetting). The major concern with desmopressin is that it can cause low blood sodium which can be harmful. Botulinum toxin (Botox) injections to the bladder may offer an alternative in those with intractable bladder muscle over activity. Nerves supplying the bladder and pelvic muscles may also be treated by stimulation of the sacral nerves (‘neuromodulation’); this may also assist in specific cases. Surgery to the bladder or pelvis The detail of the various surgical procedures to the bladder and pelvic floor are beyond the scope of this review. However the following issues in hypermobility syndromes should always be considered: Fragility and elasticity of tissues, Tendency to bleed, Delayed healing, Abnormal scarring, and Resistance to local anaesthetics. Keeping your Bladder and Bowels Healthy Lifestyle advice A common mistake made by those with bladder symptoms is to restrict their fluid intake. This only serves to make things worse as too little fluid results in more concentrated urine which can irritate the bladder and cause increased frequency and urgency. You should aim for your urine to be a pale straw colour. Remember you don’t need to only drink water but your fluid intake can come from other drinks and foods such as soup. It’s advisable to drink small amounts of fluid throughout the day rather than a large drink all at once as this will often cause you to go to the toilet more often. If you notice you need to go to the toilet frequently and urgently it may be worth thinking about what you’re eating and drinking. Certain foods and drinks can irritate your bladder. Caffeinated drinks like tea and coffee as well as alcohol increase urine production as they act like diuretics. This can result in a need to go to the toilet more frequently and an urgency to empty your bladder. Below is a list of other foods and drinks that can also irritate your bladder: Artificial sweeteners Sugar Coke Chocolate Carbonated / fizzy drinks Certain acidic fruits and fruit juices like oranges, lemons, limes and grapefruits Spicy foods Tomato based products Everyone is different – what causes irritation of the bladder can vary from person to person. If you drink a lot of tea and coffee it’s worth cutting this out for a week or so to see if your symptoms improve. It may also be worth avoiding foods that have the potential to irritate your bladder. Gradually add one food back into your diet and make a note of any urinary changes as you do this. You don’t always have to eliminate – cutting down can really make a difference in some cases. Retrain the Bladder All too often when you have an overactive bladder you end up going to the toilet too frequently, at the slightest urge and to avoid being ‘caught short’. This allows your bladder to develop bad habits so it starts sending messages to your brain telling it it’s full when it’s not. Bladder retraining helps the bladder to hold more urine by slowly stretching it. It does take time so you need to persevere. Firstly it’s a good idea to keep a record of what you drink, how often and how much you pass urine. This can help your physiotherapist or doctor to work out a schedule for you. When you have the urge to go to the toilet remember to! Keep calm – don’t panic Distract yourself Try not to focus on the need to empty your bladder Sit on a hard surface Stand still with your legs crossed or squeeze your buttocks Squeeze your pelvic floor Often the urge to pass urine will pass or lessen. Once you feel relaxed, slowly make your way to the bathroom if you still need to but ideally try to hold on for another 15 minutes. Over time, this practice can be very effective in reducing the feelings of urgency. Each week try holding on for another 15 minutes so you increase the intervals between going to the toilet. Your aim is to try to empty your bladder every three hours. Constipation Constipation will often make bladder symptoms worse and straining to empty your bowels will place a lot of pressure on the pelvic floor muscles and ligaments which can cause damage to these over time. Below are a few tips to help prevent / manage constipation: Exercise. Taking part in regular exercise is great for your general health but it also helps to stimulate the gut to work effectively. Fibre. Eat foods high in fibre such as fruit, nuts, seeds and vegetables. These are a good source of magnesium too which is good for constipation. Routine. Bowels often respond well to routine. It is most common for your bowels to empty after your first meal of the day so that’s why it’s important to not miss breakfast. If you can’t face eating anything when you first get up have something warm to drink. Try not to delay the urge to empty your bowels as this causes water to be reabsorbed from your stool making it drier and harder to pass. Position. Sitting in the correct position on the toilet can make a big difference to how easy it is to empty your bowels. Try leaning your forearms on to your thighs and relaxing. Some people find it really helpful to have a footstool under their feet (one like toddlers use to reach the sink is perfect). When you empty your bowels your back passage needs to relax. Remember to keep breathing – don’t hold your breath and push as this means you are straining and this often causes your bottom to close more tightly. Pelvic Floor Exercises The pelvic floor muscles help to give you better control over your bladder and bowels and prevent incontinence. They also support your pelvic organs (bladder, uterus and rectum). Constipation, chronic coughs, being overweight, persistent heavy lifting, pregnancy, vaginal deliveries, long periods of inactivity due to illness or surgery all weaken your pelvic floor muscles. Increasing the strength in these muscles is important when problems occur but it’s important to maintain strength in them to prevent problems occurring. Imagine you are trying to stop the flow of urine mid flow and at the same time trying to stop yourself from breaking wind. You should not be holding your breath, pulling in your tummy or squeezing your bottom muscles or legs together. Try to hold the contraction for as long as you can (your aim is to hold for 10 seconds). You should feel the muscles lower as you let go. If you can’t feel this sensation it’s probably because you have already let go so try again. Rest for four seconds between each contraction and aim to repeat 10 times. You now need to train the muscle to tighten quickly when you cough, laugh or lift something heavy. Squeeze your pelvic floor and let go immediately. Aim to repeat 10 times. Try to do these exercises 3 to 4 times a day. Some people notice a difference after just a few weeks but it may take 3 to 6 months to see good results. Dr Alan J Hakim MA FRCP, Consultant Physician and Rheumatologist and Claire-Anne Head, Clinical Lead for Women’s Health Physiotherapy, Hospital of St John and St Elizabeth, London If you would like the clinical references for the information used in this article, please contact us via the Information Standards Enquiry from.