I am 52 now and stopped taking the imipramine about 12 years ago (after a month’s treatment). The symptoms (urgency to urinate, getting up several times in the night) returned a week or so after I stopped taking the drug, and I have lived with the problem ever since. A T, Pontefract, West Yorkshire……

A:It may be some comfort to know that you are not alone. Urinary incontinence, as it is formally referred to, affects some three million adults and a half million children in the UK, , or up to nearly a third of elderly people and one adult in 15, at some point in their lives. In the US in 1987, over $10 billion was spent attempting to manage incontinence, more than the amount spent on dialysis and bypass surgery combined (The Lancet, July 8, 1995)! Nevertheless, so many adults are embarrassed and ashamed of the problem that they live with it for many years in secret dispair.

To understand the problem fully, it’s necessary to understand how the lower plumbing works. The bladder sends urine to the urethra, the tube leading out of you, via two rings of muscles, called sphincters. The first of these, which prevents leakage, is controlled involuntarily, but the second sphincter is under our control and the muscle you relax when you urinate. As the water begins to pass, the muscles of the bladder (called the detrusor muscles) contract, sending the urine out.

From what you describe, you may have one of the most common type of established incontinence, which is referred to as “detrusor overactivity”, in which the bladder muscle contracts involuntarily. The usual hallmark of this type of incontinence is a sudden, overwhelming need to urinate, often in the night. It may simply be instability of the muscle (as you appear to have) or be due to a central nervous system disease. As people get older, the bladder capacity, its ability to contract and your ability to postpone urination or control bladder contractions declines; in women the length of the urethra and its ability to close also decrease. In men, it may often be caused by an enlarged prostate, causing retention of urine on top of the other symptoms.

A enormous laundry list of drugs cause incontinence. These include: potent diuretics, antipsychotics, anti-parkinsonian drugs, sedatives and sleeping pills, such as diazepam (Valium) and the other benzodiazepines, certain narcotic analgesics, calcium channel blockers, ACE inhibitors and nasal decongestants (The Lancet, July 8, 1995). Because older adults are often taking one or more of those drugs, they may be behind the frequency of incontinence among the the elderly.

Another largely unrecognized cause of incontinence in adults and children can be food or chemical allergy or intolerance. Allergies cause swelling throughout the body. Oftentimes in the middle of the night, this swelling goes down, and water accumulated in the tissues

is sent to the kidneys and onto the bladder. Any difficulty in controlling the bladder muscles would then be exacerbated.

Usually, patients with incontinence get hopelessly mismanaged. Ironically, two of the mainstays of drug treatment for the problem anticholinergic drugs and antidepressant drugs like imipramine can themselves cause incontinence!

Anticholinergics work (and only in some 60 per cent of cases) by blocking the nerves that control the bladder, and theoretically reduce the leakage of urine. Antidepressant drugs like imipramine one of the favoured drugs for bedwetting in children may work with essentially the same effect. We don’t blame you for quitting the drugs you were taking, which only relieve the symptoms, rather than the underlying cause, but with a host of other problems thrown into the bargain. These include memory problems, disturbed attention span, delirum, dry mouth, confusion, blurred vision, sexual dysfunction, worsening of glaucoma, fatigue and sleepiness, dangerous lowering of blood pressure or rapid heart beat, and even heart attacks or stroke.

If you haven’t been thoroughly investigated, it may be worth undergoing a few tests to determine the cause of incontinence, but avoid x-rays using dye. You should also have your doctor rule out a urinary infection or diabetes or any disease of the nervous system which can cause an unstable bladder. A simple rectal exam will also determine whether an enlarged prostate is a contributing factor. (If it is, try to investigate non-surgical solutions, since having your prostate removed often causes the very problem you’re trying to solve (see WDDTY vol 4 no 1 for some suggestions).

There are many other successful non-medical solutions. The first is to working with a trained practitioner to determine whether you have any

allergies, which add to your bladder’s burden.

The Incontinence Information Bureau says that simple pelvic floor exercises in which you periodically tighten the pelvic muscles can help both men and women control both urine and bowel leakage. However, you have to be prepared to do between 30-200 of them a day (The Lancet, 8 July 1995).

A safe and highly effective solution for incontinence stemming from an uncontrollable bladder muscle is a bladder “retraining” programme. In the programme, you are often first asked to keep a diary recording how much you drink, how often you pass water and how much urine results. The object is now to extend the time between urination. If you are incontinent every three hours, you are told to urinate every two hours and to suppress any urgency in between. Once you remain dry, you attempt to extend this interval by half an hour by repeating the process, until you have achieved satisfactory control. According to Dr Neil M Resnick, of the Gerontology Division of Brigham and Women’s Hospital in Boston, you don’t need to work on retraining at night because success in the daytime will be mirrored at night (The Lancet, July 8, 1995).

Another possibility which also has good success is adding biofeedback to the process, in which you are taught how to use a number of techniques to stop or reduce your feelings of having to go to the toilet. Both techniques must be faithfully practised to avoid relapse. Another possibility which claims some success is acupuncture.

For more information, you can contact the Incontinence Information

Bureau, PO Box 29, Green Lane, Tewkesbury, Gloucester GL20 8YB, which can provide you with a full information pack about bladder retraining programmes.

A review of the literature by researchers in California found that the women less than age 60 at the time of the operation had no increased likelihood of becoming incontinent whereas women over 60 were up to 60 per cent more likely to do so. Also, the symptoms don’t appear until some five to ten years after the surgery.

The researchers concluded that women are often not adequately counselled to allow them to weigh up the short term benefits versus the long term risks of hysterectomy (Lancet, 2000; 356: 535-9).

One popular way to rearrange statistics in cancer studies is to consider only survivors as those who have “completed treatment” and to not count the fatalities who, for obvious reasons, have failed to complete the trial.

After correcting for these inaccuracies, a large population-based study comparing overall and prostate-cancer survival in almost 60,000 men with prostate cancer treated by various methods concluded that previous studies “have generally overestimated the benefits of radical prostatectomy” (Lancet, 1997; 349: 906-10).

No controlled trials have successfully demonstrated that active intervention increases survival in men with prostate cancer. A 10-year randomized trial of men with early disease that compared radical prostatectomy with watchful waiting (monitoring disease progression without undergoing aggressive treatment) found that, although fewer men who had surgery died of prostate cancer, prostatectomy did not improve overall survival (N Engl J Med, 2002; 347: 781-9).

After more than 20 years, men who have had radical prostatectomy have survival rates that, on average, are the same as those with low-grade, low-stage, untreated prostate cancer (Scand J Urol Nephrol Suppl, 1995; 172: 65-72). In addition, if you are over 65 with low-grade prostate cancer and don’t opt for surgery, you have the same life expectancy as anyone else (JAMA, 1995; 274: 626-31).

Worryingly, surgery may not catch the cancer or even spread it (J Urol, 1996; 155: 238-42). Among Medicare patients in the US who underwent prostatectomy, 28 per cent reported needing follow-up treatment for cancer – such as radiation or androgen-deprivation therapy – four years after the operation (Urology, 1993; 42: 622-9).

Diagnosis and disease progression
Each year, around 22,000 cases of prostate cancer are diagnosed in the UK (and 220,000 in the US), making prostate cancer the most common form of male cancer in the UK, and the second-most common (after skin cancer) in the US. But these statistics may simply be reflecting the fact that this disease is detected through a highly inaccurate screening blood test (see box).

Men with elevated prostate-specific antigen (PSA) levels are referred for biopsy – which can draw attention to very early prostate cancer in asymptomatic men – in the belief that early aggressive treatment is more beneficial than the evidence actually suggests (Am J Med, 1998; 104: 526-32). The majority of these men end up undergoing radical prostatectomy, although early disease does not necessarily warrant it (Prostate Cancer Prostatic Dis, 2005; e-pub ahead of print).

And even if you didn’t have advanced cancer in the first place, studies have found that taking a biopsy sample from an otherwise intact tumor can cause dissemination, or ‘seeding’, of cancer cells (Urologe A, 2005; 44: 64-7).

In most cases, prostate cancer is slow to grow, taking several years to become a detectable problem (and even longer to metastasize beyond the prostate). However, a small percentage of patients experience more rapidly growing, aggressive forms of this cancer. Biopsy can determine cancer aggressiveness through the so-called Gleason score. This is a number from one to 10 used to describe the more the tissue varies from normal. Nevertheless, there is no evidence to link the Gleason score to an increased chance of survival.

Types of surgery
Radical prostatectomy can be carried out using various techniques such as the radical perineal approach (cutting through the perineum, the area lying between the testicles and anus), the radical retropubic approach (through the lower abdomen) or by laparoscopy (keyhole surgery).

The retropubic approach
* is associated with greater loss of blood requiring transfusion (in one study all retropubic patients required transfusion compared with a little more than half in the perineal prostatectomy group (Br J Urol, 1994; 74: 626-9)

* has higher rates of urinary incontinence and urethral narrowing (J Urol, 1998; 160: 454-8; Br J Urol, 1994; 74: 626-9).

The perineal approach
* results in higher rates of faecal incontinence (J Urol, 1998; 160: 454-8)

* is associated with fewer overall complications than the retropubic approach (J Urol, 2005; 173: 1863-70)

* is usually recommended for men with pubic arches that allow for easy removal of the prostate gland.

Nerve-sparing surgery
* is an option if the cancer has not spread beyond the prostate and only a small amount of the surrounding healthy tissue is to be removed

* supposedly reduces the likelihood of erectile dysfunction (impotence) and urinary incontinence, but may be of limited benefit (JAMA, 2005; 293: 2648-53; J Natl Cancer Inst, 1997; 89: 1117-23).

Laparoscopic prostatectomy
* employs a thin, tubelike instrument – or even a surgeon-controlled robotic arm – that allows the procedure to be done via tiny, minimally invasive, ‘keyhole’ incisions

* requires fewer days of bladder catheterisation

* results in less blood loss during surgery and possibly an earlier recovery of nocturnal continence (Urology, 2003; 62: 292-7)

* requires a skilled and experienced hand, as even small differences in technique can affect the outcome (J Urol, 2005; 173: 2099-103)

* has no proven advantage over open prostatectomy.

What doctors don’t tell you
A large body of research shows that this get-in-there-early surgery can cause:

* erectile dysfunction in 60-89 per cent of men following radical prostatectomy (Urology, 1993; 42: 622-9). With nerve-sparing surgery, 60-85 per cent of men recover erectile function, but it could be up to two years later (JAMA, 2005; 293: 2648-53)

* persistent urinary incontinence. In one study five years after surgery, 30 per cent still had to wear pads or clamps, and more than 40 per cent reported occasional incontinence (Urology, 1993; 42: 622-9).

* deep vein thrombosis or fatal pulmonary embolism weeks after surgery (J Urol, 1997; 158: 6)

8 further surgery. In the US Medicare study, 6 per cent of radical prostatectomy patients needed additional surgery for incontinence, 20 per cent needed postoperative treatment to combat urethral narrowing and 15 per cent sought help for sexual dysfunction (Urology, 1993; 42: 622-9). With laparoscopy, nearly 4 per cent had to correct postsurgical complications (J Urol, 2002; 167: 51-6).

Incontinence means that either the muscles or nerves are not working properly to control your bladder. ‘Stress incontinence’ is where a small amount of urine leaks during physical activity; ‘urge incontinence’ is when the bladder empties completely.

Severe stress incontinence is usually treated surgically by colposuspension, where the bladder opening (neck) is stitched back into its normal position. Generally carried out under general anaesthesia with a hospital rest of a week, it can still take two or more months to recuperate fully.

Currently, Eli Lilly’s Yentreve (duloxetine) is the only drug available for stress incontinence. Its long-term consequences are not yet known but, according to the package insert, side-effects include nausea, vomiting, itching, insomnia, increased sweating, low sex drive and inability to have an orgasm.

For urge incontinence, GPs often prescribe anticholinergics such as oxybutynin, tolterodine and propiverine to relax the bladder. These also come with a raft of serious side-effects, many affecting the heart. And they can make an overactive thyroid worse, and cause heat prostration and hiatal hernia in addition to dry mouth, constipation, blurred vision and drowsiness.

Treating incontinence early could spare you from major surgery or drugs. Some alternatives that your doctor may suggest are:
* bladder control training, using:
pelvic muscle (Kegel) exercises to strengthen the muscles that help you to hold urine in your bladder longer
biofeedback, where electronic devices inserted into the vagina or rectum can help you to become more aware of your body’s signals. Biofeedback-assisted behavioural therapy significantly reduced incontinence compared with oxybutynin therapy (Urology, 2004; 63 [3 Suppl 1]: 58-64)
timed voiding and bladder training, where you keep a chart of urination and leaking to find a pattern. Once you learn that, you can plan to empty your bladder before you leak.

* a pessary, a small, tampon-like urethral plug. In a study of advanced pelvic organ prolapse, 62.5 per cent of patients continued to use pessaries and avoided surgery (Int Urogynecol J Pelvic Floor Dysfunct, 2005 May 10; e-pub ahead of print)

* absorbent pads and underclothing

* vaginal cones. These are cones that are held in the vagina for increasing periods of time, and help to strengthen the pelvic floor muscles.

Higher incontinence rates are also associated with obesity and carbonated drinks, whereas eating bread reduces the risk (BJU Int, 2003; 92: 69-77).

* Take herbs to calm and heal your bladder, which may ease or eliminate symptoms. A homoeopath may recommend remedies such as Causticum or Euryale for bladder control.

* Take magnesium. In a double-blind, placebo-controlled study of 40 women with urge incontinence, 11 of the 20 who were taking magnesium reported an improvement in their urinary symptoms compared with only five of the 20 taking a placebo (Br J Obstet Gynaecol, 1998; 105: 667-9).

* Ditch hormones. HRT (hormone replacement therapy) can make incontinence worse (Obstet Gynecol, 2001; 97: 116-20). Try supplementing with vitamins A, C, D, E and selenium instead.

* Try using the Conveen Continence Guard. This arch-shaped polyurethane-foam device is inserted into the vagina, and its two ‘wings’ are designed to support the bladder neck. Of the 28 women with complicated stress incontinence who used the product, 84.2 per cent were cured or improved (according to objective measures) after three weeks (Acta Obstet Gynecol Scand, 2000; 79: 1052-5). The device can be purchased from selected high-street pharmacies for around £15.

Women tend to experience involuntary urination after childbirth, surgery, or inflammation of the urethra, while men tend to get it if they have a prostate problem. Also, certain prescription or over-the-counter drugs can cause this problem; check with your doctor or read about whatever drug(s) you are taking in the Physician’s Desk Reference or some other popular drug compendium.

There are three types of involuntary urination: 1) stress incontinence, 2) overactive bladder, and 3) overflow incontinence. Stress incontinence leads to a weakened bladder, usually from childbirth or surgery, in which the person accidentally urinates while coughing or laughing. An overactive bladder occurs when the lining of the bladder is hyperactive, causing spasms. Parkinson’s disease, cancer, Alzheimer’s disease, and enlarged prostate can lead to this condition. Overflow incontinence occurs when a disease process prevents the easy emptying of the bladder, causing the person to urinate once an overflow condition is reached.

Whatever the cause of involuntary urination, any symptom must be recognized as a symptom of another problem. It is important to recognize that the word “symptom” is taken from Greek and means “sign” or “signal.” As such, a symptom is a sign or signal of something wrong, and treating it does not necessarily correct that something wrong. In fact, treating a symptom is like unscrewing your car’s oil light because it is blinking. Although such treatment “works,” it does not solve the fundamental problem of the car’s oil pressure.

Likewise, a drug may temporarily get rid of a symptom, but unless it deals with the underlying factors that led to the symptom, the condition will return.

The best way to treat a person who experiences involuntary urination with homeopathic medicines is to seek professional homeopathic care. A homeopath would individualize a natural remedy for the person based on the totality of their symptoms, not just their bladder symptoms. This individualized remedy would strengthen the person’s overall immune and defense system, not only potentially eliminating the symptom but curing the underlying disease.

Although it is preferable and ultimately most effective to seek professional homeopathic care, there are homeopathic medicines that people can learn to use on their own. In fact, a product, called EnurAid, includes many of these homeopathic medicines. It is surprisingly inexpensive, and because it is non-toxic and non-addictive, there is very little risk in trying this remedy.

The following homeopathic medicines, many of which are included in EnurAid, can strengthen your bladder and alleviate some of the discomfort you are feeling.

Homeopathic Medicines

Arnica (Leopard’s bane) is invaluable for involuntary urination after surgery.

Belladonna (deadly nightshade) is effective for people who tend to dribble urine when cold or chilled. They may experience burning pains along the length of the urethra during urination. They tend to have wild dreams, often dreams of urinating.

Causticum is useful when involuntary urination is worse in the winter and better in the summer. Various fears and apprehensions accompany the urination, especially fears that something bad will happen to them. They have a fear of going to bed in the dark. These people also tend to wet their pants when they cough or sneeze or even laugh.

Equisetum (Scouring rush) is for people who wet their pants or their bed for no known reason other than out of habit. It should be considered when the person has no other obvious symptoms. It should also be given when the person experiences wild dreams or nightmares when bedwetting. They tend to dream of crowds of people.

Ferrum phos (iron phosphate) is most effective for daytime wetting in the pants, especially when the person feels the strongest urges while standing. Their urgings to urinate are lessened while lying down.

Kreosotum (Beechwood) is helpful when the person has such a sudden urge to urinate that they do not have enough time to get out of bed to go to the bathroom, this remedy should be considered. These people tend to wet their bed during the first part of the night. Sometimes they will have dreams that they are urinating.

Lycopodium (Club moss) is valuable for people who are so anxious that they constantly worry about what others think of them tend to need this remedy. They usually have fears of trying anything new. They are more apt to wet the bed if they sleep in a warm or stuffy room. They prefer to sleep with an open window.

Taking and Accessing Homeopathic Medicines

Virtually every European city has homeopathic pharmacies, but most major American cities do not. Still, homeopathic medicines are often available in health food stores and in select pharmacies.

People who are new to homeopathy should ask for any of the above remedies in the 6th potency and should take them three or four times a day. If improvement is not noticed after one week, the remedy chosen was not the correct one, and because these remedies are not known to have side effects, no harm is created by trying them.

[a] Because
you may be uncomfortable during this part of the test, you may be given some
medication to help relax you.

Comments:

_______________________________________

An occasional sleepless night is nothing to worry about. But if insomnia bothers you for three weeks or longer, it can be a real medical problem. Some medical problems that lead to insomnia in women include:

• Depression and anxiety disorders.
  
• Over-activity of the thyroid gland.
  
• Heart or lung conditions that cause shortness of breath when lying down.
  
• Allergies and early-morning wheezing.
  
• Menopausal symptoms such as hot flashes.
  
• Any illness, injury or surgery that causes pain and/or discomfort, such as arthritis, which interrupts sleep.
  
• Any disorder (urinary, gastrointestinal or neurological) that makes it necessary to urinate or have a bowel movement during the night.
  
• Side effects of certain medications, such as decongestants and cortisone drugs.
  

Other things that lead to insomnia are:

• Emotional stress.
  
• Lack of a sex partner.
  
• Too much noise when falling asleep. This includes a snoring partner.
  
• Stimulants such as caffeine from coffee, tea, colas or chocolate and stay awake pills such as NoDoz.
  
• A lack of physical exercise.
  

The first line of treatment for insomnia is to look for and address the cause. For example, estrogen can help treat hot flashes in menopause. It comes in oral tablets or in a patch that is applied to the skin. Medication and other measures may be needed to treat other conditions that keep you from getting a full night’s sleep.

Do you have trouble falling or staying asleep because of: Pain or discomfort due to illness or injury? The need to wake up to use the bathroom? Hot flashes?
Has your sleep been disturbed since you began taking medication of any kind?
Do you still have trouble sleeping after 3 weeks, with or without self-care procedures? (See page 39)

Many old-fashioned remedies for sleeplessness work well. Next time you find yourself unable to sleep, try these time-tested cures:

• Get regular exercise, but don’t exercise for two hours before you plan to go to sleep.
  
• Avoid caffeine in all forms after lunchtime. Coffee, tea, chocolate, colas and some other soft drinks contain this stimulant as do certain over-the-counter and prescription drugs. Check the labels for ingredients.
  
• Avoid long naps during the day. Naps decrease the quality of nighttime sleep.
  
• Avoid more than one or two servings of alcoholic beverages at dinner time and during the rest of the evening. Even though alcohol is a sedative, it can disrupt sleep. Always check with your doctor about using alcohol if you are taking medications.
  
• Have food items rich in the amino acid L-tryptophan such as milk, turkey or tuna fish before you go to bed. Eating foods with carbohydrates such as cereal, breads and fruits may help as well. Do not, however, take L-tryptophan supplements.
  
• Take a nice, long, warm bath before bedtime. This soothes and unwinds tense muscles, leaving you relaxed enough to fall asleep.
  
• Read a book or do some repetitive, calm activity. Avoid distractions that may hold your attention and keep you awake, such as watching a suspense movie.
  
• Make your bedroom as comfortable as possible. Create a quiet, dark atmosphere. Use clean, fresh sheets and pillows and keep the room temperature comfortable, neither too warm nor too cold.
  
• Ban worry from the bedroom. Don’t allow yourself to rehash the mistakes of the day as you toss and turn.
• You’re off duty now. The idea is to associate your bed with sleep.
  
• Develop a regular bedtime routine. Locking or checking doors and windows, brushing your teeth and reading before you turn in every night primes you for sleep.
  
• Count those sheep! Counting slowly is a soothing, hypnotic activity. By picturing repetitive, monotonous images, you may bore yourself to sleep.
  
• Try listening to recordings made especially to help promote sleep. Check local bookstores.
  
• Don’t take over-the-counter sleeping pills or someone else’s sleep medicine. Only take sleep medicine with the advice of your doctor. Ask your doctor about taking an over-the-counter antihistamine, such as Benadryl. It may help promote sleep.