Broken nights: new thinking on why men get up to urinate

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Broken nights: new thinking on why men get up to urinate

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Broken nights: new thinking on why men get up to pass water
Source: AFR

Men whose sleep is broken by trips to the toilet are being urged to think differently about why they need to get up so many times during the night.

Most men automatically blame their prostate. They assume it has grown large with age and is interfering with their flow.

But women get up at night too and they don't have a prostate. So, what's going on?

When his male patients have this problem, Professor Gary Wittert, director of the Freemasons Foundation Centre for Men's Health in Adelaide, suggests they look beyond their prostate and beyond their bladder too.

Wittert, an endocrinologist, says there is evidence to show it can be a marker for chronic disease processes that are under way in the body.

For this reason, the condition should not just be treated. First it should be investigated to identify and manage any underlying processes.

Underlying problems

Wittert, who is also head of the Discipline of Medicine at the University of Adelaide, belongs to an emerging group of researchers who believe that if the underlying problems are treated, the urinary symptoms will improve.

This, he says, this can be seen most dramatically in men with nocturia (getting up at least twice a night to pass water) and the treatment of sleep apnoea.

In some, just treating their sleep apnoea turns the tap off and they sleep through the night.

There are two broad categories of urinary problems in men; those that interfere with the storage of urine and those that interfere with its flow.

The prostate can certainly obstruct flow. Urine that tries to leave the bladder may be blocked, delayed or reduced by a swollen prostate.

This can lead to difficulty initiating urination, a poor stream, an after dribble and a sense of incomplete emptying of the bladder.

When the prostate is shrunk with medication or rebored surgically, flow resumes and men can usually void their bladders more easily.

Storage problem

While a big prostate can contribute to nocturia, Wittert says it's usually not the sole cause and often it's not the cause at all.

Nocturia mostly results from a storage problem. Other storage problems include "frequency", which is passing water nine or more times a day; "urgency" which is feeling unable to hold on; and "urge incontinence" which occurs when an intense urge is followed by an uncontrolled loss of urine.

He says these storage issues are mostly caused by factors beyond the bladder's control.

After doing a sabbatical at the New England Research Institutes in Boston in 2010, Wittert became interested in the broader implications of bladder storage problems and has now co-published several papers on the subject.

While the bladder may look like a balloon, he says it behaves differently. When a balloon is filled with air, it distends and pressure on its wall increases. When the pressure gets too great, the balloon bursts.

In contrast, the bladder is designed to fill and empty millions of times during its life. Its walls are made of smooth muscle, which relaxes to accommodate the increasing volume so there is little tension with the distension.

The walls of blood vessels and the airways in the lungs also have smooth muscle that accommodates changes in volume without undue increases in wall tension.

Regardless of where it is in the body, smooth muscle functions in similar ways but, Wittert says, lifestyle factors can affect this functioning.

Relaxation mechanism

Factors such as inflammation, elevated blood sugar and high blood fats can irritate the muscle, making it contract or unable to relax the way it should.

This can happen with high blood pressure and asthma.

Wittert says that when the relaxation mechanism is disturbed in the bladder wall, tension increases early in the distension process. The wall wants to contract and empty the bladder rather than relax to accommodate the fluid.

As a result, the man gets a sense of wanting to void frequently or urgently, and sometimes can't hold on.

"This is known as an overactive bladder," he says.

"The prostate can have a secondary effect and make the bladder irritable but generally it is not the primary problem and there is no relationship between the size of the prostate and the presence of these symptoms."

"Indeed, a man may have a very big prostate and no storage symptoms or a small prostate and significant problems.

"So, when it comes to an overactive bladder, I tell my patients it is seldom the prostate and they should look beyond it and beyond the bladder too."

Causative factors

That is after other causative factors have been ruled out, such as progressive neurological diseases, cancer, medication and infection.

Just as physical inactivity, obesity and a low-fibre diet can affect artery walls and contribute to high blood pressure, they can also affect the bladder wall, Wittert says.

But how can lots of fibre help the bladder? He says a man on a high-fibre diet is likely to have better blood sugars and less inflammation in his body, and that helps.

In addition to obstructive sleep apnoea, Wittert says smoking and diabetes are significant risk factors for an irritable or overactive bladder.

In his research on these broad underlying processes, he has worked closely with Dr Sean Martin, an NHRMRC post-doctoral fellow at the University of Adelaide, whose PhD was on this subject.

Wittert now encourages GPs to ask their male patients about whether they get up at night. "It's such an easy question and it can reveal so much."

The research by him and Martin shows that men with storage issues are likely to have a higher risk of diabetes, cardiovascular disease, apnoea, erectile dysfunction and depression.

"One interesting observation is the very strong association between nocturia and depression. This creates an opportunity for the GP because the diagnosis of depression is often overlooked in men."

Association with nocturia

He says the association with sleep apnoea is clear. "One in four men over the age of 40 have moderate to severe obstructive sleep apnoea and many don't know it. Their doctors think the most important indicator of this condition is sleepiness."

"But while there is only a 12 per cent association with sleepiness, there is a 60 per cent association with nocturia. So, asking about nocturia can be very useful."

Last month, the Medical Journal of Australia published a position statement on the management of the overactive bladder in the absence of nerve damage.

Formulated by members of the Urological Society of Australia and New Zealand, and the UroGynaecological Society of Australasia, it focused closely on how to treat the condition, which has "a low likelihood of cure".

The statement says an overactive bladder is also likely to be under-diagnosed and under-treated due to lack of awareness, embarrassment and the misconception that it is a natural consequence of ageing.

While the development of this condition remains unclear, it says it is likely to involve multiple factors.
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amnesia
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Re: Broken nights: new thinking on why men get up to urinate

Post by amnesia »

“That is after other causative factors have been ruled out, such as progressive neurological diseases, cancer, medication and infection.”

How do you rule out “progressive neurological diseases”?
Age: 36 | Onset Age: 36 | Symptoms: Discharge (sticky and clear/offwhite); frequent need to pee, often caused by feeling of tickle / itch / burn / pressure in penis; sometimes dull ache in testicles | Helped By: not sure yet | Worsened By: catastrophic thinking, worrying things will get worse, feeling depressed, reading websites too often | Other comments: Happened after unprotected sex, initial STI likely | Details here: viewtopic.php?f=37&t=9139
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Re: Broken nights: new thinking on why men get up to urinate

Post by webslave »

amnesia wrote: Mon Dec 16, 2019 11:53 am How do you rule out “progressive neurological diseases”?
Diseases like multiple sclerosis, motor neurone disease, and Parkinson's disease have well defined diagnostic criteria.
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