Webinar 246 - Urinary Symptoms (Females), by Dr C H Asrani

Added: 2026-05-23

[00:00:00][music] >> Good evening, friends.

[00:00:12]Let's begin our 246th webinar.

[00:00:17]Four away from our 250th the milestone.

[00:00:22]Urinary symptoms in females.

[00:00:26]We all know that women present more with UTIs and other urinary symptoms than males.

[00:00:37]So, let's talk of urinary continence.

[00:00:41]Continence means control. What helps a female control her urination?

[00:00:50]It's a very complex mechanism.

[00:00:54]Requires a complex interaction between the brain, the nerves, and organs in pelvis, the bladder, and the muscles.

[00:01:07]The pelvic organs include the bladder, urethra, and muscles of the pelvic floor called the levator ani or pubococcygeal muscle.

[00:01:20]The bladder, we know has two functions, to store urine, and when the time comes to empty itself.

[00:01:32]This seems like a very simple concept, but there is a complex interplay between all the above listed variables, and then only a patient or a person can pass urine at will.

[00:01:52]The sphincter has to relax.

[00:01:55]The nerves have to get and pelvic floor muscles also have to cooperate.

[00:02:05]A feeling of bladder being full or the bladder not being full and subsequent beginning of emptying the bladder requires a coordinated action of nervous system, the nerves, the bladder muscle, the sphincters, and most importantly the pelvic floor.

[00:02:33]As we go ahead, you will see that pelvic floor plays a major role in certain complications or symptoms of urinary tract.

[00:02:45]Similarly, controlling a full bladder in the face of daily activity.

[00:02:53]You're traveling.

[00:02:55]You're sitting in a car. You're going to Pune. There's no stoppage.

[00:03:00]Just now a patient was telling me they went to Shirdi by Samruddhi Highway, 3 and 1/2 hours, and only one stop for toilet.

[00:03:11]Now, ladies can't stop and pass urine on the roadside.

[00:03:15]All this requires a perfect orchestration of nerves and the pelvic floor muscles.

[00:03:25]Controlling the outflow of urine, there are two sphincters located in the bladder neck and earliest portion of the urethra.

[00:03:40]The bladder neck sphincter is involuntary autonomic nervous system, while the urethral sphincter has both voluntary and involuntary components, but urethra is a small tube.

[00:03:59]So, a person at will cannot contract and stop urine as they can stop stools because that is a very strong muscle.

[00:04:12]The levator ani muscles act as a supporting hammock for this system and has a reflex as a voluntary activity. You can contract the levator ani muscles willingly.

[00:04:31]When any component of the entire tract right from nerves to muscles to levator ani lose their normal function, the urinary control can be affected and is affected.

[00:04:46]Injury to nerves, such a simple thing as a slipped disc, which is causing pressure on nerves, can affect your urinary control or rectal control.

[00:05:01]Damage to the bladder, trauma, damage to sphincters, supporting structures, and even the pelvic floor all lead to incontinence, passing urine without control.

[00:05:17]What are the common urinary symptoms?

[00:05:20]Dribbling incontinence, pain or burning sensation during urination or after passing urine, persistent strong urge to urinate.

[00:05:33]Doctor, I pass urine, I come out, I still feel like I have to pass more, but when I go, I can't pass anything.

[00:05:41]Urinating frequently in small amounts, passing 15-20 ml repeatedly.

[00:05:50]Has to bend backwards to urinate. I have put it in red because this is a male complaint.

[00:05:55]If the prostate is grossly enlarged, it is pressing on the urethra. Person has to sit on the commode and bend backwards to release the pressure and empty the bladder.

[00:06:08]Frequent urination more than eight times during the day or more than two times at night.

[00:06:17]Urine that smells odd, foul smell, or cloudy urine.

[00:06:24]Blood in urine, microscopic or frank blood.

[00:06:29]Pain during intercourse.

[00:06:31]That also comes under urinary symptom because the vagina and the urinary opening are all part of one organ, vulva.

[00:06:43]And a feeling of pressure and pain in the lower abdomen.

[00:06:48]What are the causes?

[00:06:51]Can be divided into infective, sexual intercourse, either new partners or aggressive intercourse.

[00:07:04]Improper hygiene.

[00:07:08]Not keeping good hygiene or maybe too good in hygiene.

[00:07:14]Many women use lot of douches and spermicides to keep the vagina clean.

[00:07:21]That may be destroying all the commensal bacteria and then causing problems.

[00:07:29]The use of tampons, douches, and spermicides.

[00:07:34]And if there is a bowel incontinence, then there'll be urinary incontinence.

[00:07:39]The first sexual intercourse as a cause of infective You all must have seen patients of honeymoon pyelitis.

[00:07:49]Newly married couple when they have sex for the first time they start getting urinary symptoms and the urine test also may show positive for pus cells.

[00:08:05]Non-infective exposure to chemicals, people working in dyes and aniline factories and smokers.

[00:08:14]Chronic bladder irritation for any cause may be a bladder calculus.

[00:08:20]Blockage to urinary flow either due to a calculus or due to prostate.

[00:08:26]Parasitic infections which are rare, but it's a list we have to give.

[00:08:32]And if a patient has undergone radiation to the pelvis for some cancer, that can also cause symptoms of urination.

[00:08:43]Common conditions in women UTI, urinary tract infection and cystitis inflammation of the bladder.

[00:08:54]Urinary incontinence overactive bladder We'll see each one of them.

[00:09:02]Interstitial cystitis also known as a bladder pain syndrome the chronic condition that causes pressure in the bladder pelvic pain and urinary urgency or frequency.

[00:09:23]And bladder cancer.

[00:09:27]Stress incontinence Common scenarios, patient to doctor. We all get such patients.

[00:09:37]Doctor, I have a very bad dry cough.

[00:09:40]Please do something about this cough.

[00:09:42]With every bout of cough, I dribble a few drops of urine and it's very embarrassing, especially working class, teachers, or even women staying in joint family.

[00:09:55]Another case, "Oh God, please don't make me laugh. Every time you tell a joke, I dribble."

[00:10:01]So embarrassing.

[00:10:04]Dribbling of urine in women accompanies sudden increase in abdominal pressure.

[00:10:12]So, when you shout somebody's name, when you call out loudly, when you laugh, then all these things or you cough, that pressure causes the urinary bladder to be compressed and the levator ani muscle giving in.

[00:10:31]This is the normal urinary bladder.

[00:10:35]And if this external urethral sphincter is strong enough, the levator ani muscle is strong enough, any amount of pressure will not cause dribbling.

[00:10:51]Whereas, if this becomes weak and the levator ani muscle is weak, the slightest pressure of cough, laughing, will cause leakage of urine.

[00:11:02]>> [clears throat] >> What are the symptoms?

[00:11:07]Uncontrolled leakage of urine with increased abdominal pressure. All the incidents that we described just now.

[00:11:14]Lifting weights, sneezing, violent sneezing, loud singing, bad bout of cough, laugh loudly, or straining to pass stool, then also the urine comes out.

[00:11:34]Why does it occur?

[00:11:37]Number one, the urethra is short in females.

[00:11:41]You don't get stress incontinence in males.

[00:11:44]In females because the urethra is very short.

[00:11:49]And the pubococcygeal muscle, the levator ani, it loses support to the bladder. I'll show you a picture subsequently.

[00:12:00]And then the bladder cannot hold urine if pressure is applied.

[00:12:06]These changes occur during pregnancy.

[00:12:09]After childbirth, repeated childbirths, normal delivery, not cesarean.

[00:12:16]Natural consequence of aging and morbid obesity.

[00:12:21]When a person is morbidly obese, the muscles have wasted. Similarly, pubococcygeal muscles have also wasted.

[00:12:31]Look at this picture. It's a hammock.

[00:12:36]A piece of cloth between two trees.

[00:12:40]The front part, the muscle is connected to the pubic symphysis.

[00:12:51]And on the back, to the tip of the coccyx.

[00:12:55]And this pubococcygeal muscle or levator ani is hanging like a hammock with two openings, one for vagina, or rather vulva, and one for rectum.

[00:13:11]Now, when this muscle becomes weak, you see this is now in the picture.

[00:13:21]This red arrow is pointing to the pubococcygeal muscle from pubic symphysis to tip of coccyx.

[00:13:28]When that muscle becomes weak, you see this is the normal line and the muscle has come down.

[00:13:38]Then this control is lost.

[00:13:42]And slightest increase in abdominal pressure will cause urine to leak out.

[00:13:48]Who's more at risk? Repeated childbirths, natural delivery, women over 50 because the muscles are weak and women may be going to the gym or walking, but they never exercise to strengthen the pubococcygeal muscle.

[00:14:07]Morbid obesity, chronic cough, chronic constipation.

[00:14:18]How do you diagnose? History.

[00:14:21]The main diagnosis is my history.

[00:14:23]Patient giving you complaint that when I cough, laugh, I dribble.

[00:14:31]You have to rule out UTI by routine urine analysis and if the infection is bad enough, culture antibiotic sensitivity.

[00:14:40]Rule out overactive bladder, also known as OAB, a frequent and sudden urge to urinate that may be difficult to control.

[00:14:53]How do you manage stress incontinence?

[00:14:55]Treatment of UTI present and exercises. Kegel exercises can improve function of the pelvic floor muscles and urinary sphincter to hold urine and suppress involuntary movement.

[00:15:16]Believe me, if Kegel exercises are done regularly, within a month, the patient will find lot of relief.

[00:15:23]So, how do I explain?

[00:15:27]If I tell a patient that if I tell you right now to contract your urethra, you'll not be able to do it. And they say, "Yes, no, we cannot."

[00:15:39]But I tell you that contract your hips as if you have to go to the toilet for a big job, pass stools, but you are contracting your anal sphincter, that they can do.

[00:15:52]So, when they are contracting the anal sphincter, the whole pubococcygeal muscle is contracting, and it is also helping the urethra.

[00:16:02]If they keep doing this throughout the day because whatever work they are doing, they can keep contracting the hips, the anal sphincter, nobody will come to know, and then the pubococcygeal muscle strengthens, and the symptoms of urinary incontinence diminish.

[00:16:24]Surgery, when Kegel doesn't work and it's very bad, there are two surgeries, sling surgery.

[00:16:34]You see this, the green color thread is a sling.

[00:16:39]The pubic arch, the sling is connected to the urethra, and then it is done like that.

[00:16:51]Second is suspension procedures.

[00:16:54]You see the bigger image is suspension procedures.

[00:17:03]Surgery is very invasive.

[00:17:07]I have yet done no surgery because patients who are sincere in Kegel get good relief.

[00:17:16]Overactive bladder causes No damage caused by abdominal trauma, pelvic trauma, or surgery.

[00:17:26]Bladder stones, chronic UTI, drug side effects, oral estrogens, alpha blockers, sedative hypnotics, antidepressants, antipsychotics, ACE inhibitors, loop diuretics, NSAIDs, and calcium channel blockers. It's not that they all will cause, but they can cause. So, patients on these medication if they have these symptoms, then you have to rule out whether it is a drug-induced overactive bladder or not.

[00:18:02]Neurological diseases, multiple sclerosis, Parkinson's disease, stroke, spinal cord lesions, or bladder cancer.

[00:18:14]Diagnosis, first you have to rule out cystitis by routine urine analysis and ultrasound.

[00:18:22]And then examination.

[00:18:25]The investigation is uroflowmetry.

[00:18:28]Patient is made to pass urine in a bucket and a machine records the flow of the urine.

[00:18:37]Females sit on a bucket and pass urine.

[00:18:40]Males stand and pass urine in a machine.

[00:18:45]Treatment is antispasmodics, anticholinergics, antimuscarinic, and drugs basically to reduce bladder urge episodes.

[00:18:56]One of the drug is darifenacin.

[00:18:59]Works on muscles of the bladder to prevent causing incontinence. Dariten OD 7.5 or 15 and Solifenacin 7.5 or 15.

[00:19:12]Tolterodine, antimuscarinic, works by relaxing bladder muscle preventing bladder contraction.

[00:19:20]Detrusitol and Roliten 1, 2, and 4 mg.

[00:19:26]Effect is seen in 1 hour after oral intake.

[00:19:32]Mirabegron, very commonly used beta-3 adrenergic agonist works by relaxing the bladder muscle and thus prevent urgent frequent urge.

[00:19:45]OAB F-25, Myrbetriq 25.

[00:19:50]Flavoxate anticholinergic, Urispas 200, Uripil 200.

[00:19:57]This we have used two TDS in acute conditions like cystitis, urethritis for 2 to 3 days.

[00:20:05]Use for minimum duration and stop once patient is relieved.

[00:20:11]Cystitis in females the first choice of agent for uncomplicated acute cystitis nitrofurantoin trimethoprim-sulfamethoxazole.

[00:20:23]This antibiotic combination, believe me, still works wonders because people have stopped using it.

[00:20:30]Or fosfomycin single dose.

[00:20:35]When resistant cases or very bad infection, beta-lactam or beta-lactamase inhibitors.

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[00:21:02]Thank you very much.

[00:21:03]Have a nice evening.