Bladder Cancer in Women

Bladder cancer is a common cancer in the U.S. affecting 65,000 and resulting in 14,000 annual deaths of both women and men. Most of the facts regarding the presentation, diagnosis, and treatment are very similar in both sexes but there are a few very important differences.

Bladder cancer begins with a localized growth of the inner wall of the bladder. Over time, it can form a tumor or mass which invades the local muscular bladder wall, spreads to the regional lymph nodes, and then the bones, liver, and lungs.

Risk factors for bladder cancer in women may include:

The most significant risk factor for bladder cancer in both women and men is cigarette smoking, accounting for a third to a half of the diagnosed female bladder cancers. This has been attributed to the cancer-promoting cigarette toxins in the urine stored in the bladder and in contact with the bladder walls prior to being excreted. Family history may also play a role in the incidence and prevalence of the disease.

Symptoms of bladder cancer include:

Bladder cancer is found two to four times less frequently in women than in men. Women, however, are often diagnosed at a later, more advanced stage of the disease with less favorable treatment outcomes. The symptoms of bladder cancer can mimic the blood spotting of menstruation or a simple urinary tract infection, common in many women, resulting in a delay in diagnosis.

• Increased urinary frequency,
• Pain or burning during urination,
• Pelvic or low back pain,
• Blood in the urine,
• Urge to urinate without the ability to do so

These can be features of both urinary tract infection and bladder cancer, requiring a doctor to determine the cause through careful examination and testing.

AUCNY urologists may use a combination of methods to determine the specific cause:

Diagnosis, as with most diseases, starts with a detailed history and physical examination. Your AUCNY doctor will question you about:

• Symptoms
• Past personal and family medical history
• Social habits including smoking

Then, the doctor will perform a physical examination of your body with special emphasis upon the affected areas.

Diagnostic Testing:

Diagnostic testing may follow, consisting of blood and urine testing, accompanied by the utilization of imaging techniques. These may include:

• Chemical and microscopic exams and culturing of urine and blood samples.

• Intravenous pyelogram (IVP) study of the urinary system where contrast dye distribution is studied by x-ray.
• CT, MRI, or PET scan may be ordered to permit the presence, location, and spread of a tumor.
• Cystoscopy is a fiber optic procedure of the urethra where a thin tube-like camera is used to visualize the inside of the bladder.
• Biopsy or tissue sampling permits a microscopic study to help detect abnormal tissue to aid in diagnosis and determination of the extent of the disease.

Treatment:

As with many cancers, treatment may involve:

• Surgery to sample or remove a tumor or portion of the bladder,
• Chemotherapeutic medication to inhibit or reverse tumor growth pre or post-surgery,
• Immunotherapy to recruit one’s own white blood cells to make them more effective in tumor suppression,
• Radiation where colleagues at Advanced Radiation Centers of NY (ARC) become teammates in the fight against bladder cancer.

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Kidney Stones in Women

Kidney stones are painful and affect some 11% of men and 6% of women during their lifetime. The causes, symptoms, and treatments are the same for men and women with only minor differences.

Kidney stones occur when the urine becomes excessively concentrated with a substance (calcium, uric acid, oxalate, or struvite) which then, instead of staying dissolved in the urine solution, crystallizes out of the urine solution onto the wall of the kidney inner surface.  It may pass or descend into one of the two ureters, the thin tubes which pass the urine from the kidney into the bladder, as a very small crystal. This sharp and abrasive crystal greatly irritates the inner wall of the ureter causing severe symptoms and a reflexive cramping or spasm of the smooth muscle wall of the tube. It may also block the ureter obstructing the flow of urine, causing the urine to back up into the kidney and painfully result in kidney damage called hydronephrosis.

If the crystal or stone is small, less than 5mm or 1/5 inch, it has a 90% chance of passing from the kidney, through the ureter, and into the bladder on its own. Doubling the crystal size to 10mm or 2/5 inch reduces the chance of spontaneous passage to 10 to 25% without medical intervention.

If waiting for a stone to pass fails, we can treat kidney stones by using shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy or open surgery. In any case, we have a variety of tools with which to help male and female patients with kidney stones.

Symptoms of kidney or ureter stones include:

• Severe, sharp flank pain known as renal colic which may come in waves and radiate into the groin or lower abdomen
• Pain or burning upon urination called dysuria with a persistent need to urinate known as increased urgency
• Urine which is cloudy, is malodorous, or is discolored or tinged with blood
• Nausea, vomiting, fever, or chills may be experienced

Causes and risk factors for stone formation include:

• Family or personal history of stone formation
• Dehydration from not drinking enough fluids or by loss of fluid such as diarrhea, inflammatory bowel disease, diabetic passing of excess sugar in the urine, excessive sweating which effectively would concentrate the stone forming substance by decreasing the volume of diluting fluid
• Diet that is high in salt, sugar, or animal protein will increase the amount of the stone forming substances which the urine needs to eliminate
• Obesity
• Post gastric bypass surgery, kidney disease, and hormonal problems such as hyperparathyroidism which affects the calcium levels in the body are other medical conditions which could promote stone formation
• Excessive use of antacids containing calcium, vitamin C, and use of some migraine/depression medications may promote stone formation as well

To diagnose your AUCNY urologist will use some of the following:

• Detailed history and physical examination – requesting details on symptoms, personal and family medical history, social history including smoking habits, physical examination with special emphasis on the bladder and kidney area including rectal/pelvic exam
• Obtain a blood sample to measure calcium, uric acid, hydration, and measures of kidney function in general
• Obtain a urine sample which may include a 24-hour urine collection to analyze the substances and their concentrations in the urine
• Imaging procedures (X-ray, CT, MRI, and ultrasound) to look for the presence, location, size, and possible composition of the stone forming substance
• Isolating the stone as it is voided out of the urethra in the urine into a strainer is the gold standard in determining the composition of the stone. The captured stone is then analyzed by our lab to determine whether it is composed of calcium, uric acid, oxalate, or struvite which aids your AUCNY urologist in ascertaining the cause of the stone formation. This information also guides both the treatment and subsequent prevention of future recurrences.

Treatment for small stones may consist of the following:

• Diluting the causative substance and help flush out the stone by significantly increasing fluid intake
• Utilizing pain medication to help ameliorate the painful spasm caused by the irritating passage of the stone through the ureter
• Prescription medications like the alpha blockers, tamsulosin (Flomax) or dutasteride to relax the smooth muscle wall of the ureter which would increase its passageway diameter and so promote easier stone passage

For larger kidney stones that will not pass on their own, other treatments that may be offered by your AUCNY doctor are:

• Extracorporeal shock wave lithotripsy (ESWL)– sound waves applied external to the body are used to fragment the larger kidney stones into very small particles that will pass through your urine
• Lithotripsy– uses shock waves internally to break up the kidney stones so they can pass through your urinary system
• Ureteroscopy/laser surgery– a minimally invasive surgery using laser beams (through a tube into the ureter) to destroy the ureteral stones, essentially another method of stone fragmentation
• Percutaneous Nephrolithotomy– a procedure using small instruments to directly remove kidney stones through small incisions similar to an orthopedic surgeon removing bone or cartilage fragments from a knee

Microscopic Hematuria in Women

Microscopic hematuria is a common condition where a relatively small number of blood cells leak into the urine from the bloodstream in such a small amount that they are only visible under a microscope. This contrasts with urine which is visibly red or red-spotted due to a relatively large number of cells and is termed gross hematuria. Your AUCNY urologist will determine the specific cause of the microscopic hematuria and decide whether it is a symptom of a benign or more serious condition.

 Some of the more frequent causes of microscopic hematuria in women are:

• Infection of the urinary tract which may present with urine having a strong odor, a persistent urge to urinate, or pain or burning during urination
• Pyelonephritis (infection of the kidney) which may cause symptoms of a urinary tract infection, possibly with fever or flank pain
• Stone formation in the kidney or bladder occurring when levels of substances which are normally dissolved in solution in the urine elevate and so crystallize into small hard particles in the urinary tract. The stones may not be associated with symptoms or may be excruciatingly painful if they are moving through the urinary tract or result in an irritation, spasm, or blockage of the tract
• Kidney and bladder diseases (both benign and cancerous) in general may result in blood cell leakage into the urine
• Vigorous exercise, especially distance runners,
• Inherited disorders, traumatic kidney injuries, and certain medications like blood thinners or arthritis pain relievers
• Contamination of the urine sample seen as “false positives” due to menstruation, urogenital atrophy, or pelvic organ prolapse

Risk factors for microscopic hematuria may include:

• Recent kidney or urinary tract infections
• Family history of kidney disease
• Medications such as blood thinners or arthritis pain relievers
• Vigorous exercise, especially distance runners

AUCNY urologists may use a combination of methods to determine the specific cause:

• Detailed history and physical examination – requesting details about symptoms, personal and family medical history, social history including smoking habits, physical examination of the body with special emphasis on the bladder area including rectal/pelvic exam

• Chemical and microscopic exams and culturing of urine and blood samples.

• CT, MRI, or PET scan may be ordered to study the presence, location, and spread of a tumor.
• Cystoscopy is a fiber optic procedure of the urethra where a thin tube-like camera is used to visualize the Inside of the bladder.
• Biopsy or tissue sampling permits a microscopic study to help detect abnormal tissue to aid in diagnosis and determination of the extent of the disease.

Treatment:

Once your AUCNY doctor reviews your tests, they will determine the specific cause your problem. Treatment plans are based upon the cause and vary from no treatment for benign conditions to prescription medications or surgical intervention for more serious diagnoses.

Pelvic Organ Prolapse in Women

Pelvic organ prolapse occurs when the muscles and ligaments which normally suspend a women’s pelvic organs weaken over time, can no longer adequately lift the organ weight, and allows for sagging of the organs into the vagina. While sagging of the bladder is the most commonly seen form, the uterus, rectum, bowel, or vaginal wall may also be involved.

Pelvic organ prolapse symptoms may include:

• Noticeable bulge or lump at the vaginal opening called a prolapse which may interfere with tampon insertion or sexual activity
• Sensation of pelvic or low back pressure, discomfort, fullness
• Vaginal dryness or irritation from clothing
• Pain during sexual activity
• Symptom exacerbation by standing, coughing, and physical or sexual exertion
• Constipation or urinary difficulties including leakage or increased frequency or urgency

Risk factors for pelvic organ prolapse include:

• Childbirth
• Post-hysterectomy or other pelvic surgeries
• Post-menopause
• Obesity

Diagnosing pelvic organ prolapse:

Diagnosis is often made with an initial visit with a simple history and physical examination, but sometimes various imaging techniques are used as well.

Treatment:

• Pelvic floor physical therapy may strengthen the weakened supporting muscles to decrease symptoms and incontinence
• Pessary use which involves the insertion of a small plastic specially sized support into the vagina to decrease symptoms and incontinence
• Pelvic prolapse surgery to provide additional support for the sagging structures

Stress Urinary Incontinence for Women

Stress urinary incontinence is a specific but common type of urinary incontinence, most often seen in women. Whereas urinary incontinence is the term used to describe the uncontrollable leaking of urine, stress urinary incontinence is the leakage due to pelvic muscle weakness. It is often experienced with the increased abdominal pressure associated with the physical activity of exercise, laughing, sneezing, or coughing. It can range in severity from mild to severe and is commonly found in older women. Overactive bladder and overflow incontinence are other types of urinary incontinence.

Risk factors:

• Aging/post-menopause
• Childbirth episodes
• Obesity
• Neurological disorders (e.g., Parkinson’s, stroke, multiple sclerosis) and low back nerve injuries)
• Smoking or chronic coughing
• Hysterectomy or other pelvic surgery
• Repeated high exertion sports or activities

AUCNY urologists may use a combination of methods to determine the specific cause:

• Detailed history and physical examination – requesting details about symptoms, personal and family medical history, social history including smoking habits, physical examination of the body with special emphasis on the bladder area including rectal/pelvic exam. Your urologist may also request that you cough hard and observe for urine loss or use a special absorbent pad which is applied, left on for a period of time, and then removed and weighed to measure urine leakage.
• Chemical, microscopic, or culturing of urine and blood samples
• Urodynamic testing to measure bladder pressures
• Post-void residual volume testing to measure the urine volume left in the bladder after urination
• Cystoscopy is a fiber optic exam of the urethra where a thin tube-like camera is used to visualize the inside of the bladder.

Treatments:

• Absorbent products such as adult pads and adult diapers and plastic jug-type urinals
• Bladder training or scheduled voiding by gradually increasing the time between voiding to train the bladder
• Pelvic floor (Kegel) exercises involve pelvic squeezing by tightening and holding the pelvic muscles which aid in urine flow control repeatedly up to 3 sets of 10 each day
• Treatment of obesity and constipation to reduce abdominal pressure on the bladder
• Quitting smoking and so reducing associated coughing
• Vaginal inserts including an absorbent tampon or a pessary, a small plastic specially sized support.
• Surgical treatments including urethral bulking injections, sling surgery where a strip of material is placed hammock-style under the urethra for support, or bladder neck suspension where the bladder neck is attached to a public bone ligament for added support.

Urinary Incontinence (UI) in Women

Urinary incontinence, experienced by up to one third of women, is the uncontrollable leaking of urine. This is often caused by the pelvic muscle weakness, failure of the muscles of the body of the bladder to remain relaxed and permit urine storage or the muscles of the neck of the bladder (called the sphincter) to remain contracted and act as a closed spigot preventing urine leakage. There are four main types of UI, although combinations are also common:

• Stress urinary incontinence, common in older women, occurs when urine leaks due to pelvic muscle weakness and is often experienced with physical activity of exercise, laughing, sneezing, or coughing. It can range in severity from mild to severe.
• Overactive bladder or urgency incontinence, common in post-menopausal women, is a problem with the control mechanism of your brain regulating when the bladder is signaled to empty. A sudden frequent urge to urinate is experienced during both day and night.
• Mixed incontinence is the combination of stress and urgency incontinence occurring simultaneously
• Overflow incontinence is likened to the constant drip of a faucet with small amounts of urine continually dripping. It has many causes including excess urine production, incomplete bladder emptying, or flow restriction but is relatively rare in women.

Risk factors:

• Aging/post-menopause
• Childbirth
• Obesity
• Diabetes, high blood pressure (hypertension), kidney disease, bladder stones, urinary tract infections, neurological disorders (e.g., Parkinson’s, stroke, multiple sclerosis)
• Smoking

AUCNY urologists may use a combination of methods to determine the specific cause:

• Detailed history and physical examination – requesting details about symptoms, personal and family medical history, social history including smoking habits, physical examination of the body with special emphasis on the bladder area including rectal/pelvic exam. A urologist may also request the patient cough hard and observe for urine loss.

• Chemical and microscopic exams of the urine and culturing of urine and blood samples.

• Urodynamic testing to measure bladder pressure.
• Post-void residual volume testing to measure the urine volume left in the bladder after urination.
• Cystoscopy is a fiber optic procedure of the urethra where a thin tube-like camera is used to visualize the inside of the bladder.

Treatments:

• Dietary changes such as avoidance of caffeinated drinks, alcohol, chocolate, tomatoes, citrus, and spicy foods in the case of overactive bladder
• Absorbent products such as adult pads and adult diapers and plastic jug-type urinals
• Bladder training or scheduled voiding by gradually increasing the time between voiding to train the bladder
• Pelvic floor (Kegel) exercises involve pelvic squeezing by tightening and holding the pelvic muscles which aid in urine flow control repeatedly up to 3 sets of 10 each day
• Medication to assist overactive bladder or estrogen therapy
• Indwelling Foley catheter is a flexible rubber tube that is placed and resides in the bladder to drain urine into an external urinary drainage bag. A Foley catheter is placed by the urologist through the urethra nonsurgically whereas a suprapubic catheter is surgically placed just above the pubis in the lower abdomen. Both need periodic changing and maintenance. There are also clean intermittent catheters that are repeatedly placed 3 to 5 times a day for urine drainage.
• Surgical treatment

Urinary Tract Infection in Women (UTI)

The urine is normally sterile (without bacteria or yeast) and travels from the left and right kidneys where it is made, down a left and right-side tube called a ureter, to a single central bladder where it is stored until it is eliminated from the body through the urethra. A urinary tract infection occurs when bacteria or yeast enter the urethra from outside the body, travel against the flow of urine up to the bladder, and then may ascend the ureters to infect the kidneys themselves. About 60% of women but only 12% of men will experience a UTI during their lifetime. Women are much more prone to UTI than men due to the short length of the urethra permitting easier access of external bacteria to the bladder. A woman having a UTI will show a greater incidence of subsequent UTI with some 80% having a second episode within 18 months.

Risk factors include:

• Female anatomy or abnormal anatomy like outpouchings (diverticula) where bacterial may hide
• Post-menopausal status
• Birth control using insertional methods (diaphragm) or condoms using spermicidal foams
• Immune system abnormalities like diabetes, steroid use, AIDS, and cancer chemotherapy agents
• Abnormalities of the urinary tract such as obstructions, kidney, or bladder stones
• Catheter use

Symptoms may include:

• Pain, burning, increased frequency or urgency to urinate
• Urine discharge or cloudiness with odor, pus, or bleeding
• Fever or flu-like symptoms (nausea, vomiting, shaking, chills)
• Pelvic pain

Diagnosis:

• Detailed history and physical examination – requesting details about symptoms, personal and family medical history, social history including smoking habits, physical examination of the body with special emphasis on the bladder area including rectal/pelvic exam. The urologist may also request the patient cough hard and observe for urine loss.
• Chemical, microscopic, and culturing of urine and possibly blood samples to determine the causative bacteria or yeast. New molecular studies are also available to identify bacterial and fungal species by PCR in more complicated or recurring cases

• Imaging methods to visualize the anatomy may be used in more complicated or recurring cases

Treatment:

• Antibiotics to target the infecting bacteria or yeast
• Vaginal topical hormonal estrogen replacement (in post-menopausal cases)
• Proper hydration, possible use of cranberry supplements to alter the acidity of the urine, probiotics to permit growth of protective organisms, D-mannose to decrease possibility of yeast
• Proper hygiene wiping from front to back
• Emptying the bladder frequently and completely (Every 2 hours while awake and triple voiding—attempting to urinate 3 times each bathroom visit. Pass urine, wait ten seconds and attempt to void again without straining, then another ten seconds and another voiding attempt without straining to eliminate residual urine and bacteria or yeast.)