In our earlier article, we discussed the kidney’s role in filtering toxins and extra fluid to keep the body healthy, and how kidney conditions can jeopardise this vital process. In this article, we address the waste elimination process from the kidney through the urinary tract, including common issues that can happen along the way, such as urinary tract infection (UTI), kidney stone, and a problem that is quite common but not openly talked about – urinary incontinence. We will also talk about age as a major risk factor for all these 3 conditions, and what elderlies can do to maintain their urinary health.
1. The Urinary Tract & Urinary Conditions
The urinary tract, also called urinary system or renal system, is responsible for filtering blood and removing extra fluid and toxins from the body through urine. It comprises two kidneys, two ureters, a bladder, and a urethra, working together to cleanse on average 180-200 liters of blood and eliminating 0.8-2 liters of urine a day.
After the kidneys cleanse the blood, toxins and wastes from the kidney’s filtering process form urine, which then travels through two tubes called the ureters to the bladder. The bladder stores urine to its maximum capacity, which can be stretched to contain up to 400ml of liquid for 2-5 hours in healthy adults. When the bladder is filled up, urine is excreted out of the body through the urethra. This mechanism is known as urination.
Interestingly, the simple act of urination requires the seamless coordination of a number of muscles – which are called the sphincters – and nerves. Located in the bladder and urethra, these sphincter muscles act as a double-valve, keeping the bladder and urethra shut. When the bladder is full, the brain sends a signal to the sphincters, telling them to relax, or in other words, to ‘open the valve’. The brain also tells the bladder walls to squeeze and push urine out. Of course, before that, it tells you to go look for a toilet.
Urinary conditions happen when one or more problems occur at any stage during the above process. For example, when the sphincter muscles are weakened or do not shut properly – which can happen quite often among the elderly, urine may leak out, causing urinary incontinence. When bacteria make their way into any part of the urinary tract, we have a case of urinary tract infection or UTI. Or when toxins are not fully removed and solidify into stones in the kidney, it can cause intense pain and make the kidneys work less efficiently.
The urine itself can also signal a number of health conditions. For example, a dark urine colour indicates you are dehydrated. Pinkish urine colour is a sign that urine contains blood and there is bleeding somewhere in the urinary tract. Soapy or foamy urine signals protein gets into urine, which means the kidneys fail to filter blood effectively – often a case of kidney failure or near kidney failure. (Read our earlier article to know more about kidney failure and its prevalence in Singapore here.)
All these urinary conditions require timely medical attention. In the next part of this article, we will discuss in detail the following three common urinary conditions: urinary tract infection, urinary incontinence and kidney stone.
2. Urinary Tract Infection (UTI)
A urinary tract infection (UTI) describes a number of diseases characterized by the growth of microbes in some part of the urinary tract. The vast majority of UTIs result from bacterial species that crawl up different structures of the urinary tract. Some UTIs can arise from fungal and viral infections.
UTI is categorised into upper UTI where the kidneys or the ureters are affected, or lower UTI where the bladder or the urethra is affected. Most UTIs are lower UTIs and are not serious. On the contrary, upper UTIs where infections involve the ureters and kidneys can be very severe.
Depending on where infection happens, UTI has its specific name. UTI at the urethra is called urethritis. UTI affecting the bladder is called cystitis. When this condition affects the kidneys, it is called pyelonephritis, which can be life threatening if bacteria manage to make their way from the infected kidneys into the blood – a condition called urosepsis.
UTI can happen to both men and women, but women can be 30 times more likely to contract UTI than men. After the age of 50, however, the gap reduces. In other words, men above 50 are much more likely to develop UTI than younger men. Among women, those over the age of 50 are 75% more likely to catch UTI than younger adult women.
Causes and Risk Factors of UTI
A UTI often occurs as a result of bacteria or other microbes overcoming the body’s defense mechanism and entering the urinary tract from the urethra. Urination in fact is a part of the defense line. During urination, the body can flush out bacteria that have made their way into the urinary tract. An infection happens when bacteria manage to hold on and grow.
The most common bacteria causing UTI is E.coli which are often present at the rectum. With a shorter urethra that is located close to the rectum, women are at much higher risk than men to have E.coli or other bacteria crossing over and entering the urethra, and then travelling up the bladder. The good news is, if detected promptly, this type of UTI can be easily cleared out by a dose of antibiotics. However, when the defence mechanisms of the lower urinary tract fail to halt the invasion of bacteria, the risk of upper UTIs increases significantly.
In some cases, the bacteria causing pyelonephritis (i.e., UTI affecting the kidneys) can reach the kidneys via the bloodstream, due to causes such as intravenous drug abuse and endocarditis (an inflammation of the heart chambers and valves).
Common risk factors for UTIs include:
- Age: being above 50 years of age makes you more prone to UTI.
- Gender: the female anatomy makes UTI more likely to happen among females.
- A previous UTI episode: people who have had UTI before are more likely to contract it again.
- Kidney stone or other causes that obstructed the urinary tract, such as an enlarged prostate in men (more on kidney stone later).
- Prolonged period of being confined to bed or immobility: this status causes urinary retention, making it difficult to wash out bacteria entering the urinary tract through the natural defense mechanism of urination.
- Prolonged usage of urinary catheters: statistics found that 75% of UTI acquired in hospitals are related to urinary catheter usage.
- Diabetes: according to a study, diabetics are found to be more susceptible to UTI, and develop more severe UTI if it occurs compared to non-diabetics. The risk is even higher in diabetics who have developed kidney conditions such as Chronic Kidney Disease (CKD) . Read about CKD and diabetic kidney disease in our article about kidney diseases here.
- Pregnancy: the bladder and urethra are under increased pressure during pregnancy, making pregnant women more susceptible to UTI. In fact, all pregnant women are advised to go through a UTI test in the early stage of their pregnancy.
- Other risk factors include congenital urinary tract malformation, or compromised immune system (immunosuppression). Frailty is also found to put patients at increased risk for UTI, according to research.
Signs and Symptoms of UTI
Lower UTI and upper UTI are presented with different signs and symptoms. Lower UTI often manifests with symptoms related to bathroom behavior, such as:
- Burning sensation during passing urine, especially towards the end
- Increase in frequency and/or urgency to urinate without being able to pass much urine
- Lower abdominal or pelvic pain in women and rectal pain in men
- Abnormal urine colour such as cloudy or bloody urine, or abnormal urine smell
Upper UTI affecting the kidneys however could cause a different set of symptoms, such as pain at the kidney area (middle back), nausea and vomiting. Some patients may experience fever, chills, dehydration and fatigue.
Diagnosis of UTI
An uncomplicated lower UTI can often be diagnosed with urine dipstick analysis at the GP. In other cases, the doctor may order full urine and blood culture tests, especially if patients show signs of upper UTIs. A number of other tests may also be ordered for severe cases, such as imaging tests such as CT scan, MRI, MR urography.
Treatment of UTIs
Treatment of UTI often involves antibiotics to get rid of the bacteria. Depending on the site of infection, antibiotics can be administered orally (for uncomplicated lower UTI) or as IV fluids (for upper UTI). In some cases, such as with severely ill patients, elderly patients, those with underlying conditions or pregnant women, hospitalisation may be required to avoid complications. If UTI is caused by an obstruction in the urinary tract, surgery may be required to remove the blockage.
It is a common misconception that UTI can be treated at home with cranberry juice. Cranberry juice cannot clear the bacteria once UTI has occurred. Whether cranberry juice can prevent UTI or aid with recovery is also not proven by research. However, it is not harmful and therefore doctors do not recommend against it.
Complications of UTIs
Though highly treatable, delay in UTI can cause infection to spread and become severe. Complications resulting from UTI include:
- Sepsis: this happens when bacteria make their way into the bloodstream from the infected kidney.
- Permanent kidney damage: severe acute UTI can permanently damage the kidneys and impair their functions.
- Recurring UTI: a previous episode of UTI makes an individual more susceptible to UTI, especially in women.
- Other consequences such as premature birth in pregnant women and narrowing of the urethra in men.
Preventing UTI and UTI Complications
Even when you have risk factors such as an earlier incidence of UTI, older age or diabetes, UTI can be prevented by:
- Supplying the body with sufficient water every day. Doctors advise drinking 6–8 glasses of water a day
- Maintaining regular urination habit, avoiding urine stagnation for long periods of time
- Keeping the urinary tract healthy, managing disorders, such as urinary incontinence and bladder conditions if you have them.
If you see signs of urinary tract infection, it is crucial to visit a GP for immediate treatment. Untreated UTI can progress quickly and leave consequences. However, it is highly treatable with early detection.
3. Urinary Incontinence
Urinary incontinence (UI) is a common inconvenience that is often not openly discussed. The condition can affect both men and women, but it is found to be more common in women over the age of 50. According to statistics, urinary incontinence affects up to 14% of the adult population. The rate goes up with age, and is believed to be significantly underreported, as people tend to find it embarrassing to talk about the issue even with their doctor or GP.
Urinary incontinence describes the involuntary loss of control of the bladder, leading to unwanted flow of urine. Symptoms range from mild to severe forms, causing inconveniences and even embarrassments in patients’ daily life, such as multiple trips to the bathroom daily, or feeling a strong urge to urinate but unable to ‘hold’ until reaching the bathroom. This is not a disease, but a big nuisance for those suffering from it. You might even feel psychological stress due to urinary incontinence, leading to withdrawal from social interaction in some cases.
Types of Urinary Incontinence
In general, urinary incontinence is triggered by weakened bladder muscles – called sphincters, or a nerve issue. Depending on what the trigger is, urinary incontinence is categorised into three types:
- Stress urinary incontinence (SUI): This type of incontinence gets triggered by physical activity such as exercising, coughing, sneezing, or laughing. These activities place stress on the sphincter muscle which acts as a valve to hold the urine inside the bladder. As a result, the sphincter muscles relax involuntarily, causing urine to leak.
- Urge urinary incontinence, also known as overactive bladder (OAB): Urge incontinence refers to the loss of bladder control after having the urge to urinate. When the bladder is full, the brain sends a signal for you to look for a bathroom to flush out urine. But due to the poor control, the bladder muscles contract abruptly, triggering urine to flow. In simple words, you might not make it to the bathroom when you get the urge. This type of incontinence is usually the result of overactive nerves of the bladder.
- Overflow incontinence: As the name implies, this type of incontinence occurs when the bladder fills up more than its capacity, leading to ‘overflow’. This can happen as a result of a nervous system problem, causing the brain not to know when the bladder is full, or of a blockage, preventing the bladder from being able to empty completely. Overflow incontinence is more common in men than women, especially men with a history of prostate issues.
Patients can also experience mixed incontinence. This refers to a case when both stress and urge continence happens in the same person.
Causes and Risk Factors of Urinary Incontinence
There are several causes and risk factors of urinary incontinence, including:
- Age-related muscle weakness: As you age, the muscles of the bladder become weaker, predisposing you to urinary incontinence.
- Physical damage to the pelvic floor muscle (typically after trauma): When the muscles of the pelvic floor get injured, the sphincter muscles and nerves can get damaged, disrupting the urination process. Pelvic floor injury can also occur after surgeries, such as a hysterectomy. For women, pregnancy and childbirth may also lead to the looseness of the bladder muscles. The risk unfortunately goes up with the number of children.
- Urinary tract infections (UTIs): Urinary tract infections are a classic cause of urinary urgency and incontinence. In fact, urinary urgency is a symptom of UTI, especially when it happens suddenly and is accompanied by pain during urination and other signs of UTI. However, when it happens gradually and without the other signs of UTI, it is likely to be a case of urinary incontinence – which requires different treatment and management from UTI.
- Interstitial cystitis (IC), also called Painful Bladder Syndrome (PBS): this is a chronic inflammation of the bladder, which can have the same symptoms as a UTI at the bladder discussed above. But different from UTI, it is not caused by infection and therefore requires different treatment. Urinary incontinence happens as a result of the inflammation of the bladder.
- Diabetes, stroke and some conditions of the nerves (for example multiple sclerosis): these conditions can damage the nerves controlling sphincter muscle of the bladder, causing urge or overflow incontinence.
- Prostate problems in men is also a risk factor for urinary incontinence: both prostate conditions and some medications used to treat them can contribute to the risk.
- Other causes: Being overweight can put extra pressure on the bladder, causing incontinence issues. Other medical and lifestyle factors such as high blood pressure and smoking are also found to be linked to urinary continence, though not directly causing it. In some cases, irritation, constipation, or vaginal infections in women can also cause temporary incontinence.
Signs and Symptoms of Urinary Incontinence
It is easy to spot the signs and symptoms of urinary incontinence. However, each type of urinary incontinence manifests with different symptoms.
- Stress urinary incontinence: The most typical sign is urine leaking when you exert efforts, such as heavy lifting, jumping, coughing, laughing.
- Urge urinary incontinence (or overactive bladder – OAB): Symptoms include strong, sudden urge to visit the toilet, and the inability to hold until you reach the toilet.
- Overflow urinary incontinence: Patients experience frequent trips to the bathroom, dribbling, passing small amounts of urine each time, having difficulty starting to urinate even when the urge is there, nocturia (bed wetting at night).
The Treatment of Urinary Incontinence
Treatment of urinary incontinence depends on the type of incontinence, causes and severity. If there is an underlying cause such as UTI or prostate problem, incontinence will go away when the underlying condition is treated.
For cases of chronic stress and urge incontinence in which causes involve bladder muscle control, medications, techniques and procedures to improve control of the bladder muscles can be prescribed, including biofeedback, electrical stimulation or in rare cases, surgery. In cases of overflow incontinence, neuromodulation of the bladder nerves such as acupuncture or an outpatient pacemaker can help address the issue.
A number of tools and procedures can help patients improve their quality of life and relieve the psychological stress from incontinence, such as using absorbent products (adult diapers or pads, protective underwear), toilet substitutes (commode seats, bedside commodes). There are also specific types of catheters and urine drainage bags, which are of great help to patients with mobility challenges.
In addition to treatment, management of the condition through behavior modification and physical therapy can be very helpful. Doctors often advise following a fluid restriction and voiding schedules. A type of pelvic floor muscle training called Kegel exercises are found to be very popular and effective in improving urinary incontinence problems and self-esteem for both adult male and female patients of all ages.
4. Kidney Stones
A kidney stone – also known by other names of renal colic, nephrolithiasis, or urolithiasis – is a solid mineral formation that accumulates inside your kidneys. Though the name is kidney stone, it does not just reside in the kidneys but can travel along the urinary tract.
According to one study, kidney stones affect up to 12% of the general population in a lifetime. Kidney stones are common among those who are overweight and diabetic, and more common in men than women.
Signs and Symptoms of Kidney Stones
Kidney stones are characterised by a classic pain – a symptom that helps your doctor make the diagnosis. The pain is often described as one of the most intense types of pain, but episodic, which means patients may experience severe pain on one day, then nothing on the next. Pain often happens suddenly.
Kidney stone pain is often felt on one side of the mid-back then radiates to the lower abdomen and groin region. The pain moves as the kidney stone moves. The severity of the pain varies significantly from one patient to another, depending on where the stone is in the urinary tract, how fast the distension occurs and the level of obstruction. The size of the stone can also affect the level of pain.
In addition to the classic intense pain, there can be other signs and symptoms, including:
- Pain during urination (also called dysuria): this happens when kidney stones reach the ureter and bladder.
- Blood in urine: The irritation of the inner layer of the urethra causes small blood vessels to bleed. As a result, urine will have a pink, red, or brownish colour.
- Smelly or cloudy urine: this is a sign that kidney stone has caused infection in the urinary tract (UTI)
- Urinary incontinence: more frequent and stronger urge to pass urine
- Nausea and vomiting, fever and chills can also happen.
Treatment for Kidney Stone
Treatment for kidney stone depends on the size and location of the stone. If the stone is small and can be passed without intervention, doctors often prescribe painkillers to relieve pain and medication to help passing the stone quickly. Drinking lots of water also helps to accelerate the process.
Large stones however need intervention to be removed. This includes a procedure called extracorporeal shock wave lithotripsy (ESWL) to break down the stones which can then be passed naturally, or for very large stones, surgery to remove the stone directly.
After being removed, kidney stones can form again. For individuals with predisposition to form certain types of kidney stones such as calcium stones and uric acid stones, medications might be necessary to prevent this process. In all cases, ongoing lifestyle changes are often recommended to prevent recurrence, including the following:
Dehydration is a primary factor that triggers kidney stones. Therefore, it shouldn’t come as a surprise that drinking enough water helps with this condition. In fact, proper hydration is what you will receive at the hospital.
You can get a sense of your hydration status by looking at the colour of your urine first thing in the morning. If it’s dark-yellow or brownish, it means you’re not drinking enough water.
Drinking beverages with low pH prevents the aggregation of minerals and the growth of bacteria.
The vast majority of stones form when the pH is alkaline (above 7), which is also the case for bacterial infections. When you decrease the pH of your urinary tract, minerals will not be able to stick together, and bacteria will die. Acidic drinks that are easily available at home include lemon juice and apple cider vinegar.
Over the years, researchers identified several foods with nephro-protecting (protect the kidneys) properties, including basil, apples, oranges, grapes, and Vitamin B6.
5. Takeaway Message
Urinary conditions can greatly affect quality of life, but they are often not discussed enough. It is estimated that nearly half of all women and a quarter of all men experience urinary incontinence at some point, but do not seek medical advice. Elderlies are at higher risks for urinary conditions, due to their age, generally weakened muscle strength and a range of age-related conditions that are risk factors for urinary conditions, such as diabetes, high blood pressure, kidney conditions, etc. Aside from the physical effect on the body, urinary conditions, especially when involving urinary incontinence, can hurt the person’s self-esteem and lead to psychological distress.
With this article, we hope to highlight the medical aspects of urinary conditions. In all cases, we need to treat it as a medical condition and initiate a discussion with the doctor and family members to find treatment. Like other medical conditions, it can be treated and managed once the causes are identified.