Dr. Khant Shahil Ramesh Bhai
Urology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
I am a 31-year-old woman. This problem started four years ago when I was diagnosed with Hashimoto's thyroiditis. And I suffer from a constant and persistent urge to urinate concentrated in my urethra. Sometimes, it is accompanied by pressure, discomfort, slight pain, twitching, or spasming. My urine flow is weak and hesitant, and I have to strain or push to empty my bladder, and sometimes I feel that I have not completely emptied my bladder. The urodynamics study did not show an overactive bladder, and my urogynecologist told me it showed that my bladder did not mount a good contraction. Please advise.
Hello,
Welcome to icliniq.com.
You may be suffering from an underactive bladder. Tablet Urivoid (Bethanechol), one tablet in the morning and evening, should help. Please send me the urodynamics report with graphs.
Patient's Query
Hello doctor,
Thank you very much for your reply. I am attaching my urodynamics report with graphs in an eight-page PDF file. My urogynecologist wants me to try the Interstim neuromodulator device, but I want to try medications first, as you suggested. My symptoms now are a constant need to urinate centered in my urethra that comes again immediately after urinating, a very weak flow, hesitancy, straining and pushing to empty, and a feeling of incomplete emptying. I am currently not taking any medications as the Detrol caused urine retention. Based on the urodynamics report, is it an underactive bladder, or is something wrong with my urethral sphincter muscles? I would appreciate any help you can give as I suffer from this condition.
Hello,
Welcome to icliniq.com.
I have seen the reports and graphs sent you (attachment removed to protect patient identity). It suggests an underactive detrusor. Since you have an underactive bladder, you will suffer from retention if you take Detrol LA (Tolterodine). Sorry, but there are not many options for an underactive bladder. Once the bladder muscles get damaged, it is challenging to gain strength. Strangely, you are very young to have an underactive detrusor. You can try a Urivoid tablet (Bethanechol) 25 mg in the morning and evening. Another option is a clean intermittent catheter. Twice a day, you need to catheterize and empty your bladder. It is not as difficult. Interstim is also an option, but how much relief it would give cannot be predicted. If you are going for Interstim, they will run a trial for two to three weeks. After that, they would keep a permanent implant if you feel better. So, you can take a trial run, and if you feel better, only go ahead.
Patient's Query
Hello doctor,
Thank you for your clear response. My doctor here does not want to prescribe the Urivoid for me. I used to hold my urine a lot when I was a teenager. Could that have weakened the muscle? When I was a child, I used to stop my urine flow in the middle a lot and then start it again. Could that also be a reason? Could it be related to my underactive thyroid, although I am now taking thyroid hormones and monitoring my dose?
Hello,
Welcome back to icliniq.com.
Unfortunately, faulty bladder habits (such as prolonged holding and stopping urine in between the flow) formed during childhood and teenage years can cause bladder problems later in life. Currently, in your urodynamics graph, your voiding pattern looks fine. There is no problem with the pelvic floor or sphincter while voiding, as sometimes a tight pelvic floor during voiding can cause obstructed flow. Constipation can also aggravate your problem. I also suggest you avoid constipation altogether. It is not related to your thyroid, for sure. But your bladder is not zero. It has a moderate amount of power still left. So, do not lose hope. Urivoid is a safe medicine, and I recommend it. Also, it would be best if you did a timed voiding. You should void every two to three hours even if you do not feel like it. Double voiding means, after passing once, you should again try one more time to give the remaining urine. These measures will not improve the flow but will help you retain less urine. You should feel better with this; if you get 70 to 80 percent benefit, that should be fine.
Patient's Query
Hello doctor,
Thanks again for giving me a precise diagnosis and steps to follow. I had used a catheter before when I could not empty my bladder fully, and it helps me sometimes empty two cups. I do not have a problem with doing that twice a day. The symptom that bothers me very much is feeling like I need to urinate all the time. This feeling is constant, and it comes back immediately after voiding. Is this typical with an underactive bladder? Is there anything I can do to eliminate that constant feeling of needing to go? It is not urgent because I can ignore it for an hour or two, but it is always in my urethra. I also want to mention that yesterday I felt I needed to urinate, but I could not urinate at all, and when I used a catheter, nothing came out. So, I still get this feeling even when my bladder is empty. Why is that? Is there anything that could be done about the constant feeling that I feel in my urethra that I need to urinate? It is annoying me very much and has almost destroyed my life.
Hello,
Welcome back to icliniq.com.
I can understand your suffering. Your above symptoms are not related to underactive detrusor. It is a urethral syndrome. Besides the medicines, it would be best to change your bladder habits. Avoid food and liquids which make the urine more acidic. Drink adequate water. Aoid every two to three hours. Practice double voiding. Prevent constipation. Apart from Urivoid, I also suggest taking tablet Urispas (Flavoxate), one tablet three times a day, and syrup Cital (Disodium hydrogen citrate), 2 teaspoons in the morning 1 teaspoon at bedtime. It is to make the urine more alkaline.
Patient's Query
Hello doctor,
I am so grateful for your straightforward response and your extensive knowledge. I have a few questions: Two days ago, that constant need in my urethra was intense. So, I went to an urgent care clinic, and they found out that I had leukocytes and some blood in my urine, and they prescribed Nitrofurantoin 100 mg twice daily. Is there an antibiotic I can take in the long term in a low dose to prevent infections with this underactive bladder? By the way, I will start the Urecholine today. My bladder muscle was working fine, and I was voiding considerable amounts with a strong flow about a year and a half ago. So, could the power become underactive suddenly like that?
Concerning that constant feeling in my urethra that I need to urinate, could it be that the muscles around the urethra are tight or something like that? I am saying this because sometimes I feel spasms around the urethral opening. Could Urispas cause the bladder muscle to relax more? I read that it soothes the urinary tract. Or does it only affect the urethra? Is this urethral syndrome curable by medications and good habits with a non-acidic diet? Will it go away? It is driving me crazy. Thanks a lot. I am looking forward to your response, as you are the only doctor who gives me satisfying responses and who really cares.
Hello,
Welcome back to icliniq.com.
Yes, you will have an infection due to urine retention, as urine is a nidus for infection. Regarding antibiotics, any antibiotic is harmful in the long term. But, you can take a low dose of Nitrofurantoin 100 mg once daily for a long time. Please consult your specialist doctor, talk with them and take the medicines with their consent. Regarding your bladder muscle working well before one and a half years, it is because of slow damage in the bladder. Before, you may void good because of abdominal straining plus moderate bladder contractions. As the bladder contractions decrease, your flow is also reduced.
Regarding the spasm of the urethra muscle, we do not have any objective evidence as your urodynamics did not show any spasm of the urethral or pelvic floor muscles. So, I think that can be better appreciated by physical examination of the vagina. Your gynecologist has examined you properly. She would have told you if there was any problem with the pelvic floor or urethra muscles. Urispas should give relief. It may relax the bladder, but not much, and it is not powerful as other drugs. I am sorry, but the bladder damage is less likely to recover. In your case, we need to focus on your constant urge and other symptoms. If you get symptomatic relief, that would be great. It is a very tricky disease and requires great patience from your side. You can also self-catheterize in the morning and evening so that there is less residual urine and fewer infections. There are other drugs for your symptoms, but we better go slow.
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