DEPARTMENT OF UROLOGY

BLACKBURN ROYAL INFIRMARY

PATIENT INFORMATION LEAFLETS

The following sections are based on the leaflets that we distribute to patients either as instructions on how to manage their medical condition or as information on a proposed procedure. More sections will be added in the future.

We are keen to receive feedback on how useful you find this information and on any suggestions for improvements that you may have. Write to us.

INSTRUCTION LEAFLETS: Advice for Patients with Kidney Stones; Bladder Retraining; Pelvic Floor Exercises for Stress Incontinence; PSA Blood Test; Localised Prostate Cancer
PROCEDURE INFORMATION
LINKS AND HELP LINES

Advice for Patients with Kidney Stones

1. Increase Fluid Intake:: This is the single most important thing you can do. Aim for at least 5 pints (2.5 litres) per day, preferably of clear fluids with a low sugar content.
2. Increase Fibre Intake:: There are many ways of doing this, for example by eating wholemeal bread, high bran breakfast cereals, fruit and vegetables or by adding bran to other foods.
3. Decrease Animal Protein Intake:: Cut down on red meats particularly.
4. Decrease 'Oxalate' Intake:: Oxalate is a constituent of many kidney stones and is found in a variety of foods. Things that you should cut down on are tea, chocolate, peanuts, spinach and beetroot.
5. Decrease Refined Sugars:: For example sugary drinks, sweets and cakes.
6. Decrease Salt Intake.

Bladder Retraining

Sometimes the desire to go to pass urine too frequently can be due to the bladder becoming overactive or oversensitive. Although it is a normal size and capable of holding normal amounts of urine it gives you the feeling that it is full when really it is not.

Bladder retraining aims to slowly increase the amount of urine you can hold in your bladder so that you don't need to go to the toilet as often.

The bladder can be retrained by lengthening the times between visits to the toilet. It takes perseverance.

Stage 1

Identify how long you can comfortably wait between visits to the toilet (e.g. 1 hour). For the next week go to the toilet to pass water regularly by the clock with no less than your individual time interval between each visit e.g. if your initial interval was 1 hour - then go to pass water every hour. Be strict with yourself and do not vary from this pattern. You may need a "holing on" strategy - see delaying tactics below.

Stage 2 (one week later)

Now try to increase the interval between visits to the toilet by 15 minutes. Continue to be strict with yourself.

Stage 3 (another week later)

Increase the intervals by another 15 minutes.

Continue to increase the intervals by 15 minutes each week. After approximately 6 weeks you should have increased the interval between visits by about 1 hour 30 minutes. It is important to stick to this routine.

Delaying tactics

The symptoms of urgency are made worse by anxiety so try to keep calm. When trying to "hold on" -

Keep still
Immediately tighten up your pelvic floor muscles. Pull up the muscles around your back passage (as if trying to stop passing wind) and at the same time around your front passage (as if trying to stop passing water).
Press firmly between your legs with your hands or sit on something firm (e.g. a rolled towel or the edge of a chair).
If standing, cross your legs.
Breathe slowly and steadily.
Think of something to divert you attention away from your bladder (e.g. counting backwards from 100, shopping lists etc.).

In a few seconds, the urge to pass urine will ease.

DO NOT reduce your fluid intake. You should drink about 1500 - 200 mls per day (about 7 - 7 mugs). Avoid or reduce your intake of drinks containing caffeine i.e. coffee, tea, coke, chocolate. These may make your symptoms worse.

Pelvic Floor Exercises for Stress Incontinence

What is stress incontinence?

Stress incontinence means that the bladder leaks urine when put under sudden pressure e.g. coughing, sneezing, laughing, aerobics etc. Weak pelvic floor muscles are one of the main causes of this type of leaking. It can affect people of all ages but often starts during pregnancy, after childbirth or the menopause when the muscles of the pelvic floor become weak and lose tone. The good news is that once stress incontinence is diagnosed, leakage can usually be improved by exercising the pelvic floor muscles.

What is the pelvic floor?

The pelvic floor is a layer of supportive muscle that lies like a sling between your thighs. These muscles lie at the base of the pelvis. The back passage (anus), birth canal (vagina) and urinary passage (urethra) pass down through them.

Functions -

Prevent leakage of urine on sudden movements.
Support the contents of the pelvis e.g. the bladder, bowel and uterus.
They affect the enjoyment of sexual intercourse for both partners.

How to do pelvic floor exercises?

They may be done in any position, but these may be best to start with -

Lying on your back with your knees bent and comfortably apart.
Sitting down (leaning forward, resting your elbows on your knees).
Standing with feet slightly apart (more difficult).

To contract the pelvic floor muscles -

Pull up the muscles around your back passage (as if trying to stop the passage of wind) and at the same time pull up the muscles around your vagina and urinary passage (as if trying to stop passing water). Hold as strongly as possible, then relax and rest for a few seconds.
Try not to hold your breath or tighten your buttocks or squeeze your legs together.

Repeat stages 1 and 2 as many times as possible for a couple of minutes or so, several times a day. It is a good idea to empty your bladder before doing the exercises, so why not try doing them after you have passed water when still sitting on the toilet.

It is not advisable to practice "stopping and starting" mid stream when you are passing water. Do not expect too much too soon - weak muscles tire easily.

General Tips

The Counter Brace. If you are about to lift, push, cough, laugh, blow, sneeze or do any action that causes a downward pressure, prepare yourself to take the increased stress by contracting your pelvic floor and holding it tightly until the exertion is over.
Being Overweight. This gives the muscles extra work to do. Getting down to your correct weight can make a considerable improvement to your symptoms.
Constipation. Straining to force the bowels open stretches the pelvic floor. Diet is the best way to cope with constipation, try to keep a healthy fibre diet with plenty of fresh fruit, vegetables and wholemeal bread.
Liquid Intake. You should drink approximately 1500 to 2000 mls (about 6 - 7 mugs) of liquid a day. NO NOT restrict your intake - it will not make you leak less. If you don't drink enough your bladder will be irritated by the small volume of strong urine which could make things worse.
Heavy Lifting. Puts a strain on the pelvic floor so repeated heavy lifting should be avoided when possible. If you need to lift something heavy remember to tighten the pelvic floor muscles before you do so, continuing until after you have put the load down.
Strenuous Tummy Exercises. Such as sit ups and double leg lifts (lying down and lifting both legs together) put severe pressure on the pelvic floor and must not be done if they cause leakage.
Frequency of Bladder Emptying. Try not to get into the habit of emptying your bladder too frequently as this can reduce its capacity. Do not develop bad habits by going (voiding) "just in case". Up to eight times a day is considered the normal.
Bladder Emptying. It is important to completely empty your bladder each time you go to the toilet. Any small amount of urine left inside may irritate the bladder lining and cause inflammation. If you feel you may not have fully emptied your bladder try standing up, turning around and sitting back on the toilet, then try to pass water. When passing water you will not be able to completely empty your bladder if you do not sit on the toilet seat. It may also help to lean forward as you push to pass urine. Take your time to empty your bladder - do not rush.

PSA Blood Test

Recent publications from the British Association of Urological Surgeons (BAUS) have suggested that patients who are offered this blood test for their prostate gland should fully understand the implications of the test before having it performed. The patient is then within their right to agree or not to agree to have the test. The following is intended to clarify the issue and help in making the decision.

What is PSA?

PSA stands for Prostatic Specific Antigen. PSA is produced by the prostate gland for the semen although a small amount is also released into the blood stream. The blood test measures this small amount and gives your doctor some information on the state of your prostate gland.

Although the main reason for doing the blood test is to look for prostate cancer, an elevated result can be due to other reasons...

Increasing age
Large prostate size in the absence of cancer
Prostate or urine infection
Recent trauma to the prostate e.g. prostate operation

What does it mean if the test is normal?

If the blood test is normal and the prostate feels okay when examined by your doctor, then you are very unlikely to have prostate cancer. The few cancers that are missed by combining the two tests are usually small and slow-growing. Normal results, however, do not guarantee against developing prostate cancer in later life.

What does it mean if the test is abnormal?

This raises the possibility of prostate cancer but, only a third of patients with an abnormal result turn out to have it. To investigate this further, the doctor may want to get some small samples of tissue from the prostate ("biopsies"). This is done using a probe placed into the back passage.

What if I do have prostate cancer?

A lot of men develop prostate cancer but only a few will die of it. If it is felt that your cancer is unlikely to be a problem, your doctor may initially suggest no treatment but will keep a close eye on you in the clinic. This is called a "watch and wait" policy.

If it is felt that your cancer will progress then the recommended treatment depends on whether it is confined to the prostate gland (termed "localised") or has spread outside. If localised, then treatment attempting a cure is possible. This can be either an operation to remove the whole prostate gland (called a "radical prostatectomy") or some X-ray treatment ("radiotherapy"). If the cancer has spread outside the gland then hormone treatment may be suitable to reduce, but not cure, the disease.

Localised Prostate Cancer

If we use the term "localised" we feel that the cancer is confined within the prostate gland and has therefore not spread elsewhere. In this case it may be possible to cure the disease. Things to be aware of , however are...

Variation in the growth rate of prostate cancer
The different treatment options available

Growth of Prostate Cancer

A range of possibilities can occur. At best the cancer may not spread or grow any more during the rest of your natural life. At worst the cancer may spread to other parts of your body, at which point the disease will become incurable (although thins can be done to help). We get some indication of how a prostate cancer will behave but there is no reliable way of predicting this accurately.

Treatment Options

There are three choices available, each with its advantages and disadvantages...

Surgery
Radiotherapy
Watch and Wait

There is no evidence from research that one treatment is better than the others. Treatment is influenced by patient preference after discussion with their doctor.

1. Surgery: This involves a major operation to remove all of the prostate gland and the cancer within it. It possibly gives the best chance of curing the disease. The main side effect is impotence and this occurs in most patients. The second possible problem is incontinence (leakage) of urine. Up to 20% will occasionally leak a few drops but 1-2% will be continually wet, although further treatment can help cure this.

2. Radiotherapy: This attempts to destroy the tumour using powerful X-rays. It involves attending every day for treatment for up to three weeks. Adjacent bowel and bladder can be affected by the treatment causing diarrhoea and "cystitis-like" symptoms. There is a risk of impotence of about 30% but incontinence is very unusual. Recently, "brachytherapy" has been introduced whereby radioactive "seeds" are inserted directly into the prostate gland.

3. Watch and Wait: No treatment is given initially but the patient is monitored closely in the Out-Patient clinic. If there is no sign of the cancer growing then all of the potential problems of the above treatments will have been avoided. If the cancer does progress then surgery or radiotherapy can be considered later but there is the risk of "missing the boat" and the disease may become incurable. As localised prostate cancer tends to grow slowly over many years, we generally advise watch and wait for the older or infirm patient who is more likely to die of a cause other than prostate cancer.

Any of the active treatment options (i.e. surgery or radiotherapy) can cause impotence but this can be treated.

Prostate Cancer Helplines

Prostate Cancer Support Association:

Name:	Tel No:	Time Available
Angus	0181-446-3896	10am-8pm
Mark	01634-570309	10am-8pm
Ray	0181-883-9571	5pm-11pm
Bernard	0941-101057 (Pager)	10am-8pm

BACUP:

Staffed by cancer nurses. Free helpline 0800-181199.

Cancerlink:

Staffed by information officers. Free helpline 0800-132905.

Vasectomy

This is a small operation performed on the scrotum to render a man sterile. A segment of the tube that comes from each testicle (called the vas deferens) is removed. It can be performed under a local or general anaesthetic. Things to be aware of are:

The sterility is intended to be permanent. The operation can be reversed but the results are poor.
Follow-up semen samples are required at 10 & 12 weeks after the operation. Until you are informed that these samples contain no sperm you cannot consider yourself sterile and should use another form of contraception.
Potential complications:

Recanalisation (sperm can reappear in semen):	1 in 3000 chance of pregnancy
Significant bruising or wound infection:	5% of cases
Long-term scrotal discomfort (Post-Vasectomy Syndrome):	3% of cases

There have been suggestions of subsequent increased risk of heart disease, prostate cancer and testicular cancer. These have been discounted by recent studies.

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