Possibly the second most common complaint from middle aged women is about their unruly bladders! They leak, they dribble, they empty at the worst times, and even if the symptoms are not so severe as that, they are a confounded nuisance.

Bladder malfunctions in a normal woman are an excellent example of what is known as a conditioned response. When you open the door of the toilet, the bladder is already getting itself toned up for a big muscular effort to empty itself. After you have had a couple of vaginal births, or even just getting older and losing tone in your pelvic muscles, the problem can arise more easily. I have also noticed that women who have always had a slight build, and have kept trim waistlines without much trouble (yes, such women do exist!) she may never have had to hold in her stomach, never had to worry about a bulging belly, and so the bigger girls have the advantage of having better abdominal and pelvic muscles, which helps their bladder control.

Re-training your bladder so that it does not automatically decide when to empty is a chore, but not a long or arduous one, and so is well worth doing. If we look at the syndrome I have called “your bladder knows you’re home”, then we can use this as a model for re-training in other ways.

Sometimes you drive into your driveway at home, have barely got the shopping bags out and the key in the door when already your bladder is starting to leak. You rush to the loo, lucky to get there in time and heave a sigh of relief. If you do not re-train this bladder it will start earlier and earlier in the cycle of home-coming, and one day will let you down. The way to do it is to start well before the response sets in, i.e. at least two blocks away from your house. Slow down and stop the car. Squeeze your bladder tight and decide you do NOT want to go to the toilet. Then start up the car and hold on to both your bladder and the thought that you DO NOT WANT to go. Arrive more slowly than normal. Stay in place in your car for a moment and renew your wish to NOT GO to the loo.

Once you are in the house, you can then go to the loo at a measured pace, instead of the usual rush to get there! If you repeat this exercise several times a week, you will find that your bladder is tamed into submission!

So let’s talk about the various other types of bladder problems that can arise.

Firstly there is the really common condition called stress incontinence, which the TV adverts are referring to as “light bladder leakage”! This is where the tight exit muscle from the neck of the bladder has been traumatised by any one of a number of factors, including long labours, recurrent infections, slack muscles generally, etc. The bladder neck cannot hold up an amount of urine effectively if there is any additional pressure such as coughing, sneezing, jumping or running. There will be some drips escaping, maybe even more than drips. This condition can be helped in some women by pelvic floor exercises, but the recently developed TVT or “sling” operation has been a blessing. If it is appropriate in the case, it will fix the problem. The only thing is, it is not always going to be appropriate, after volume testing of the bladder.

Then there is the symptom called urge incontinence. This is where the bladder holds the urine ok until there is the urge to go to the toilet, when bingo, it’s too late! If this occurs outside the home it is extremely embarrassing and the woman needs help urgently. Urge incontinence is more difficult to treat, and needs time and patience to train the bladder to hold more urine before hitting the “go” button and releasing it’s load!

Then there is the problem of recurrent UTIs, or urinary tract infections. For some reason women in middle to later years do seem to get more than usual numbers of bladder infections. Sometimes this will be because any one infection is not adequately treated. The villain in this scenario might be the woman herself who, having felt better, did not take the last few tablets in the course! No, none of us ever did such a thing?! Or, the problem may be that the doctor, having assessed the UTI himself may have thought it unnecessary to send a sample to the laboratory, and simply made an educated guess at which antibiotic would be effective. If the guess was wrong, the infection persists.

My policy with UTIs is: if the woman (and it usually is a woman not a man) has not had a UTI for over two years, then I will guess at the antibiotic once, but she must take the whole course. Then if it comes back, she must have a sample of urine sent to the lab to check what infection and what antibiotic we are dealing with. Then after the whole course of tablets has been taken, wait three days and repeat the urine sample to be sure the infection has completely cleared.

An interesting story comes to mind. When I was practicing in North Fitzroy, in Melbourne, I had a group of patients who were not keen on medical treatment but nonetheless asked if I would undertake any investigations for them, to arrive at a proper diagnosis, but leave the treatment to them. I thought about it and said I would agree on two conditions: that they would not hold me responsible for the outcome, and if I said it was a matter of life and death that they would agree to let me treat them.

Things went along well for some time until a young woman came in, heavily pregnant, with the dipstick in her urine showing a bad urinary infection, with blood, albumin and leukocytes all positive. Her urine was sent to the lab but I told her that as she was pregnant, I really had to insist she have treatment as the baby might be harmed otherwise. She begged me to give her 24 hours to treat it herself, and as she had clearly had it for more than that anyway, I agreed but insisted she come in the very next morning for review.

When she arrived the next morning, the dipstick was entirely normal! No blood, no leukocytes and no albumin, and she had no symptoms either. I was shocked. I asked her what she had done, and her reply has stayed with me and helped many a patient since then. She said she had cut up three cloves of garlic into tablet sized pieces and swallowed that amount three times a day. Since that time I have had great respect for the antibiotic effects of garlic and recently, having been caught on a weekend with nothing else to take for a UTI, I was very glad I had a good stock of garlic in the house!

So, you can see that bladders are often troublesome, but none of the problems above are without remedy. The one that is Extremely Difficult is the condition known as interstitial cystitis. This is an inflammation (not infection) of the substance of the bladder wall. The causes are not well understood, and the treatment can be very tedious and not always successful. I have not tried the garlic treatment, but it might be worth a go for any of you out there with this ailment.

Thankfully modern uro-gynecologists are more sympathetic to women’s bladder problems than in the old days. As a young doctor I can recall being very shocked to hear an old-style gynae say that neurotic women eventually develop mythical bladder symptoms but it was all in their minds! Wish I could get him now by the scruff of his rude neck…. I’d give him a piece of my mind, I can tell you!