This week is World Continence Week. From the 23rd – 29th June 2014 it is about raising awareness of incontinence and it’s related issues.
According to the International Continence Society (2014) “incontinence affects an estimated 200 million people across the world. Historically, conditions affecting the bladder and bowel have often been uncomfortable or “taboo” subjects and accordingly these medical disorders have been under-reported and under-diagnosed. Surveys have shown that fewer than 40% of persons with urinary incontinence mention their problem to a doctor or nurse and this figure is even higher for those with bowel incontinence.”
In light of this week, a friend and colleague of mine who is a renal nurse specialist asked me to write something about drinks that are suitable for people who may have urinary continence issues. To be honest, despite my pretty extensive knowledge of renal physiology and nutrition I have still learned a lot in researching this topic! As usual I have gone a bit overboard and also mentioned foods but it was hard to separate food from drinks….you will see what I mean when you keep on reading…..
One of the most common bladder problems is urge incontinence. Frequency (having to pee more than average – over 7-10 times a day having drunk around 2L fluid) often goes hand in hand with urgency. Frequency and urgency problems are usually the result of over-active muscles which control the bladder (the detrusor muscles that line the bladder which contract when you have a pee). This is called having an over active bladder (OAB). When the detrusor muscles go into spasm, you get a strong and uncontrollable urge to empty your bladder (referred to as OAB dry) and if you can’t make it to the loo fast enough, urine leaks from the bladder without you wanting it to happen (hence called OAB wet). Urge incontinence may only be temporary – perhaps as a result of a urinary tract infection such as cystitis, the effects of certain types of medication or as a result of drinking too much, especially caffeine and alcohol based drinks. Some people however are affected by interstitial cystitis (IC), or painful bladder syndrome. Both men and women suffer from IC (with women being affected around ten times more often than men) who experience significant pain alongside very frequent urges to have a pee. IC can be very debilitating (having to pee ~16-40 times a day) yet there is no known cause. It appears to be a result of the bladder being irritated and inflamed for a long period of time.
IC is a chronic disease that affects the lining of the bladder. Normally a healthy bladder is coated internally with mucin – a gel-like substance that protects the bladder tissue from irritation by the urine. A deficiency of this mucin layer is thought to cause interstitial cystitis as the lack of protection allows irritants in the urine (potassium is thought to be one) penetrate deeper into the bladder where all the nerve endings are located. These irritants in the urine cause inflammation of the bladder wall and activate the nerve endings which basically causes the symptoms that people with IC have.
Part of this cascade of events that occurs is the release of pro-inflammatory chemicals from some of our immune (Mast) cells that release histamine and prostaglandins. It appears it is particularly the histamine that causes the bladder to sense pain, frequency and urgency.
[You may have heard of antihistamines that we take to manage hay fever and other allergy related symptoms as they stop the Mast cells releasing histamine which makes us feel so rotten]. The constant irritation leads to the development of scar tissue in the bladder, which is less elastic than normal bladder tissue, contributing further to the frequency problem..
Medical and health practitioners will usually commence a treatment programme by starting with the least invasive and surgery free options. One of these is to look carefully at the diet and drinking habits of sufferers alongside consideration of medication (which I am not able to comment on). Most of these symptoms can be addressed if the problem is reported to your GP or Continence Nurse specialist. Investigation need not be invasive and often starts with the completing of a Bladder Diary which is vital to diagnosis.
Here is a list of suggestions that may help an over-active bladder. Specifically I need to mention that if you have been diagnosed with IC it would be recommended you be referred to a registered dietician for advice.
Top 10 Tips
1. Volume of drink
Many people think that by reducing their fluid intake, they will have to pee less so it will help their condition. You couldn’t be further from the truth really as the less you drink, the more concentrated your urine will be and the more likely the bladder will be irritated. It is believed that highly concentrated urine can actually make you wish to go to the toilet more. However, on the other side of the coin, over drinking can increase the activity of the bladder so what do you do?
Limiting fluid intake can contribute to constipation, which in turn can lead to further problems as the bowel can press on the bladder so an ideal fluid intake for an adult with continence issues is somewhere between 1.5-2 litres per day.
2. Timing of drink
The time of day when you drink fluids may also be a factor. It is best not to drink large quantities at one time e.g. meals, but to spread the intake over the course of the day. To help manage the problem of frequently getting up in the night, try to drink most of your fluids by 6pm and avoid any alcohol and caffeine in the evening – see the next tip!
3. Avoid Caffeine & Alcohol
Caffeine and alcohol can give a triple whammy as they have a stimulant effect on the body and bladder, they can contain histamine so can contribute to inflammation and further irritation and have diuretic effects (in other words they make you pee). So avoid wine (and any sparkling varieties), beers and spirits and energy drinks are an absolute no no as they are loaded with caffeine. It is not just coffee that contains caffeine either – so does ordinary black tea and green tea. Avoid these too.
White tea, decaffeinated tea (Rooibos / Red bush) and any herbal teas like peppermint and chamomile are fine but decaf coffee is not (because just removing the caffeine does not remove all the potential irritant properties). Go for water or milk instead (non-dairy rice or almond milks can make a refreshing change). If you are a regular caffeine drinker, it is advisable to cut down your caffeine intake gradually so you don’t go ‘cold turkey’ and get withdrawal symptoms (particularly headaches).
4. Avoid Chocolate
Chocolate also contains histamine, caffeine and many other chemicals that can trigger symptoms so it is best to avoid if you know it makes symptoms worse. It’s not just the bar of dairy milk you need to avoid either. Unfortunately you should also avoid mocha / hot chocolate or milk shake drinks, chocolate-containing ice cream, cereals and biscuits.
5. Avoid Potassium rich foods
Because of the theory that potassium can particularly cause the bladder muscle to go into spasm avoiding potassium rich foods can help. Having said that, some people find eating bananas and melons which are high in potassium can have a soothing effect so again it’s not necessarily black and white!
Other Potassium rich foods include the following:
Many vegetables and vegetable juices are rich in potassium so only have them in small amounts and see if you tolerate them.
5. Avoid acidic drinks and foods
Anything acidic has the potential to irritate the bladder further and worsen any inflammation already there. Acidic foods and drinks include these examples:
- citrus fruits and juices (oranges, lemons, grapefruit, pineapple, kiwi and any other sour / tart fruit such as granny smith apples, grapes and cherries)
- cranberry juice (can be useful in mild cases of bacterial cystitis as components in the cranberry can prevent the bacteria from growing but this is ineffective in IC and actually makes symptoms worse)
- vinegar of any sort
- any carbonated drink
- anything pickled (beetroot, cabbage, eggs, onions)
- sour yoghurt or cream
- tomato juice, acidic sauces and salsa
Its worth noting too that many vitamin and mineral supplements contain vitamins C (ascorbic acid) so these may also make symptoms worse. Eating ‘real’ food is probably going to be better for you anyway.
6. Avoid Spicy and highly seasoned foods
Anything with chilli or products that are highly seasoned should be avoided. These include:
- Indian, Thai and Mexican foods
- Chilli peppers
- Highly seasoned, salted, cured and flavoured fish, meats and sauces
- Instant soups and noodles
- Stock cubes and gravy
Chilli and spices can have a stimulant effect on the body and bladder and many processed foods contain flavour and colour enhancers like Mono Sodium Glutamate (MSG) and sodium nitrite. People with IC have long reported that foods containing high levels of MSG and/or nitrites trigger bladder symptoms and discomfort so these are best avoided whenever possible.
7. Avoid fat-free and diet products
Research has shown that most artificial sweeteners like aspartame and saccharin appear to be bladder irritating, particularly aspartame (i.e. NutraSweet®). Most diet products, such as sugar-free sweets, drinks and yoghurts are loaded with artificial sweeteners (that may reduce the Calorie content) but worsen symptoms.
8. Eat more fibre
It is recommended that you increase your intake of dietary fibre as constipation can put pressure on an over-active bladder. As of today (26th June 2014) a draft consultation has been released by the Scientific Advisory Committee for Nutrition (SACN) that suggest increasing our fibre intake from 18g to 30g. This is still achievable if we aim to eat our 5 portions of fruit and veg (non-acidic, lower potassium), wholemeal breads, cereals, pasta and rice. Grains are not usually a problem for people with IC unless they have other underlying conditions like coeliac disease.
Good choices of fruit and veg include:
Fruits – Bananas, blueberries, honeydew melon, watermelon, pears. Dried fruits are not advisable because of the artificial ingredients to preserve them.
Vegetables – Broccoli, Brussels sprouts, cabbage, carrots, cauliflower, celery, cucumber, mushrooms, peas, radishes, squash, courgettes, white potatoes, sweet potatoes & yams
9. Eat meat and fish
In terms of poultry and meat, chicken, turkey,beef, pork and lamb are all fine.
Fish is also good, particularly oily fish that can be beneficial as the ‘healthy’ omega 3 polyunsaturated fats in them can have anti inflammatory properties. So go for:
- fresh tuna
10. Go nuts!
Nuts and seeds can be a bit hit and miss. Nuts also contain healthy fats which can be anti inflammatory but some nuts appear to worsen symptoms.
Almonds, cashews and peanuts appear to be fine but pistachios, hazelnuts and pecans are best avoided.
If this post simply makes people more aware about bladder issues and able to talk about having a pee more freely, I am happy!