There is a bodily function whose mere mention provokes such angst and embarrassment that most fat people avoid referring to it in discussions about their health. Although many difficulties can arise in this area, especially for super sized folk, most doctors never even ask about it. And so, as with many other issues, fat people mostly try to cope on their own with problems in the genito-urinary system.

In the last issue of Dimensions I discussed the diagnostic value of urine: how many disorders can be elucidated by just examining this waste fluid. Subsequently, I have received requests to further discuss urinary tract problems, especially those prevalent in large people. Let us begin with childhood problems.

As we grow out of the diaper stage we learn to hold back until a socially acceptable opportunity to void presents itself. Most kids achieve bladder control by age four or five. No one is sure why enuresis (bedwetting) occurs, but some researchers believe that each of us has a unique maturation clock which progresses at its own pace. As a rule, seven percent of seven-year-olds gain control at a later than usual age. Three quarters of these have another close family member with a similar history. Lest your children succumb to low self esteem, remind them of another fact: former enuretics often mature earlier than their peers when they reach their teen years. The reason for this apparent paradox remains unclear.

A fat child would be no more prone to enuresis than a thin one, except where the abdomen is so large that constant pressure is put on the bladder, or the child is a diabetic. In the case of diabetes, sugar cannot be used properly and flows freely throughout the body, acting as a kind of sponge and sucking fluids out through the bladder. Thus, diabetic kids urinate more often than normal and often just can't keep up with going to the bathroom several times at night. (There usually are other symptoms as well, such as excessive thirst.) But in most cases, fat or thin, enuretic kids are physically and emotionally healthy.

There are many so-called "treatments" on the market, such as herbs, vitamins, and special diets. Most are unsuccessful. Fluid restriction is a waste of time, and nightly "wake-ups" are equally flawed. The good news is that regardless of treatment, most cases resolve themselves by the teen years.

Enuresis is most commonly associated with children, but it certainly isn't restricted to this age group. Uncontrollable leakage of urine, or incontinence, affects a significant portion of the adult population. Three quarters of sufferers are senior citizens, and most of these are women. Younger women may also experience incontinence, sometimes as a result of multiple pregnancies. In some women who either have had many children or surgeries to the pelvic area, the bladder's neck (a sort of faucet) becomes weak or droopy, and sudden stress (such as laughing, or straining when constipated) causes leakage.

Women of size also may have the added disadvantage of increased pressure on the bladder and/or diabetes. Super size adults often find difficulty in wiping themselves or attending to personal hygiene. They often tell me they are ashamed to have a doctor examine them because of this. I then remind my patients that doctors and nurses are used to quite an array of odors and bodily substances, and this should never stop them from discussing their worries directly.

Some readers may be physically challenged as a result of injury. The bladder muscle relies on an electrical cable hook-up to the spinal cord for proper function. If the cables are cut, the bladder and faucet system are put on a kind of "automatic pilot". In this mode, the reflexes allow the bladder to fill up to a certain "tank full mark," and then the system automatically releases urine. Normally, our brain can control this "auto release" by sending a "stop" message down the spinal cord cable, but if the cable is damaged or cut, there is no control over the reflex.

In some cases the bladder faucet may become too strong, or or it may simply become obstructed. Some people are born with an anatomical defect such as a narrow spout. Stones, growths, or tumors also can back up the system until the bladder can't swell any more, and sheer pressure causes a dribbling overflow. The best example of a narrowing faucet involves the male prostate gland. Rarely in medicine can we say a disease is 100 percent guaranteed to occur, but it is generally believed that every man who lives long enough will have some sort of prostate problem.

In adult males the urethra is a pipe through which semen and urine flow to the outside world. The prostate, a small, walnut-shaped gland with the consistency of a rubber ball surrounds the urethra at the base of the penis. One of the prostate's function is to close off urine flow when ejaculation takes place, thereby preventing a mixing of semen and urine.

After age forty the prostate begins to grow, which squeezes the urethra, often interfering with urine flow. No one is sure why this occurs, although we know it is related to the presence of male hormones. The first symptom usually occurs when men notice that they can't seem to get the flow started. When the flow does begin, it may come in little bits, and there often is dribbling at the end. Because the tap is only partially open, there is a feeling that the bladder is still full after voiding, accompanied by a need to make frequent trips to the bathroom.

The best treatment is a simple operation which involves enlarging the passageway with a special electrical torch. Another approach is to use drugs that stop the production of male hormone, which in turn causes the prostate to shrink.

There are many other causes of incontinence in both men and women, such as psychogenic factors, decreased mobility, and even constipation. I will not describe these in this issue for the sake of brevity, but you should discuss their possibility with your physician if you are concerned.
Methods of treatment vary with the situation. Some drugs, such as the anticholinergics, allow the bladder to fill and retain more for longer periods. These medicines are closely related to the antihistamines we take for colds and congestion. Other drugs which fix and tighten the faucet are also similar to some cold medicines and/or antidepressant drugs (chlorpheniramine, imipramine). In females whose spout has become weakened or out of its normal shape, surgery can re-suspend the tissues upward, leading to better control. New surgical techniques involve transplanting muscle, either to strengthen contraction or to improve the function of a leaky faucet. Biofeedback and retraining techniques help people to gradually learn to hold urine longer. If retention is a problem, self-catheterization also can be taught. There are even prosthetics or artificially implantable faucets available.

I trust that those of you who expressed concerns about these delicate matters will now have enough of a basic understanding (and new-found courage) to have a frank discussion with your doctor.
Until next time, be well and enjoy life. ß

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Heretic Physician