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
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
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
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