Dear Dr. Eva,

I am an overweight woman in my 30s. I’m having a problem where, even though I feel like I have completely emptied my bladder on the toilet, when I stand up, I often briefly leak a little bit. When I asked my doctor about this, she just told me to lose weight. I am so tired of everything being blamed on my weight, I didn’t pursue the conversation with her any more. How does it make sense for this to be related to my weight? Do you have any practical suggestions as to what this is and what I can do about it?

BMI 33

Dear 33,

What may be happening is that some urine is flowing backward into your vagina while you are urinating because there is not enough room for it to flow out between your thighs. That’s why, even though you correctly feel that your bladder is empty, when you stand up the small amount of urine which has become trapped in your vagina leaks out. This can be solved by making sure to hold your thighs widely open while you are urinating. This keeps urine from flowing into the vagina. This problem is not always due to weight. It can happen to any woman who holds her legs too close together while peeing. However it is often related to weight in that the larger a person’s thighs, the farther apart she has to keep them to prevent urine backflow into the vagina.

Dear Dr. Eva,

I am 58 and have developed a strange new problem. When I urinate, I feel like I am completely emptying my bladder, but if I wait a minute or two, I am able to urinate again, a small amount. What is causing this? Should I be concerned?

Repeater

Dear Repeater,

The answer to this question depends on whether your urinary anatomy is male or female.

If you have a prostate gland, by far the most likely explanation at age 58 is that your prostate is enlarged and blocking your urethra, the tube that drains urine out of the bladder. In this situation, your bladder cannot empty completely. To see if this is happening, your doctor can order a sonogram to measure how much urine is left in your bladder after you have emptied it as much as you can. If your prostate is enlarged, there may be urine remaining in the bladder after you have tried to empty it. Whether treatment is needed depends on how much urine is retained (this amount is called “post-void residual”) and whether you have had urinary infections. Prostate enlargement can be serious because when the bladder doesn’t fully empty, the retained urine can become infected and this can lead to sepsis, a whole-body infection also called blood poisoning. Sepsis can be deadly. If you have this problem the treatment is surgical, a trans urethral resection of the prostate, or TURP. The medical name for enlarged prostate is benign prostatic hypertrophy or BPH. BPH is not related to prostate cancer, they are two completely different conditions.

If you do not have a prostate – that is, if you are a woman or a transman with XX sex chromosomes – the problem is a different one and not as serious. In XX people, the most likely cause of double urination is poor muscle tone in the bladder. This occurs with getting older. You have less bladder muscle tone when your bladder is full (big), and better muscle tone when the bladder is closer to empty (small). After you urinate the first time, your bladder is smaller allowing the muscles to contract better and push out the small remaining amount of urine. This condition does not usually require medical treatment unless you develop urinary tract infections. In that case, if the problem does not go away after the infection has been treated with antibiotics, medications can be tried to improve bladder muscle tone.

Dear Dr. Eva,

I have developed this weird condition where my urine sprays in two or more directions. It ends up on the wall or the floor. What could be causing this and what can I do?

Messy

Dear Messy,

This is happening because you have a blockage in the urethra, the tube that drains urine out of the bladder. This can happen in both sexes but is much more common in people with male anatomy, who have a much longer urethra. It can be caused by anything which creates a partial blockage in the urethra. Commonly this is due to scarring or inflammation from a current or past infection or to scarring from a prior surgical procedure like cystoscopy, in which a lighted tube (cystoscope) is inserted through the urethra into the bladder to examine it. More rarely, the obstruction can be due to a small kidney stone stuck in the urethra. Scarring can also result from inserting objects into the urethra for sexual pleasure. This is done using medical equipment called sounds and is referred to as sounding. The treatment for urethral blockage depends on the condition. If there is a current infection, sometimes treating the infection will take care of the problem. If there is scarring in the urethra, this is treated by dilating (opening up) the urethra. This is done with the patient under anesthesia. If there is a stone, it often can be washed out by drinking large amounts of water. If that does not work, the stone must be surgically removed with a cystoscope.

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