The Photographs Your Urologist Has Never Shown You

Exhibit ACystoscopy, male, 61

The pale, cracked area is not tissue. It is mineral sediment, laid down out of this man's own urine over roughly four decades and bonded flat to the bladder wall. He was told his results were normal, because by every test that was run, they were.

Dr. Alan Reeves, MD

Urology, Portland OR - reviewed and updated this week

I have been a urologist for twenty years, and in that time I have looked inside several thousand bladders.

What I want to do here is simple. I want to show you five photographs, in order, and explain what each one has to do with why you are awake at two in the morning.

I am doing it this way because I have run out of patience with the alternative. The alternative is what almost every one of my patients over fifty-five has already been through: a test, a clear result, a shrug, and a sentence about not being twenty-five any more. That is not a diagnosis. It is what gets said when nobody has looked at the lining.

What you are actually looking at

The inside of a healthy bladder is smooth, pink and wet. It is also, and this is the part that matters, elastic. It has to be. Stretching is the only way the organ has of knowing how full it is.

Now look at the second photograph. This is a section of bladder lining, opened flat.

Exhibit BLining section, female, 58

The grey-beige crust covering the inner surface is mineral, not tissue. It has cracked into plates the way limescale does, because that is essentially what it is. Underneath it, the muscle is in good condition.

I want to be very clear about that last sentence, because it is the single most useful thing on this page. The muscle underneath is usually fine.

Almost everybody who comes to see me about this has spent years believing their bladder is worn out, weak, or failing. In the overwhelming majority of cases it is none of those. It is a good bladder wearing a bad coat.

Why every test you have had came back clear

A standard urine test looks for three things: infection, blood and sugar. A scan looks for stones and for anything with a shape. None of those is what we are discussing.

Here is the third photograph. It is an ordinary sample, left to stand.

Exhibit CStanding sample, 40 minutes

The grey layer on the bottom came out of solution on its own, in under an hour. This sample was reported as normal, and it was. Nothing on a standard panel measures the mineral load that does this - or what happens when it comes out against a wall instead of into a pot.

Most of that material never reaches a pot. It comes out of solution against the nearest available surface, which is the bladder wall, and once it is there nothing in the body removes it. There is no mechanism for that. It simply accumulates.

So the tests are not wrong, and your doctor was not careless. You were measured for the wrong thing, and then reassured on the strength of it.

“Nothing is wrong with your bladder. Something is on it. Those are completely different problems and only one of them is on the form.”

Dr. Alan Reeves, MD

You already understand this perfectly

Go and look inside your kettle. Actually go and look - I will wait, because it makes the point better than another paragraph will.

Exhibit DDomestic kettle, approx. 2 years

Two years of ordinary tap water. Nobody finds this surprising or alarming. It is simply what happens when water carrying dissolved minerals sits against a surface for long enough.

Nobody thinks a kettle like that is defective. Nobody suggests it is old, or weak, or that it should accept its limitations. They descale it, and it works again.

Here is a pipe out of the same house.

Exhibit EDomestic pipe, approx. 20 years

Twenty years, and the bore is down to a third. The pipe was not damaged and nothing unusual ran through it. This is the same process as Exhibit D, given ten times as long.

Now hold those two pictures against the first two, and ask the obvious question.

Your bladder has held more mineral-bearing water than that kettle and that pipe combined, for fifty or sixty years, at body temperature. Nobody has ever descaled it. Nobody has ever suggested it could be.

I call what builds up in there bladder sludge. It is not a term you will find in a textbook, and I use it because it is accurate and because my patients understand it immediately.

Why a coated bladder wakes you up

This is the part almost nobody has had explained, and it takes about thirty seconds.

Your bladder does not have a gauge in it. It reports how full it is by stretching - nerve endings in the wall fire in proportion to how far the tissue has been pulled. Gentle signal at half full. Firmer one later. That is the whole system.

Now put a rigid mineral film across that wall.

Clear lining - stretches

Coated lining - cannot

The tissue reaches the end of what it can stretch to almost immediately, so it sends the full signal at around a third of capacity - and because it has skipped the gentle early stage, it sends it hard.

That accounts for all four of the complaints I hear, and it accounts for them with one mechanism rather than four:

The two o'clock trip, on a day you barely drank anything. The urge that arrives with no notice, where you once had ten minutes and now have ninety seconds. Going, and standing there, and still not feeling empty - because you were not full to begin with. And the leak on the way, which is not weakness but a signal that arrived far too late to act on.

It does not sound like much. It is not supposed to - the point is not the volume, it is the coverage. A film two teaspoons thick spread across the entire inner surface of a bladder is more than enough to take the stretch out of it, in the same way a coat of paint is more than enough to stop a balloon inflating properly.

It begins somewhere in the mid-forties and thickens by a few per cent a year, every year, for the rest of your life.

What it quietly takes off the list

I ask patients what they have stopped doing. Almost nobody says "nothing", and almost nobody has ever been asked before.

• The aisle seat, every time, without it ever being discussed
• The four-hour drive that became three legs, then stopped being worth it
• The overnight bag that gets packed and does not get picked up
• Fluid after four in the afternoon, which never helped and made you thirsty
• The show, the service, the long lunch - all of it, with a good reason ready each time

None of that is a medical complaint, which is exactly why it never comes up in a seven-minute appointment. It is also, for most people, the entire cost of the condition.

What actually lifts a mineral film

Once you see the problem as a coating rather than a weakness, the answer stops being mysterious. You need three things happening at once, and almost everything sold for bladder health does exactly one of them.

Flow matters here only as the exit route. The sediment has to leave the body somehow, and that is the only reason it comes up. I am not interested in making anyone go more often - my patients are trying to go less, and telling a man who is up three times a night to increase his output is the sort of advice that makes people stop listening to doctors.

I have no involvement in how it is priced and I am not going to pretend otherwise about what it is: a supplement, not a prescription, and not a cure for anything.

What I will say is that it is built around the right problem, which after twenty years of watching people be handed a photocopied pelvic floor sheet for a mineral deposit is not something I say lightly.

If the photographs at the top of this page explained something nobody had bothered to explain to you before, the rest of it is worth ten minutes.