Overactive Bladder
Overactive bladder can cause a sudden and strong desire to urinate. Patients usually come for a urologic evaluation if the symptoms begin to affect quality of life. Perhaps you avoid long road trips for fear of overactive bladder symptoms. Do you know where every restroom is at the local grocery store? The urinary leakage can be embarrassing and result in the avoidance of social activities such as dinner with friends and family. Many patients feel there is nothing to be done for bladder overactivity. Fortunately, over the last decade there have been many new and promising treatment options.
The sensation of urinary urgency results from inappropriate bladder contractions. We often think of the bladder as an uncomplicated urinary reservoir. However, when things go wrong, the true complexity of the bladder and urinary system reveals itself. In a simple sense, the bladder is meant to store urine at low pressure and allow for the adequate emptying of urine at a socially acceptable time. The bladder is a muscle with complex input from the peripheral and central nervous systems. The simple act of urination requires perfect function of a complex neural circuit. Urinary symptoms, such as those seen with overactive bladder, result when the nervous system input fails, the bladder muscle itself fails, or the sphincter muscles fail. Treatment options for overactive bladder are directed to target specific areas of this complex neuromuscular process.
Prior to initiating treatment, you will likely undergo a simple evaluation to determine the cause of the symptoms. Several conditions can mimic overactive bladder. Urinary tract infections, kidney stones, and certain forms of bladder cancer can cause similar symptoms and must be ruled out. Your urologist may recommend a cystoscopy (looking into the bladder with a small camera), a urodynamic study (pressure test of the bladder), and a urine culture. On occasion, it may be necessary to obtain imaging studies such as a CT scan or ultrasound.
If the evaluation confirms the diagnosis of overactive bladder, there is a relatively standard treatment approach. It makes sense to start with the least aggressive treatments first. The treatment options for overactive bladder are listed below in the order in which they are utilized.
Behavioral Therapy is an effective treatment option with no risk to the patient. Your urologist will often ask you complete a voiding diary. The voiding diary involves recording how many times you urinate over a 24-48 hour period. The diary allows for recording of volume and the presence or absence of symptoms. Information provided from the voiding diary is valuable to the urologist and will help to clarify the problem. Once the diary is completed, simple lifestyle changes can be implemented to improve symptoms. For example, if the primary problem is waking during the night to urinate, double voiding and decreasing fluid intake prior to bedtime can be extremely helpful. Patients experiencing severe urgency may be helped by proper KEGEL maneuvers which are taught in the office. Pelvic floor strengthening and biofeedback can also be helpful. Bladder irritants such as caffeine and spicy foods can be avoided.
Medication Therapy has been the mainstay for treating overactive bladder symptoms for many years. All of the medications work to “calm” the bladder by preventing unwanted bladder contractions. The most commonly used medications are referred to as anticholinergics. These medications include oxybutynin, vesicare, enablex, sanctura, and many others. Anticholinergic medications work to relax the bladder by blocking the effect of acetylcholine. Blocking the effect of acetylcholine on the bladder results in fewer unwanted bladder contractions and more appropriate bladder relaxation. Anticholinergic medications are effective in controlling the symptoms of overactive bladder, however, their use can be limited by the side effect profile which include dry mouth and constipation.
More recently, a newer class of medications have been approved for overactive bladder symptoms. The new class of medications are referred to as sympathomimetics. The only FDA approved medication within this class is Myrbetriq. This medications promotes bladder relaxation, but the mechanism of action is different than the anticholinergics. The benefit of Myrbetriq is fewer side effects. The efficacy is similar to the anticholinergic class of medications.
Bladder Botox. We often think of botox for its cosmetic uses, however, botox has many other clinical indications such as treating migraine headaches, muscle contractures, and, of course overactive bladder. Botox is a potent muscle contraction inhibitor and works by preventing untimely bladder contractions which result in the frequency and urgency associated with bladder overactivity. The injection of botox can be done in the office with local anesthesia or in the surgery center which will provide the opportunity for light sedation. Bladder botox is extremely effective for treating the symptoms of overactive bladder. The results usually last around 9 months, therefore, the procedure is often repeated at 9 month intervals. The risks include urinary retention (inability to urinate), blood in the urine, and urine infection.
Neuromodulation. Proper bladder function involves the coordination of a complex neuronal circuit. The electrical circuit is responsible for promoting bladder relaxation during urine storage and triggering a bladder contraction to initiate the urination process. Several “feedback” loops work in coordination with input from all parts of our nervous system. For reasons that are unclear, the neuromuscular circuit can malfunction resulting in severe overactive bladder symptoms. It is almost as if the bladder reverts back to the electrical circuits which predominate in infants. Neuromodulation is an attempt to “reset” the neuromuscular circuit to return to “normal” urination habits. There are two methods commonly used to repair the pelvic electrical circuits: peripheral tibial nerve stimulation (PTNS) and Interstim. PTNS is an office procedure performed by placing a tiny electrode behind the ankle and stimulating the tibial nerve. The electrical current is carried along the tibial nerve back to the pelvic or bladder neural circuit. Often times this “new” electrical current can result in a reset of the pelvic neuronal plexus. Interstim works by a similar mechanism, however, a small surgical procedure is performed to allow the electrode to be placed directly into the nerves that control bladder function. Interstim is an outpatient procedure which can result in significant symptom improvement.
Many patients are unaware of the treatment options for overactive bladder symptoms. I have many patients who are pleased with the treatment plans we offer and their only complaint is they wish they would have sought care earlier. If the medications prove ineffective or intolerable, you should ask your urologist about some of the other treatment options mentioned in this article. Please send me a message with any questions regarding this article or overactive bladder.
Dr. Bryan J. Allen
