Overactive Bladder

Overactive bladder (OAB) is a condition that affects approximately 33 million Americans. It can disrupt activities of daily life. The estimated economic impact of OAB in the U.S. exceeded $12 billion dollars in 2000. Women tend to be affected more commonly than men, and it occurs more frequently as people age.

The most common symptoms that suggest overactive bladder are: 

• Urinating frequently (more than 8 times) during the day (frequency)
• Sudden strong urges to urinate (urgency)
• Having to wake from sleep to urinate more than twice each night (nocturia)
• Leaking urine before you get to the bathroom (urge incontinence)
• Unconscious leakage of urine

Do You Have An Overactive Bladder

These questions can help you decide if you need further evaluation for an overactive bladder:

• Do you go to the bathroom so often at night that it interrupts your sleep (2 or more times)?
• Do you go to the bathroom so often that it interferes with your daily activities (more than 8 times in 24 hours)?
• Do you always have to know where the bathroom is because of frequent, strong, sudden urges to urinate?
• Do you sometimes have trouble making it to the bathroom in time?
• Do you wear pads to protect your clothes from getting wet?
• Do you limit the amount of fluids that you drink?

If you answered “YES” to more than two of these questions, make sure to ask your doctor about evaluation and treatment for an overactive bladder. The sooner you begin, the sooner you can return to more normal living

Though the underlying cause of OAB is unknown, the nervous system is thought to play an important role in the irritability and overactivity of the bladder. Processes such as diabetes, Parkinson’s disease and multiple sclerosis, which affect the nervous system, can initially present with urinary complaints. Low back pain in association with OAB raises the possibility of a “slipped disc” with nerve root irritation. Bladder pain accompanying OAB may be the first signs of interstitial cystitis, which follows a different treatment approach. A thorough medical history and exam can usually diagnose these problems.

Progression to Incontinence

The urgency and frequency of OAB can progress to Urge incontinence, although not all cases do. Patients will complain “I can no longer get there in time” and “I leak before I get there.”Because it is generally thought to be a progression of the same symptoms (urgency and frequency of urination), it is usually treated with the same class of medications. If OAB medicines do not improve the leakage, additional evaluation with cystoscopy and urodynamics may be indicated. These tests will give additional information to help your doctor decide what other forms of treatment may be considered. Urologists broadly categorize incontinence into two classes: Stress Incontinence and Urge Incontinence. While the two classes share some similarities, they are treated by very different approaches; so careful evaluation is important. Stress Incontinence is leakage that occurs when physical pressure or “stress” is placed on the bladder and leakage of urine results. Most commonly, these individuals will leak when they cough, laugh, sneeze, or lift heavy objects. OAB medications will generally not help this type of leakage. If you think you have OAB, contact your doctor for an evaluation.

Common Steps to Evaluate Overactive bladder

• History
• Physical Exam and Pelvic Exam
• Urinalysis
• Ultrasound for Post Void Residual
• Voiding Diary
• Cystoscopy
• CT Scan of Abdomen and Pelvis
• Urodynamics

Other Conditions That May Have Similar Symptoms

• Urinary Tract Infection
•  Diabetes (polyuria)
• Pelvic Radiation
• Neurologic Disorders
• Parkinson’s Disease
• Multiple Sclerosis
• Disc Disease
• Colorectal Cancer
• Bladder Cancer
• Gynecologic Conditions
• Pregnancy
• Uterine Fibroids
• Ovarian Cysts
• Endometriosis

Treatment Options for Urge Incontinence

Once the doctor has eliminated other causes of frequency and urgency, treatment of OAB can proceed. Management of Overactive Bladder usually involves medicines called anti-muscarinics (common brand name medications include Detrol, Ditropan,Vesicare, Sanctura and Enablex). These drugs are very safe, effective, and quick in onset. They improve quality of life by dramatically cutting down on the frequency of urination, both daytime and nighttime, and the severity of urgency. Overall, the side-effects of the anti-muscarinic medications are minimal and may include dry mouth, constipation and rarely mental confusion. Some medical conditions may be worsened by these medications, such as Alzheimer’s disease, gastroparesis, or narrow-angle glaucoma.

Behavioral Modifications can also help symptom control. Some patients do not realistically consider these therapies because they don’t seem as sophisticated as a pill or medication. Studies, however, have repeatedly shown the benefits of these conservative therapies in helping bladder behavior for those who adhere to them. These include Timed Voiding, Kegel Exercises, Bladder Retraining, Dietary and Lifestyle Modification, and keeping a voiding diary. The simple task of keeping and paying attention to a voiding dairy can be therapy in and of itself. Dietary restriction avoiding alcohol, caffeine, and spicy foods can make a major impact.

In some cases of urge incontinence or intractable OAB, a “bladder pacemaker” (called Interstim) can be surgically implanted to help alleviate symptoms of urgency and frequency. This InterStim device can help. InterStim therapy is FDA-approved in the United States and has been used for over 20 years, providing relief for many individuals. Also referred to as sacral neuromodulation, it is used primarily for managing overactive bladder, fecal incontinence, and non-obstructive urinary retention. InterStim therapy involves the use of a small device called a neurostimulator, which is placed under the skin near the sacral nerves in the lower back. 

These nerves control the muscles of the bladder and bowel, and they help regulate abnormal activity and reduce symptoms such as urgency, incontinence, and retention. This therapy aims to restore normal function to the sacral nerves by delivering electrical pulses to the nerve. These electrical pulses from the neurostimulator can be controlled from an app on a smart phone. InterStim therapy can be helpful when other first-line treatments, like medication or lifestyle changes, have not been effective and it offers a solution for those individuals seeking a long-term resolution to incontinence. This therapy is often recommended when more conservative medications and therapies are unsuccessful or poorly tolerated. For patients with intractable OAB, however, it can mean resolution of their problem.

Another new option for treating OAB is Botox. Nearly everyone has heard of Botox related to cosmetic applications. Botox can also be injected into the bladder to control severe symptoms of OAB. The procedure is performed using a scope to look into the bladder and inject areas of the lining of the bladder. While it is a relatively new therapy, it offers yet another option if traditional therapies are unsuccessful.

Kegel Exercise Routine

Nearly everyone has heard of Kegel exercises, usually related to an OBGYN’s recommendation to women after childbirth. While Kegel exercises are generally used to help control stress urinary incontinence, the Kegel routine can be effective to exercise the pelvic floor muscles and improve bladder hyperactivity. However, one must do the exercise properly. Many cases fail simply because the patient is not trained properly or is not exercising the proper muscles. Kegel’s are NOTsimply “tightening up the belly muscles” or “clinching the buttocks.” The best way to correctly perform Kegels is as follows. For the first week, learn to isolate the proper muscle for urinary sphincter control. Whenever you feel the urge to urinate, go to the restroom and let the urine flow being; then stop the stream midstream. Pay attention the muscle you are contracting to stop the stream, as this is the sphincter muscle. Then in the weeks to come, you can exercise this muscle at times other than when you are urinating. To do a repetition of Kegels, one must tighten up the muscle and hold it for a count of 5, then relax it. A repetition of Kegels means you “Tighten-count to 5-Relax” five times in a row. This should be done multiple times each day as a daily exercise. Try to do it every time you come to a stoplight in your car or every time you see a commercial on the television. Linking you Kegel Routine to an activity of daily living will insure that you do it multiple times every day FOREVER.

Dietary and Lifestyle Modifications

• Avoid CAFFEINE (Coffee, Tea, Colas, Chocolate)
• Avoid CARBONATED SODAS
• Avoid CITRUS JUICES and FRUITS
• Avoid ALCOHOL
• Avoid SPICY FOODS (Italian, Chinese, and Mexican type dishes)
• Stop Smoking (Smoking causes bladder muscle irritability)
• Lose Weight (Extra weight can place extra pressure on your bladder)
• Bladder Retraining Technique (helps the bladder hold urine better)

Bladder Training Techniques

• When you feel the urge to urinate, STOP what you are doing, sit down or STAND STILL, and remain still.
• SQUEEZE your pelvic muscles quickly several times, but do not completely relax the muscles in between.
• Relax the rest of your body by taking several DEEP BREATHS.
• CONCENTRATE on suppressing the urge, and wait a few minutes to let the urge subside.
• Then WALK, DO NOT RUSH, to the bathroom.
• REPEAT this routine whenever abrupt urges begin
• Timed Voiding Technique (Helps to avoid abrupt urges to urinate)
• Determine usual frequency of”emergencies.
• For example, if you have emergencies every 2 hours, plan trips to the bathroom every 90 minutes
• When successful for several days in a row, increase the interval by 15 minutes
• Target an interval of 4-6 hours
• MUST stick to the plan
• Plan to devote 4-6 months to “recondition”

Special Considerations:

MALE PATIENTS
Many men have symptoms of overactive bladder. The cause may be the bladder of the cause may be the prostate. The symptoms, in general, are identical. Your urologist can determine which is the appropriate focus of treatment.

URINARY INFECTION
UTI, urinary tract infection or bladder infection, can give the same symptoms as overactive bladder. In most cases of UTI, treating the infection will lead to correction of the symptoms. In such cases, long term OAB medications will not be necessary. Controlling the infections will often control the aggravating bladder symptoms.

BLOOD IN URINE
Anytime there is blood in the urine, further evaluation is needed. By far the most common cause of the blood in the urine is infection, even in the absence of any major symptoms. While there are many other causes of blood in the urine, your physicians will want to make sure that there is no chance of bladder cancer as the cause. Bladder cancer can give the same symptoms as overactive bladder, but bladder cancer also usually has blood in the urine. To rule out bladder cancer, your physician will likely recommend a CT scan.

Overactive Bladder: Things You Might Not Know

…Overactive Bladder can have dangerous consequences. If you are having to get up 3-4 times per night to urinate, the chances of tripping or stumbling in the dark increase. Elderly patients are even more prone to falls during the nighttime. Elderly female patients are also more prone to breaking a hip with a fall because of osteoporosis. Even in today’s world of modern medicine, a hip fracture in an 80 year old patient has a mortality rate of 25-50%.

…Controlling overactive bladder can help restore more normal sleep patterns. If you have to wake up 3-4 times each night to urinate, normal sleep patterns are disrupted and patients don’t really get rested. If vou rest better, vou have more energy and are more alert.

Many of the overactive bladder medications cause a mild dry mouth. This is usually well tolerated, but if not, sucking on hard candy can help increase saliva production and minimize the side effect.

.. Many patients decline to treat overactive bladder citing the high cost of the medications but still pay top dollar for huge quantities of adult diapers or “Depends.” Patients should consider the overall cost of not treating the condition.