Overactive Bladder 2017-09-06T17:03:24+00:00

OVERACTIVE BLADDER

DEFINITION

The term “overactive bladder” is sometimes used to refer to any of the following conditions:

  • Frequency ( number of times a patient goes to the bathroom)

  • Urgency (a powerful urge to urinate, that is difficult to put off)

  • Nocturia (waking up at night to urinate that is bothersome to the patient)

  • Urge incontinence (leakage of urine associated with an urge to urinate, or not making it to the bathroom in time)

  • Nocturnal Enuresis (bedwetting)

CAUSE

In most cases, no particular cause can be identified. Sometimes overactivity of the bladder may happen if there is a bladder infection or a foreign body (stone) in the bladder. Although this is rare, a bladder tumor may also cause irritative bladder symptoms such as urgency and frequency.

MECHANISM OF BLADDER CONTROL

In a child, the bladder is controlled by a spinal reflex arc. As the bladder fills up, it sends a signal to the spinal cord which automatically tells it to contract and empty. Therefore a child has to use a diaper. Over time, as the intelligent lobe (frontal cortex) of the brain develops, the child understands that he/she has to go to a bathroom to empty the bladder. The frontal cortex blocks the bladder contractions until it is an appropriate time to urinate.

In patients with OAB, the frontal cortical inhibition of the bladder diminishes and the local reflex arc becomes dominant. Therefore, when the patient has urgency to urinate she has to rush to the bathroom and may start leaking before she can actually get her pants down. Why this happens, is unclear.

DIAGNOSIS

a. History: The validated forms such and the MESA and the UDI-6 are provided to the patient and help obtain a proper history. Classically, the history is a sudden urgency that usually results in leakage. Patient also may be going several times to the bathroom both in the daytime and at night.

b. Exam: Patient is examined to make sure that she does not have any pelvic condition that could be causing the urgency incontinence.

c. Post void residual (PVR) test is done with a bladder ultrasound in the office to see how well the patient has emptied her bladder. This is very useful as one of the commonest causes of urgency is a patient who is not emptying her bladder well.

d. Urinalysis, sometimes including urine culture, to rule out an infection. This is important as patients with a bladder infection often have urgency and frequency.

e. Urinary voiding diaries are very important as it helps us understand how many times leakage episodes happen to the patient over a 3-4 day period, as well as how much fluid she is drinking and how often she uses the bathroom.

f. Urodynamic testing is a very important test that we perform in the office. This test helps us correlate the patient’s complaints with the actual type of incontinence. This is especially of relevance when the patient has multiple complaints such as leakage with stress and urgency, or if she has failed prior treatment.

g. Cystoscopy is looking inside the bladder with a camera and a light. It is done in the office under local anesthesia, which is a gel, to numb the urethra. It is usually recommended in a patient with irritative bladder symptoms, such as urgency or bladder pain, especially in the presence of blood in the urine.

MANAGEMENT OF OVERACTIVE BLADDER

Behavioral training, exercises and lifestyle changes, and medicines are usually tried first. If the problem does not get better, your doctor may try another treatment or do more tests.

When there is more than one cause for incontinence, the most significant cause is treated first, followed by treatment for the secondary cause, if needed.

Fluids that can be Bladder Irritants

1- Caffeine – Try to stop your caffeinated beverages like coffee, tea, and soda to see if your bladder control improves. If you drink a lot of caffeine, you should taper down slowly to avoid a caffeine withdrawal headache.

2- Artificial Sweeteners – Beverages that contain artificial sweeteners like aspartame or saccharin can also be a bladder irritant. Diet Pepsi, Mountain Dew or Coke then would be especially problematic because of the artificial sweetener and the caffeine.

By the time the patient senses urgency to urinate, it may be too late and urine may start coming out before she can make it to the bathroom.

In these cases, it is important to empty the bladder at regular intervals so as to avoid an overfull bladder- the 11th hour effect.  Voiding at a fixed schedule, also called “Timed Voiding” would help with the leakage.

Interval between voids will be determined by the voiding diaries. Usually this will start at every two-hour intervals between voids. You will be going to the bathroom irrespective of whether you have an urge to urinate or not. Once there has not been an episode of urinary incontinence during the first week, the interval in the subsequent week will be increased by 15 minutes. This will continue weekly until 3 hours between two urination episodes is reached. This will be then maintained for life. Three hours is a long time between voids and is very acceptable especially in the daytime.

Most bladder control problems are caused by weak pelvic muscles. These pelvic floor muscles attach to the bones of the pelvis in a way that creates a trampoline of support for the pelvic organs. These muscles help prevent urine leakage. Pregnancy, childbirth, increasing age all weaken the muscles of the pelvic floor. Exercising the pelvic floor muscles can strengthen the pelvic muscles and improve bladder control.

Identifying the correct muscles to exercise is the key. These are the same muscles you would use to hold back gas or to stop the flow of urine midstream. We can help make sure that you are contracting the right muscles. Once you have correctly identified the muscles, you contract and hold the squeeze for a few seconds and then completely relax the muscles before the next squeeze.

Different ways to ensure that the correct muscles are being squeezed:

  • Try to stop your urinary mid-stream. If you succeed then you have identified the right muscles to exercise. This is a learning tool. Do not stop your urine frequently as there is concern that this may create problems with bladder emptying.
  • Imagine you are going to pass gas, then, squeeze the muscles that would prevent that gas from escaping from your rectum. Exercising the muscles around the rectum will also strengthen those around the vagina and under the bladder.
  • Use a hand mirror to look at your vaginal opening and the perineum (the muscle wall between the vagina and rectum). You should see the perineum lift up when you contract your pelvic muscles.
  • While lying or sitting, place one finger inside your vagina. Squeeze as if you were trying to stop urine from coming out. You should feel your finger lifted and squeezed if you are correctly contracting your pelvic muscles.
  • If you are just not sure that you are doing the exercises correctly ask us to check if your squeeze is working the right muscles.
  • Do not hold your breath while exercising. Remember not to tighten your stomach and back muscles or squeeze your legs together. These should be relaxed as you isolate and contract just your pelvic muscles

Pelvic floor muscle stimulation is done with a specialized equipment that helps improve the strength and tone of the pelvic muscles. This uses:

  • one channel of rectal intracavity EMG
  • one channel of accessory muscle EMG
  • one channel of intravaginal Electrical Stimulation.

Pelvic floor therapy comprises of two parts: first, where the patient is squeezing her muscles and the second part where the machine is stimulating the muscles. During the first part, the accessory EMG applied to the belly makes sure that the only muscles contracting are the pelvic muscles. During the second part (stimulation), the patient may feel like a slight vibration in the vagina as the muscles are being stimulated.

The goal of pelvic floor therapy is: Recruitment. This means that more muscle fibers are “recruited” to activate and perform when called upon to do so.

There are no complications or discomfort associated with this procedure. It is usually done in the office on a weekly schedule for about 4-6 weeks. Each session lasts about half an hour. No preparation before or after the procedure is required. Patients can return back to work immediately after the treatment. Most patients will notice at least some improvement if not total improvement in their symptoms.

How do medications work?

Medications control the abnormal activity of the bladder which is responsible for leakage.

What are the different types of medications available?

There are essentially two groups of medications: anticholinergics and Beta agonists. Some of the anticholinergic medications are Oxybutynin, Oxybutynin ER, Detrol LA, Vesicare, Enablex, Sanctura XR, Toviaz and Oxytrol patch. The Oxytrol patch, now available over-the-counter, is applied to the skin twice a week. The Beta agonist medication is called Mirabetriq.

Is there any specific medication for bedwetting?

In young women who have a bedwetting problem, Imipramine is a medication which works better. It helps not only improve the urethral sphincter tone but also relaxes the bladder. In women over the age of 65, this should be use with caution because of possible heart side effects and may cause agitation and sleep disturbance at night.

Is there any specific treatment for patients with mainly nighttime urinary frequency i.e. nocturia?

Desmopressin (DDAVP) reduces the amount of urine production by the kidneys. When it is taken at night, the amount of urine that is produced by the kidneys decreases and therefore there is less urine available to the bladder and hence the urinary frequency at night can improve. In the daytime, the urine is released but this is acceptable to the patient as she is now awake.

What happens if I have tried medications and nothing is working?

This is called refractory overactive bladder. It is very important to make sure that the urodynamic testing clearly confirms that you have urgency incontinence.

It happens in almost 30% of patients with overactivity of the bladder.

What is Interstim?

It is a bladder control therapy option for patients who did not respond to OAB medications such as Detrol, Ditropan, Vesicare or Myrbetriq. With Interstim we start with a test. The test (PNE) that is done in the office under local anesthesia tells us if you would be a candidate for long-term therapy.

Will Interstim cure my OAB complaints?

It is possible that this may happen however our main focus is always realistic expectations. At least 85% of patients notice 50% or greater improvement in their symptoms.

Botox® Therapy

How does Botox work?

Botox acts on the bladder wall and blocks irregular bladder contractions that results in urgency incontinence (leakage).

How is the Botox procedure performed?

It is performed in the office under local anesthesia via a cystoscopy. It takes about 15 minutes to perform the procedure. Most patients go home within about half an hour after the procedure.

How successful is Botox from the standpoint of controlling overactive bladder symptoms?

Over 75-85% of patients will notice their overactive bladder symptoms decrease by at least 50%. This is similar to medications and also similar to other procedures such as Interstim.

The major advantage of Botox is that it is done in a single sitting. It usually takes under 30 minutes to do the procedure. It is done entirely under local anesthesia and the patient will go home within 1 hour of the procedure. Moreover, it eliminates the need to take medications on a daily basis and also avoids the medication side-effects such as dry mouth, constipation, and dry eyes. Thus, Botox becomes a great choice for women who cannot tolerate medications, who do not improve with medications and those who cannot take medications such as those with stomach problems or glaucoma.

Percutaneous Tibial Nerve Stimulation (PTNS)

This is a procedure that involves placement of an acupuncture-like tiny needle just above the ankle bone.

It stimulates the tibial nerve which has essentially similar nerve roots as the bladder. Therefore, it modulates the bladder nerves and helps with overactive bladder symptoms.

This is done in the office and takes about 30 minutes. It is done on a weekly basis for the next 10-12 weeks.

How successful is PTNS?

In clinical trials, it has shown at least 70-80% improvement in symptoms and noted to be more effective than Detrol medication.