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)
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.
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
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.
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.