“I suffer from this condition called overactive bladder or OAB. I’ve had this for several years now. This is a condition where I lose bladder control before I can make it to the bathroom. Usually, I have urgency that precedes it but sometimes it just comes on suddenly without any urgency or warning. I’ve gone through numerous tests and I have had several treatments done without much improvement in my symptoms. I have tried all possible medications. All I have done with medications is incur the cost and side effects with minimal improvement in my symptoms. It seems that I am resigned to wearing pads now and diapers eventually. This has completely consumed by entire life. There’s got to be something that should help me!”
This is the typical story of a patient who presents to our office with refractory overactive bladder. A lot has changed for the management of refractory urge urinary incontinence/overactive bladder and very few patients are resigned to wearing pads or diapers.
What is refractory overactive bladder?
This is a condition where the patient has tried 1 or 2 medications for urgency and urgency leakage but does not notice improvement.
How common is this condition?
It happens in almost 30% of patients with overactivity of the bladder. However, it is very hard to determine the exact incidence because most patients do not come back for a follow-up visit to their doctor.
It has been shown that 70% of women who’ve seen a specialist do not return after just one visit. This is mostly because the problem persists and there is no improvement.
Why do medications not work in patients with refractory overactive bladder?
First and foremost, it is important to make sure that the diagnosis of overactive bladder is correct. The patient may have stress incontinence or significant bladder prolapse with urinary retention. Then, there are so many other conditions that could influence bladder control. Is the patient’s diabetes under control? Does she take strong diuretics? What is her BMI? What is her fluid intake? Does she have significant edema or congestive heart failure? Does she have obstructive sleep apnea? These and several more medical conditions influence the bladder, urine production and incontinence. So, a thorough evaluation of the refractory OAB patient is important.
How do you manage patients with refractory overactive bladder?
As stated earlier, it is crucial to make certain that she has refractory OAB and not something else. Many a times we realize that the diagnosis is wrong and the patient has stress incontinence and not overactivity of the bladder. This is managed completely differently. Therefore, we start the workup with a proper history which involves validated questionnaires, detailed physical examination including gynecologic examination to make sure that there is no associated pathology such as prolapse, urinanalysis to rule out a bladder infection, assessment of postvoid residual urine to rule out any problems with completing urination ( voiding dysfunction), voiding diaries and urodynamics. We may also perform a cystoscopy to make sure that there is no pathology in the bladder which could be causing refractory overactive bladder.
We also make sure that the patient does not have any underlying neurological disorder which could affect the bladder.
We then confirm the diagnosis of refractory overactive bladder. It is important to note which OAB medications she has taken and for how long. Sometimes, a patient may have just taken it for a few days and because of side effects or cost, she may have discontinued it. In other words, she may not have truly failed that medication.
What treatment do you offer these patients once the diagnosis is confirmed?
There are several treatment options available for the management of refractory overactive bladdern such as PTNS, Botox and Interstim.
However, the most important thing is to make the patient understand her own responsibility. It is critical for a patient who is a diabetic to keep her hemoglobin A1c in check. If this does not happen, urinary frequency, frequent infections and urgency leakage may still continue. Similarly, if the patient is morbidly obese, it is important for her to consider losing weight because this would also help with her symptoms.
It is equally important to provide “realistic expectations” to the patient by telling them that the treatment may improve the situation, hopefully satisfactorily, but may not cure it completely.
We tell the patient that she may need more than one treatment options and it could very well be a combination of different treatments such as medications, pelvic floor therapy and neuromodulation that would eventually help her problem.
In summary, refractory OAB is a concerning problem for the patient as she has already gone through a lot and still continues to suffer from that very same condition. It is very important to show all OAB patients the treatment road map as this will give them hope by showing them that there are a lot more options that still remain to be tried.
Finally, in our experience, we have always had at least satisfactory improvement with refractory OAB provided the following are met:
1- The condition is correctly diagnosed
2- Bladder infection, vaginal prolapse, voiding dysfunction, stress incontinence or other conditions are ruled out
3- Patient is educated as to the disease state and why does this problem happen
4- Patient understands how certain medical conditions impact bladder control and how important it is to manage them
5- Realistic expectations that the condition will improve but may not get cured are stressed
6- Patient has to take responsibility of her own health and avoid caffeinated beverages and watch how much she drinks or go to the bathroom at set intervals
7- Proper follow up at our office is crucial.
8-We may need to use more than one treatment option to improve this problem.