Overactive Bladder
The term "overactive bladder" (OAB) is relatively new, first used in the "got to go, got to go right now" television commercials that appeared in the 1990's. A more market appealing term than "incontinence", millions of dollars were invested in wide scale media campaigns that launched this "new" condition into the public mainstream. At the time, some physicians worried that it could confuse or delay the diagnosis of bladder diseases such as interstitial cystitis.
OAB is thought to be a neuromuscular disorder where the smooth muscle of the bladder, the detrusor, contracts abnormally. The dominant symptom is "urgency" and this is how it differs from other bladder conditions such as interstitial cystitis. Sudden, dramatic moments of urgency that are so strong that a patient must find a bathroom or they may become incontinent.
The International Continence Society defines OAB as "urinary urgency, with or without urgency urinary incontinence, usually with frequency and nocturia, in the absence of causative infection or pathologic conditions and suggestive of underlying detrusor overactivity (phasic increases in detrusor pressure)." (1)
OAB WITH URGE INCONTINENCE is the term used to describe patients who struggle with frequency & urgency that leads to leakage and incontinence. The sensation of "urgency" is sudden, difficult to ignore and creates a compelling need to urinate. Frequency is defined as urinating more than 8 times in a 24 period. Nocturia (difficulty sleeping and/or waking one or more times a night to urinate) is common.
OAB WITHOUT URGE INCONTINENCE describes patients who may have more moderate levels of just frequency and urgency.
The impact of OAB both personally and ecomically is undeniable. Social isolation, fear of accidents, embarassment as well as the high cost of medical care and supplies can result in a dramatically diminished quality of life for some patients. An estimated $12.6 billion dollars per year is spent in OAB related costs. (3)
Epidemology
Two studies have assessed the prevalence of OAB. The National Overactive Bladder Evaluation (NOBLE) Program conducted a US national telephone survey to estimate the prevalence of overactive bladder with and without urge incontinence. A sample of 5,204 adults ‡18 years of age and representative of the US population by sex, age, and geographical region were contacted. The results suggested that 16% of men and 16.9% of women had symptoms consistent with OAB though there was considerable variation between men, women and age levels. (2,3)
Women struggled more with incontinence than men in all age groups. Aging and weight also played a significant role. In women, the prevalence of urge incontinence increased with age from 2.0% to 19% with an increase after 44 years of age. Men suffered an increase in their symptoms after the age of 64. Women also showed higher levels of OAB with incontinence as their body mass increased whereas men showed no difference in weight.
A recent Finnish population study, however, suggests that the numbers may be less than reported due to some flaws in the research methodology of the earlier studies.(5)
Several risk factors have been identified. Caucasians, people with insulin dependet diabetes and/or patients struggling with depression are 3 times more likely to develop OAB. Other risk factors include aging, arthritis, weight gain and people using hormone replacement therapy. (6)
Causes & Diagnosis
OAB can occur after a neurologic injury such as a spinal injury or stroke. It may be caused by some neurologic conditions such as multiple sclerosis, dementia, parkinsons, medulla lesions and diabetic neuropathy. There may also be no obvious neurological cause. Bladder contractions can occur if the bladder fills suddenly, if the patient changes position suddenly, by coughing or exercising. Patients struggling with heart failure, various vascular diseases or who are using diuretics may also experience symptoms typical of OAB. Aging and declining estrogen levels can also be a contributing factor. (1)
Because OAB appears to involve neurological and/or muscle dysfunction, the diagnosis requires careful evaluation and review. Other conditions which cause frequency and urgency must be excluded.
#1 - Symptoms - Does the patient present with typical OAB symptoms? Urgency is not the typical sensation one feels when they need to urinate. This urgency is much more intense and difficult to ignore. It can arise suddenly and lead to incontinence. It is very helpful if a patient brings symptom and voiding diary to their first appointments.
#2 - Physical Examination - Your physician should be examining the belly and genitourinary tract. Women will have a brief gynecological examination to assess the pelvic floor and rule out the presence of pelvic organ prolapse and/or other muscle disorders. Men require a rectal examination to assess the prostate and pelvic musculature.
#3 - Urinalysis - Your urine will be assessed for microhematuria (microscopic blood), UTI, pyuria (pus in your urine) and glucosuria (glucose in the urine).
#4 - Post Void Residual Test - Are you emptying your bladder fully? Your doctor may want to use the restroom and then may catheterize you briefly to determine if you can empty your bladdder fully.
#5 - Urodynamics - A urodynamics test helps to assess your badder function. It Is not a first line test but can be helpful for patients who appear to have a neurologic origin.
First Line Therapy - Behavioral Therapy & Self-Help
For both interstitial cystitis and overactive bladder, first line therapies are generally non-invasive and behavioral in nature. Patients must be motivated and willing to work hard and apply themselves. They MUST be willing to adopt various diet and lifestyle changes. Bladder training and pelvic floor therapy are often recommended and often succesful in reducing symptoms. In otherwords, passive patients who rely on pills may struggle far more than patients who are willing to consider what they can do at home to help improve their bladder and overall health.
DIET - The bladder can be extremely sensitive to the foods that we eat. Foods high in caffeine, for example, will trigger more urination thus patients with both IC and OAB are always advised to avoid caffeinated foods and beverages such as coffees, black tea, green tea, sodas and chocolate.
Similarly, foods that are high in acid or alcohol are well known to trigger bladder irritation for patients who have interstitial cystitis, thus you might find it helpful to avoid those foods as well. Foods high in acid, for example, such as vinegar, citrus drinks, concentrated tomato products and even Vitamin C and multivitamins have been known to trigger bladder irritation. Click here to read more about the IC Diet
BLADDER TRAINING - Bladder training and a scheduled voiding program can help you regain control over excessive frequency and some incontinence. Your doctor will give you more information on how to do this.
PELVIC FLOOR THERAPY - Because muscle strength and function is an important factor in bladder conditions and incontinence, patients may need to work with a physical therapist to strengthen their muscle tone.
Does behavioral therapy work? Yes! The International Continence Society suggests that pelvic floor therapy be offered to women struggling with all forms of incontinence. The research proves it!
When behavioral therapy was compared with drug therapy in an outpatient geriatric medicine clinic, behavioral therapy yielded a mean 80.7% reduction in incontinence episodes. Behavioral therapy was significantly more effective than oxybutynin given at a dosage of 2.5 mg/day to 5 mg 3 times per day (mean 68.3% reduction in incontinence episodes; P = .04). Both therapies were better than placebo (mean 39.4% reduction; P < .001 and P = .009, respectively). In addition, patient-perceived improvement was also greatest among those treated with behavioral therapy. In a randomized clinical trial of bladder training, Fantl et al (1991) observed that episodes of incontinence decreased by a mean of 57% in women aged 55 years and older who underwent bladder training compared with little improvement in a no-treatment control group.(1)
Pharmaceuticals
Anticholinergic medications are often first suggested by physicians. They work by inhibiting involuntuary destrusor muscle spasms. Oxybutynin (Ditropan, Ditropan XL) was one of the first medications used with solid success. Tolteradine (Detrol, Detrol LA) has a similar method of action and effectiveness but causes fewer side effects.
There are several other anticholinergics available, including: trospium chloride (Sanctura), solifenacin (Vesicare), darifenacin (Enablex), oxybutynin patch (Oxytrol) and fesoterodine (Toviaz). Propiverine hydrochloride isonly approved in Europe.
Pamela Ellsworth MD, author of Overactive Bladder, offered " The available literature suggests that these agents are clinically similar and that none appears to offer a major distinct advantage over the others. However, slight differences in these agents may be clinically useful in drug selection." (1) The extended release Ditropan XLand patch version appear to have fewer side effects than the original formula. Darifenacin appears to cause fewer cognitive effects. Trospium may be more suitable for patients who are being treated with cytochrome P-450 medications.
Side effects are the biggest drawback of this type of medication. Dry mouth, constipation, blurred vision and drowsiness can occur. Confusion and diminished cognitive function (primarily in the elderly) have been well documented and risk of cognitive impairment appears to increase with the more anticholinergic medications taken.
BOTOX
The Injection of botulinum toxin A into the detrusor muscle has been under study for several years for a variety of bladder disorders. Under anesthesia, a patient may receive 20 to 30 injections of botox in various locations in the bladder. Numerous studies have been conducted though only four of the more rigorous randomized trials.
Researchers at the University of Rochester (NY) studied 22 patients with OAB-incontinence who were non responsive to anticholinergic therapy. The detrusor was injected at 8-10 sites in varying dosages and placebo. Statistically significant improvements in daily incontinence episodes and quality of life questionnaires were seen in the botulinum-A toxin group with no changes in the placebo group. In this review of their early data, no change was seen in nocturia, daily voiding frequency, peak flow or detrusor pressure. The authors concluded that botox inuections can significantly reduce incontinence episodes. They do cite, however, a risk of urinary retention that may require self-catheterization after treatment. (7)
Researchers in France conducted a five year randomised, double-blind placebo-controlled trial of 99 patients who received a single treatment of 100u or 150u BoNTA. At three months after treatment, they "observed a >50% improvement versus baseline in urgency and urge urinary incontinence (UUI) in 65% and 56% of patients who respectively received 100U (p=0.086) and 150U (p=0.261) BoNTA injections and >75% improvement in 40% of patients of both groups (100U [p=0.058] and 150U [p=0.022]). Complete continence was observed in 55% and 50% patients after 100U and 150U BoNTA treatment, respectively, at month 3." Quality of life and frequency showed sustained improvement at the six month visit. (8)
Researchers in Portugal studied the efficacy and safety of botox on patients struggling with incontinence due to multiple sclerosis or spinal cord injury. Patients received 30 injections of either 200u, 300u or placebo. Results occurred at week two and had increased significantly by week six. Improvements were seen in detrusor contraction via and a dramatic decrease incontinence episodes. Prior to the study, patients had an average of 33.5 incontinence epsidoes which had reduced -21.8 (200u) and -19.4 (300u).(9)
British researchers studied the quality of life of patients with multiple sclerosis and OAB in a prospective study involving 137 patients treated with repeated detrusor injections of botulinum type A. Before treatment 83% of the patients were incontinent; 4 weeks after the first treatment, 76% were completely dry. The median interval between retreatments was 12-13 months. (10)
As mentioned in the Univ. of Rochester study, one risk is the development of urinary retention. Patients who undergo Botox treatment should first be evaluated for their ability to self-catheterize, should the need arise.
Neuromodulation
Neuromodulation uses mild electrical stimulation of the sacral nerve. For patients with extreme frequency/urgency and who have failed other therapies, this therapy is a fairly new treatment option. Patients with urinary and/or fecal incontinence have also had positive results.
(A) Post Tibial Nerve Stimulation
First developed by Dr. Marshall Stoller at UCSF, Post Tibial Nerve Stimulation is the least invasive and most affordable neuromodulation option for patients to consider. During an office visit, a simple acupuncture needle is placed ina specific location about the ankle bone. It is then attached to a electrical stimulator and gently stimulates the post tibial nerve. It typically requires ten weekly treatments to determine if the procedure is beneficial. It is medicare approved and the most affordable neuromodulation option available due to the fact that it requires no multiple procedures and surgeries.
The Urgent PC Neuromodulation System by Uroplasty, Inc. is now available throughout the USA and abroad. There have been no serious adverse events filed with the FDA for this therapy. Only a single report is present in the FDA's MAUDE database, a report of foot tingling. A large number of published research and studies are available for your review on the Urgent PC website.
(B) Sacral Neuromodulation
Developed by Dr. Richard Schmidt and colleague, sacral neuromodulation is a more invasive form of therapy, requiring a trial procedure, implantation surgery, long-term management, programming and eventual revision, battery replacement and/or explantation surgery.
Patients are first required to undergo a test stimulation (an outpatient procedure which implants the electrode), which is a three to five day trial period of stimulation. If the results are favorable, doctors may then recommend a permanent implant. During the trial, patients will be asked to keep a voiding diary to track their symptoms. If, after that period, your diary indicates that it significantly helped your symptoms, you may be recommended to have the permanent implant.
Interstim is approved for the treatment of OAB and it's very easy for patients to get excited about this procedure as "the" long awaited answer to their symptoms. It's VERY important that you take time to thoroughly research this before agreeing to have the procedure done. In our support forum, you'll find patients on this web site who have had disappointing and, in some cases, terrible experiences with the procedure. You will also find patients who have found great results... usually in reducing their frequency.
You HAVE to do the work to learn about this procedure and how it works, to ask tough questions about successes and failures, and to review the experience level of your doctor. We urge caution when approaching this, the most controversial treatment approach, for IC. In the Summer of 2011, we discovered more than a twenty fatality reports that had been filed as adverse events relating, in some way, to Interstim. The FDA website offers no explanation as to why these deaths have occurred. We feel that further investigation is warranted and urge caution when exploring this therapy further. You can read these adverse event reports yourself by searching the FDA Manufacturer and User Device Experience (MAUDE) database.
References
(1) Ellsworth P, et al.Overactive Bladder - Etiology, Diagnosis, and Impact. Medscape CME Publicatio. March 25, 2011.
(2) Stewart WF, et al. Prevalence and burden of overactive bladder in the United States World Journal of Urology 2003 May;20(6):327-36." (PDF).
(3) Milsom I, et al. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int. 2001 Jun;87(9):760-6.
(4) Bailey KL, Torigoe Y, Zhou S, et al. Overactive bladder cost of illness: Analysis of Medi-Cal claims. Presented at the International Society for Pharmacoeconomics and Outcomes Research 5th Annual International meeting,. Arlington, VA. May 21-24, 2000.
(5) Tikkinen KAO, et al. Is the Prevalence of Overactive Bladder Overestimated? A Population-Based Study in Finland PLoS ONE 2007 2(2):e195."
(6) DuBeau CE. Interpreting the effect of common medical conditions on voiding dysfunction in the elderly. Urol Clin North Am. Feb 1996;23(1):11-8. [Medline].
(7) Flynn MK, et al. Outcome of a randomized, double-blind, placebo controlled trial of botulinum A toxin for refractory overactive bladder. J Urol. 2009 Jun;181(6):2608-15.
(8) Denys P, et al. Efficacy and Safety of Low Doses of Botulinum Toxin Type A for the Treatment of Refractory Idiopathic Overactive Bladder: A Multicentre, Double-Blind, Randomised, Placebo-Controlled Dose-Ranging Study. Eur Urol. 2011 Oct 25.
(9) Cruz F, et al. Efficacy and safety of onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity: a randomised, double-blind, placebo-controlled trial. Eur Urol. 2011 Oct;60(4):742-50.
(10) Khan S, , et al. Long-term effect on quality of life of repeat detrusor injections of botulinum neurotoxin-a for detrusor overactivity in patients with multiple sclerosis. J Urol. Apr 2011;185(4):1344-9
