Summary for HealthiNation’s Health Insights: Overactive Bladder

The following is an interview with Dr. Harris Foster, Professor of Surgery in the Division of Urology at the Yale University School of Medicine

Hosted by Dr. Holly Atkinson

Insights: OAB – Is it Overactive Bladder?

DR. HOLLY ATKINSON
Welcome to Healthination. I’m Dr. Holly Atkinson. Have you seen all of the advertisements for overactive bladder and wondered if some of your symptoms might be OAB? I sat down with Dr. Harris Foster, Professor of Surgery in the Division of Urology at the Yale University School of Medicine to talk about what overactive bladder is.

DR. HARRIS FOSTER
Overactive bladder is a condition. It primarily is a constellation of a variety of symptoms, urinary tract symptoms:

· Urinary frequency, primarily more than eight times per day;

· Urgency, that is, the inability to wait when the urge comes to get to the bathroom and sometimes;

· Urge incontinence, when you actually don’t make it and there’s a loss of urine, or incontinence.

Frequently, there is also a symptom that we call “nocturia,” which means getting up at night to urinate, which is abnormal.

There are some differences in how one describes OAB. There’s OAB, or Overactive Bladder Dry, that is, there’s no incontinence. So, you just have frequency and urgency – you’re able to make it to the bathroom. And then there’s what we call OAB Wet. Those are the patients that have urgency incontinence.

DR. HOLLY ATKINSON
So, who has OAB?

DR. HARRIS FOSTER
Almost anybody can have OAB, theoretically, [including] children, particularly those that are bed wetters. But primarily it’s a disease of aging. Some recent [studies] that I’ve seen estimate that about 13 million Americans or, some have said one in six adults, both in the United States and Europe {have OAB].

DR. HOLLY ATKINSON
Men? Women? What’s the balance there?

DR. HARRIS FOSTER
Probably more women, but certainly it can happen in both genders [and] does happen in both genders.

DR. HOLLY ATKINSON
Does OAB run in families?

DR. HARRIS FOSTER
It’s such a prevalent problem, and the causes are probably what we call multi-factorial. It may be that what we see as OAB is a combination of many different inputs … but I’m not sure that at this point we can state that there is a genetic component.

DR. HOLLY ATKINSON
What should the typical patient expect to undergo in terms of a diagnosis?

DR. HARRIS FOSTER
OAB, given that it’s a constellation of symptoms, can mimic other diseases. You have to rule out other potential causes before one gives that diagnosis, such as:

· Urinary tract infection

· Bladder cancer

· Bladder stones

· Neurologic causes, [such as] multiple sclerosis, Parkinson’s disease, [and] Alzheimer’s disease

· Obstruction of the bladder, such as in men with enlarged prostate, [which] can give similar symptoms

DR. HOLLY ATKINSON
When you end up with a diagnosis of true OAB, does that mean we don’t know what causes it?

DR. HARRIS FOSTER
Exactly. In the absence of some of the other diseases that are very definable and you have the symptoms of OAB, then the answer is that we don’t know exactly what causes it and it may be a process of aging whereby the nerves are less active so that bladder function becomes abnormal, resulting in the symptoms that we see with OAB.

DR. HOLLY ATKINSON
So here’s the insight. Overactive bladder is very common. Anyone can have the condition, but it does tend to affect older women the most. If you are experiencing symptoms and haven’t been diagnosed, it’s important to see a doctor to determine if you do have OAB or some other medical condition.

Insights: OAB – Talking to Your Doctor

DR. HOLLY ATKINSON
Welcome to Healthination. I’m Dr. Holly Atkinson. Many people with overactive bladder let their embarrassment stand in the way of talking to their doctor. But Dr. Harris Foster, Professor of Surgery in the Division of Urology at the Yale University School of Medicine, says it’s really worth it to have that conversation.

DR. HARRIS FOSTER
The big issue, as a physician who treats patients with OAB, is determining how it affects their quality of life. And that primarily is what drives them into our office because there are some patients who, if they leak a drop of urine, are tormented and there are other patients who are in diapers and aren’t bothered. And that impacts treatment – how far does one want to go in terms of treatment really is dictated by how bothered the patient is or how OAB affects their quality of life.

DR. HOLLY ATKINSON
How long has the typical patient had his or her symptoms before they get to you?

DR. HARRIS FOSTER
In my experience, there is a significant delay from the onset of the symptoms to them actually presenting in my office.

DR. HOLLY ATKINSON
What do you think the biggest barrier is to getting into a physician’s office?

DR. HARRIS FOSTER
I think it’s embarrassment and self-denial and not acknowledging that this is actually happening.

DR. HOLLY ATKINSON
I know so many people have suffered with this for so long and we do have good treatments today, but they don’t get into the physician’s office because they are embarrassed. What do you want to say to that patient?

DR. HARRIS FOSTER
Well, I would say that it’s more common than you think. All you have to do is look at the TV ads – it’s very common and very treatable. There are other types of treatments not associated with medicine or surgery that could potentially be of benefit.

DR. HOLLY ATKINSON
Is there anything people can do to prevent the development of OAB?

DR. HARRIS FOSTER
Not that we know of for sure based on current, available medical literature. There may be an association with patients who are significantly overweight. Some think that it’s due to pressure on the bladder from the abdomen or increased abdominal girth. But the reality is that we don’t really know for sure how one can prevent the development of OAB.

DR. HOLLY ATKINSON
So here’s the insight. While it can be tough to ask your doctor about OAB, it’s the first step to treating your condition and improving your well-being. Overactive bladder is very common, so don’t be embarrassed to bring it up at your next office visit – there are great treatment options available.

Insights: OAB – Behavioral Therapies

DR. HOLLY ATKINSON
Welcome to Healthination. I’m Dr. Holly Atkinson. There are options for managing overactive bladder that don’t require surgery or drug therapy. I talked to Dr. Harris Foster, Professor of Surgery in the Division of Urology at the Yale University School of Medicine, about small changes you can make that may yield big results. It’s called behavioral modification.

DR. HARRIS FOSTER
Since this is a quality of life disease, when patients come to me, I don’t tell them what to do; I say, “These are your options.”

DR. HOLLY ATKINSON
The first thing you do is start with behavioral modification?

DR. HARRIS FOSTER
Correct. Behavioral modification is alteration in fluid intake. I typically like to look at it as moderation in fluid intake. I do not want the patient to dehydrate themselves. But then there are also substances that increase urine output – what we call diuretic substances, such as caffeine [and] alcohol.

DR. HOLLY ATKINSON
Now, we’ve been talking about fluids. Are there any known foods or does diet in anyway contribute to OAB?

DR. HARRIS FOSTER
In my experience, pure OAB, that is without pain, other than diuretics – caffeine, alcohol – I don’t find that diet plays as much of a role.

DR. HOLLY ATKINSON
Tell us how you go about training the bladder.

DR. HARRIS FOSTER
Well there are different ways. There’s what we call time voiding or prompted voiding and is difficult sometimes to teach. And that is going to the bathroom on a schedule. So let’s say instead of waiting until you have to go to the bathroom, and if you have OAB Wet, you may not make it … so in these situations, you have the patient go to the bathroom, let’s say, every two hours. So essentially, trying to beat the bladder to the punch. It’s a paradigm shift for the patient. It’s telling them to do something that they haven’t done all their lives. Other ways that one can “train” the bladder is to do what you call Kegel exercises, which is to essentially contract the muscles of the pelvic floor, to contract them and relax them in sets of 10 or 20 or so, three or four times a day, to try to strengthen the muscle. But that’s primarily for stress incontinence, which is leakage with coughing and sneezing. There is a reflex, or a nerve pathway, whereby if you contract the sphincter muscle, it sends a signal back to the spinal cord to help relax the bladder. So, sort of the opposite of prompted voiding or timed voiding, would be when you have the urge, actually stop [and] contract the sphincter muscle. Sometimes that can turn off the urge to go and give you a little bit more time to get to the bathroom. So in some ways, there are conflicting ways of dealing with the problem. In some, prompted voiding is beneficial, and in some patients, particularly those who have strong pelvic floor muscles, bladder retraining is a possibility.

DR. HOLLY ATKINSON
So, here’s the insight. Training your bladder with techniques like timed voiding and making some small changes, like eliminating caffeine and alcohol, may improve your symptoms. It’s worth trying a number of techniques to find the right one or combination that works best for you. Work with your doctor to develop a plan.

Insights: OAB – Medication Therapies

DR. HOLLY ATKINSON
Welcome to Healthination. I’m Dr. Holly Atkinson. Is drug therapy the right approach to treating your overactive bladder? I talked to Dr. Harris Foster, Professor of Surgery in the Division of Urology at the Yale University School of Medicine, to find out what options are available and how they work.

DR. HARRIS FOSTER
OAB is thought to occur because of involuntary contractions of the bladder and that mechanism is via nerves and primarily is driven by a substance called acetylcholine, which attaches to the muscle of the bladder and causes it to contract. To treat OAB, some people call them “anti-cholinergics,” some people call them “anti-muscarinics,” but in essence, you’re blocking this interaction between that substance and the bladder muscle to reduce the increased contractions or contractility of the bladder that’s associated with patients who have OAB.

DR. HOLLY ATKINSON
How do you decide which drug to use?

DR. HARRIS FOSTER
There are a host of drugs, none of which are necessarily particularly better than the other. Most of the newer drugs are once a day, which has an advantage in terms of patient compliance and ease of use. There are generics that you have to take more than once a day. The newer drugs are more expensive. One of the newer drugs actually is a gel that you just rub on your forearm and it’s absorbed through the skin. One of the potential advantages [is that] when it goes through the skin, it avoids that first liver passing, [so] the drug gets directly into the bloodstream and the side effects sometimes can be less.

DR. HOLLY ATKINSON
Talk to me about the side effects.

DR. HARRIS FOSTER
Potential side effects of these drugs, of the anti-cholinergics, the anti-muscarinics, are primarily dry mouth and constipation. Now, other side effects can include cardiac—or heart—side effects, which I find are much less common. Sometimes what we call central nervous system side effects … They can cause mental status changes, forgetfulness, drowsiness, sleepiness, etc.

DR. HOLLY ATKINSON
Other classes of drugs that are commonly used?

DR. HARRIS FOSTER
There are occasions where we’ll use some of the old antidepressants for OAB because what they found is that when they used them for depression, patients had difficulty urinating. And so, OAB is the opposite. They [patients] have difficulty controlling urination. So sometimes [antidepressants] can be beneficial either alone or in combination with one of the other drugs I spoke about. Sometimes the drugs that we use for enlarged prostate, those medications in men can sometimes ameliorate the symptoms of OAB in those with enlarged prostate and the symptoms of OAB.

DR. HOLLY ATKINSON
The medical literature suggests that sometimes local use of estrogen may be appropriate in women. What’s your take on that?

DR. HARRIS FOSTER
It can. In those women with low estrogen levels, [women who are] post-menopausal, there’s some evidence that local application of estrogen can sometimes be of benefit.

DR. HOLLY ATKINSON
A lot of people have heard that Botox has been used for OAB. Does it work?

DR. HARRIS FOSTER
It can. It can help. A couple of caveats about Botox. One is that it’s not FDA approved for use in overactive bladder. Two, it, in current form, needs to be injected via a minimally invasive procedure. Three, it has to be repeated. It’s not a one-time deal.

DR. HOLLY ATKINSON
Who’s the typical patient that it would be used on?

DR. HARRIS FOSTER
I would think that it would be someone who has significant OAB, who has tried traditional medical therapy, which is the primary treatment, and has failed and is trying to undergo additional treatment that’s minimally invasive.

DR. HOLLY ATKINSON
So, here’s the insight. There are many effective drug therapies available to treat overactive bladder. You’ll need to work closely with your doctor to figure out which medication is best for you.

Insights: OAB – Surgical Options

DR. HOLLY ATKINSON
Welcome to Healthination. I’m Dr. Holly Atkinson. Treating overactive bladder with surgery is an option when lifestyle and drug therapies haven’t worked. I spoke with Dr. Harris Foster, Professor of Surgery in the Division of Urology at the Yale University School of Medicine, about the surgical options to treat overactive bladder.

DR. HARRIS FOSTER
There’s nerve stimulation, either through the skin or actually surgically implanted. Essentially, the way I describe it, it’s a bladder pacemaker. The first step is to place an electrode next to one of the nerves that goes to the bladder and you stimulate the nerve and you assess whether or not stimulation of the nerve improves the overactive bladder symptoms. And the second phase is to go back to the operating room and connect that electrode to a pace-making device, which is about the size of a wafer, and you place that underneath the skin.

DR. HOLLY ATKINSON,
Now, who’s a good candidate for this procedure?

DR. HARRIS FOSTER
Well I think anybody with OAB who’s healthy enough to have a minor surgical procedure.

DR. HOLLY ATKINSON
Now are these for people who have tried medications and for the most part the medications have not worked or for people who prefer not to take medications and would rather go for something like this?

DR. HARRIS FOSTER
Well, in my experience, it’s almost exclusively for patients who have tried medications, because when given the option, most patients are going to choose medication over surgery.

DR. HOLLY ATKINSON
What are the complications from sacral nerve stimulation?

DR. HARRIS FOSTER
Well, there’s the general risk of any surgery and that is bleeding, infection, reaction to anesthesia. There is risk because it is a foreign body. Whenever you put a foreign body into a human, there’s a risk of infection right after the operation, and there’s a risk down the line.

DR. HOLLY ATKINSON
Any percentage for this operation?

DR. HARRIS FOSTER
I’d say it’s low, less than five percent. But it is there.

DR. HOLLY ATKINSON
Other surgical options?

DR. HARRIS FOSTER
More aggressive surgery to in fact enlarge the bladder. We use it more often in patients who have overactive bladder due to [neurological] diseases, such as spinal cord injury, multiple sclerosis, where it’s totally uncontrollable. Essentially what it is, you go into the operating room, you open up the abdomen, you split the bladder in half, you take a piece of intestine, turn it into a patch and put it on top of the bladder to make it bigger. It’s called augmentation cystoplasty. It’s a major operation. It’s multiple days in the hospital. Most patients who have that operation are unable to empty their bladder because it interrupts the bladder’s ability to empty and they have to do what we call self-catheterization.

DR. HOLLY ATKINSON
So, here’s the insight. Bladder enlargement is a surgery for a small minority of patients. Sacral nerve stimulation is worth considering if lifestyle and drug therapy haven’t worked. As with any surgery, this procedure has risks, so be sure to discuss them with your doctor.

Insights: OAB – The Future of Treatments

DR. HOLLY ATKINSON
Welcome to Healthination. I’m Dr. Holly Atkinson. For the millions of Americans with overactive bladder, there are many good treatment options. But what’s on the horizon? Dr. Harris Foster, Professor of Surgery in the Division of Urology at the Yale University School of Medicine, updates us on the latest research.

DR. HARRIS FOSTER
There’s Botox, botulism toxin … There may be some developments to prolong the duration of the response to Botox. People have looked at delivering it in solution without having to inject it into the bladder. That is, combining it with a solution of another agent and just instilling it into the bladder and hoping that it diffuses into the bladder wall. They’re looking at combining agents using alpha blockers, which block the contraction of the muscles of the prostate and the urethra, with the anti-muscarinics, which block the contraction of the bladder muscle…using both types of drugs together as a combination agent.

DR. HOLLY ATKINSON
For men, that would be for men?

DR. HARRIS FOSTER
For men, but maybe even for women. There’s some data to suggest that the alpha blockers can help symptoms of OAB in women. Substances that occur in chili peppers – capsaicin – and there’s another agent called resiniferatoxin or RTX [which] when put in the bladder can help relax the bladder to reduce the over-activity. A lot of interest [is going] into additional research in nerve stimulation. The traditional nerve stimulation is the sacral nerve through the tailbone. People have looked at what they call pudendal nerve stimulation, which is a nerve closer to the bladder.

DR. HOLLY ATKINSON
Any myths you want to dispel?

DR. HARRIS FOSTER
Well, I’ll say that some patients will come in and say, “Well, when I was a child, I had this problem of frequent urination, of bedwetting.” I’m not sure that that’s necessarily proven to be an association with OAB. There are patients who will come in and say, “Well, my mother had it, my sister had it.” And again, we can’t prove that. Is it possible that there could be a genetic component to this? Yes. Have we proven it? No.

DR. HOLLY ATKINSON
Final words to people out there who may have OAB?

DR. HARRIS FOSTER
OAB is more common than you think. Your neighbor may have it right next to you. It can significantly impact quality of life. There are a number of treatment options, some of which don’t even involve drugs or surgery. The drugs, however, and surgery are relatively safe and well-tolerated. I think it should not go untreated if it’s bothersome in one’s daily life.

DR. HOLLY ATKINSON
So here’s the insight. While there are a lot of good treatments today, many new, exciting options are being studied. Be sure to continue talking with your doctor about your current treatment and keep the dialogue open to new possibilities.

HealthiNation offers health information for educational purposes only; this information is not meant as medical advice. Always consult your doctor about your specific health condition.

Last Review Date: July 13, 2010

Reviewed by: Dr. Preeti Parikh

Reviewed by: Dr. Holly Atkinson