Overactive Bladder​

Overview

Have you ever planned your morning errands around when and where you could find a bathroom? Do you often leak urine as you rush to unlock your front door so you can make it to the toilet in time? Are you waking up a few times every night because you feel an urgent need to pee?

If you have a combination of any of these issues, you may have a condition called overactive bladder.

Overactive bladder (or OAB) is not a disease, but the name for a group of symptoms. Women with overactive bladder may feel the need to urinate (pee) more often than other women (this is called urinary frequency). They may have a sudden strong urge to pee, which causes them to leak urine or not make it to the bathroom in time (this is called urinary urgency and can be with or without urinary leakage). And they may need to use the bathroom many times at night or they may accidently wet the bed (this is called nocturia or nocturnal enuresis).

As many as 40 percent of women live with some symptoms of overactive bladder. About 33 million Americans (women and men included) may have OAB. The number is likely much higher because many people don't seek help. They may be embarrassed by their symptoms or they don't think there are any treatments (there are!).

Overactive bladder is not harmful. But it can take a toll on quality of life. Women with OAB may limit certain activities in their work or social lives, feel embarrassed, and isolate themselves. As a result, OAB can lead to stress, depression, anxiety, trouble sleeping, and issues with sex. Overactive bladder also can be harmful if it keeps women from exercising or other healthy routines. Good news is that the condition is easy to diagnose, and in many cases, it can be treated.

Diagnosis

Symptoms

Many women with overactive bladder find they go to the bathroom more often than normal, and often with urgency, during the day and night. Pressure or spasms in the pelvic area trigger the urge to pee. Even after urinating, a woman may feel that her bladder isn't completely empty.

Symptoms of overactive bladder include:

• Urinating more than eight times during the day (frequency).
• A strong, sudden and uncontrollable urge to pee (urgency).
• Urinating more than two times at night (nocturia).
• Leaking urine when you feel the sudden urge to go (urgency incontinence).

OAB does not cause pain. If you have pain when you pee, you may have a urinary tract infection or a muscle problem with your pelvic floor. Since overactive bladder is a group of symptoms that may or may not be related to one another, we will try and talk about the individual symptoms separately.

Causes

First, it's helpful to understand how your urinary tract works. When you pee, your urine exits your body by flowing through a 1.5 inch tube called the urethra. In women, the opening to the urethra is just below the clitoris. (In men, it's at the tip of the penis). As you drink fluids and your bladder fills, your bladder sends nerve signals to your brain to trigger the urge to pee. A woman with a healthy bladder can tell that her bladder is full or getting full, but she can delay going to the bathroom until it is convenient.

In people with urinary urgency, there is less warning and suddenly the bladder muscles squeeze, making you feel like you have to pee. This is called "urgency."

As you pee, nerve signals tell the pelvic floor muscles and the muscles in the urethra to relax. At the same time, muscles in the bladder squeeze and push the urine out. In women with urinary urgency, spasms in the bladder, as well as weak pelvic muscles, may cause urine to leak or may cause a person to lose control of her urine.

Risk Factors

Women are twice as likely as men to have overactive bladder most likely because pregnancy, childbirth and menopause can all contribute.

Other factors that increase your risk for overactive bladder include:

Weak pelvic muscles. During pregnancy, the baby's head pushes on nerves to your pelvic floor and urethra causing muscle weakness that makes it difficult to contract the pelvic floor and stop unwanted urinary leakage. While the muscle damage that occurs during childbirth is often permanent, women can use their other pelvic floor muscle to compensate. Once we reach forty years of age, our ability to compensate starts to reduce and women may start to have urinary leakage symptoms.

Age. Yet another joy involved with more candles on the cake! By nature of getting older, you are more likely to develop overactive bladder. However, overactive bladder is not a normal part of aging. Like all muscles in your body, muscles in and around the bladder lose some function with age. Women over 75 are most at risk.

Menopause. We aren't certain why menopause results in worsening overactive bladder symptoms. We do know that some women improve their mild symptoms when they use safer estrogen replacement such as vaginal estrogen cream.

Bladder conditions. Bladder cancer, bladder stones, and urinary tract infections may mimic some of the symptoms of overactive bladder, which is why talking with a provider can be very helpful..

Excess weight. Women who are overweight or obese are more likely to develop symptoms of overactive bladder and urinary leakage due to the increased work required by the pelvic floor.

Nerve damage or brain disorders. Some diseases and conditions, including diabetes, multiple sclerosis, Parkinson's disease, Alzheimer's disease, and sleep apnea, can affect the nerves that communicate with the bladder and result in worsening urgency incontinence. Other types of trauma, such as pelvic surgery or back surgery, a herniated disc, stroke, or radiation, can also affect the ability of the bladder to hold back urine.

Medications, alcohol, caffeine. These substances can cause an increase in urine production, which results in faster filling of the bladder and more episodes of urinary urgency.

In women with overactive bladder, certain activities trigger the urge to pee—nearing a bathroom, the sound of running water, drinking water, getting out of the car at home. The link between constipation and urgency incontinence is well-known, although the exact reasons for the link are not as well-known.

Seeing Your Healthcare Provider

Many women suffer with symptoms for a long time before seeking medical advice. If you're experiencing symptoms of overactive bladder, see your health care professional. He or she can discuss your symptoms with you, perform a physical exam and/or refer to you a urologist or urogynecologist, a medical doctor who specializes in diseases and conditions of the urinary tract. They will also ask about how much these symptoms bother you and interrupt with your daily life.

To prepare for your appointment:

• Take note of your symptoms and how they affect your daily life.
• Make a list of all medicines you take.
• Be ready to talk about your medical history, including any past surgeries you've had.
• Write down any questions you have and take the list with you.

Diagnosis for OAB will most likely include:

Medical history. Your healthcare professional will ask you questions about your medical history. These questions will cover your symptoms, how long you have had the symptoms, and how they affect your life. Your healthcare professional will also ask questions about your past and current health problems and any surgeries you have had. This will help ensure that your symptoms are not caused by some other condition. Be ready to discuss any over-the-counter and prescription drugs you are taking.

Physical exam. Your healthcare professional will conduct an exam. He or she may do a simple abdominal and pelvic exam.

Urinalysis. Your healthcare professional may want to get a urine sample to rule out an infection and check for blood.

Your healthcare professional will want to know how much fluid and what type of fluid you are drinking, as well as how often you are peeing during the day and at night. For some women, additional information may be needed for diagnosis. This may include:

Bladder diary. Your healthcare professional may ask you to keep a bladder diary, where you write down how often you go to the bathroom and when you leak urine on a daily basis. He or she may also ask you to record what you eat and drink to identify any food triggers. Excessive fluid intake can cause excessive peeing, which mimics OAB symptoms.

Symptom quiz. Some healthcare professionals use a written quiz to ask questions about your bladder symptoms.

Other tests that may be used include:

• Cystoscopy. During this procedure, your health care professional will insert a narrow tube connected to a tiny camera lens into your bladder to look inside and rule out other possible causes of your symptoms.
• Bladder scan. A bladder scan is a type of ultrasound that reveals how much urine is left in the bladder after you pee. If your bladder doesn't empty completely when you pee, it can mimic some of the symptoms of overactive bladder.
• Urodynamic testing. This procedure measures how the bladder is functioning as it is being filled and as it empties. During the test, a health care professional inserts a thin tube called a catheter into your bladder to measure bladder pressure and fills it with warm water. Another catheter with a sensor will be placed into your vagina or rectum to measure nerve and muscle function in the bladder, pressure around the bladder, urine flow rates, and other factors that could be contributing to your symptoms of overactive bladder.

Treatment & Prevention

If your health care professional determines you indeed have overactive bladder, there are several treatments that can help. No single treatment is right for everyone, and you may have to try a few different treatments or use several at the same time to achieve results. Talk to your health care professional about what you're looking for in a treatment, as well as the benefits and drawbacks of each treatment choice.

Treatment options for overactive bladder include lifestyle changes, medications, and surgery and devices. Healthcare providers start with treatments such as behavioral therapy that has little to no risk to patients. If needed, medications would be offered as an option next. Although most treatments can improve symptoms, they usually do not eliminate them.

First-line treatments: Behavioral therapies

Health care professionals will often suggest behavioral therapy (also called lifestyle changes) before moving to medicines or surgery when treating overactive bladder. These treatments are tailored to the needs of the individual. Here are some of the things they may suggest:

1. Keep a bladder diary. Write down how much you drink, the type of fluid, and the time and amount that you pee. Do this for a couple of days. You may notice patterns that give you insight into your bladder. A bladder diary is also helpful to complete for the first visit with a specialist.
2. Limit foods and drinks that make your symptoms worse. Certain foods and drinks can irritate the bladder for some women, leading to symptoms of overactive bladder. These include:
   1. Coffee/caffeine
   2. Tea
   3. Alcohol
   4. Soda and other carbonated drinks
   5. Artificial sweeteners
   6. Chocolate
   7. Citrus fruits
   8. Tomatoes or foods made with tomatoes
   9. Spicy foods
   To get a better idea of whether foods and drinks contribute to your symptoms, remove all these foods and drinks from your diet and then add them back in one at a time. If your symptoms go away when you remove them and then return when you start eating or drinking a certain food or drink, you'll know that item is a culprit. To control urination issues at night, drink less fluids in the evening.
3. See a qualified physical therapist. He or she will devise a plan that works for you. This may include but is not limited to pelvic floor exercises, new voiding techniques, and urge control techniques that can help to distract your brain.
4. Consider biofeedback. The goal of biofeedback is to take information about something happening your body and present it in a way that you can better understand. Biofeedback can be helpful in diagnosing overactive bladder, as well as in its treatment. During biofeedback, you will be connected to sensors that help you make changes in your body. When you have the urge to pee, biofeedback can help you strengthen your pelvic muscles so you can suppress the urge.
5. If you smoke, quit. Smoking cigarettes is linked to bladder cancer. Coughing associated with smoking can worsen urinary leakage.
6. Avoid constipation. When you're constipated, it can affect bladder function through nerve pathways that are shared by the bladder and the bowel. By keeping your bowel movements regular, you may prevent constipation, and in turn, some of the symptoms of overactive bladder. To keep your bowels regular, eat as many high fiber foods as you can. These include beans, whole grain breads, apple sauce, prune juice, oatmeal, bran, and fresh vegetables and fruits. Regular exercise can also help.
7. Maintain a healthy weight. If you're overweight, a 10% weight loss has been shown to improve urinary leakage symptoms in women with stress or urgency incontinence.

If lifestyle changes fail to help your symptoms of overactive bladder, your healthcare professional may suggest medication. You may take medication by itself or combined with lifestyle changes.

Second-line treatment: Medications and Physical Therapy

There are several medications that help treat overactive bladder by relaxing the bladder muscle. They work by preventing your bladder from contracting when it's not full. You may need to try several different medicines or doses before you find what works best for you. These therapies are considered next in line after lifestyle changes because they can reduce symptoms, but they also cause side effects, mostly ones that are not life-threatening.

Some drugs are pills taken by mouth and others are gels or skin patches. The types of drugs are called anticholinergic drugs, antimuscarinic drugs, and beta-3 agonists.

• Anticholinergic medications:
  • Oxybutynin (Ditropan, Ditropan XL)
  • Oxybutynin as a skin patch (Oxytrol)
  • Oxybutynin gel (Gelnique, Gelnique 3%)
  • Trospium (Sanctura)
  • Tolterodine (Detrol, Detrol LA)
  • Solifenacin (Vesicare)
  • Fesoterodine (Toviaz)
  • Darifenacin (Enablex)
• Beta-3 adrenergic medication:
  • Mirabegron (Myrbetriq)

Common side effects of anticholinergics include dry mouth and eyes, blurry vision, and constipation (which ironically, can worsen overactive bladder). There are some studies that suggest an association between anticholinergic medications and cognitive decline, so your healthcare provider may try you on an anticholinergic for a short-term trial. These same concerns are not common with Beta-3 adrenergic agonists, which have a side effect of raising blood pressure 2-3 mmHg and should not be given to a woman taking 3 or more medications for high blood pressure. Talk to your healthcare provider if you have any of these side effects.

Third-line treatments: Treatments to try when medications and behavioral therapies are not enough

• Botox injections. When injected into the bladder, small amounts of botulinum toxin (Botox®) may prevent overactive bladder symptoms by paralyzing the bladder muscles and preventing them from spasming. Your healthcare professional will monitor you after treatment with Botox to make sure you're not holding too much urine in your bladder. If not, he or she may have to use a catheter to drain the excess urine. Treatments with Botox last about six to 12 months.
• Sacral nerve stimulation (SNS). You may have heard of a pacemaker for the heart. Sacral nerve stimulation (SNS) is like a pacemaker for the bladder. It works by stimulating the sacral nerve, which is near the base of your spine and carries signals between the bladder and spinal cord. In people with overactive bladder, these signals may not work correctly. Using a device like a pacemaker, SNS reinforces the healthy brain signals that tell the bladder to stay relaxed. Placement of the device involves surgery. The surgeon makes a small cut and places a thin wire close to the sacral nerves. He or she then tests the device to make sure it works well to improve symptoms of overactive bladder. Then, the surgeon connects the wire to a small battery-operated device placed under the skin. The device sends electrical impulses to the bladder to interrupt the abnormal signals that can cause overactive bladder.
• Percutaneous tibial nerve stimulation (PTNS). Like sacral nerve stimulation, percutaneous tibial nerve stimulation stimulates the tibial nerve. The tibial nerve runs along the knee to the sacral nerve at the base of the spine. Your healthcare professional can perform PTNS during a 30-minute office visit. A needle electrode is placed next to your ankle and sends pulses of electricity to the tibial nerve. These pulses help block nerve signals that are not working correctly. Most patients receive one treatment per week for 12 weeks, and then monthly treatments after that.

Fourth-line Treatment: Surgery

If other options have not worked, a woman may be treated with surgery. Surgery is only recommended in extremely rare cases. Types of surgery include:

• Augmentation cystoplasty – This procedure increases the size of the bladder so it can store more urine.
• Urinary diversion – This procedure moves the tubes that go from the kidneys to the bladder and routes them to outside of the body. An ostomy bag is then used to collect the urine.

An additional management option is the use of a catheter. Using a catheter to fully empty the bladder is generally not recommended but can be used as a last resort option for certain patients. Talk to your healthcare professional about whether this treatment is an option for you.

Facts to Know

1. According to the Urology Care Foundation, as many as 40 percent of women live with some symptoms of overactive bladder. About 33 million Americans may have OAB. The number is likely much higher because many people don't seek help.
2. Overactive bladder is not a normal part of aging. The condition is more common in older people, but that's because some of the factors that cause it, such as weak pelvic floor muscles, are more common in older age.
3. Symptoms of OAB include:
   • Urinating more than eight times during the day (frequency).
   • A strong, sudden and uncontrollable urge to pee (urgency).
   • Urinating more than two times at night (nocturia).
   • Leaking urine when you feel the sudden urge to go (urinary incontinence).
4. Women are twice as likely as men to have overactive bladder, most likely because of changes to the pelvic floor with childbirth and menopause.
5. Along with a physical exam and a bladder diary, a healthcare provider may run certain tests to see what could be contributing to your symptoms.
6. A healthcare provider will suggest lifestyle changes before treating with medicines or surgery. Lifestyle changes include limiting certain foods and drinks, physical therapy, quitting smoking, and maintaining a healthy weight.
7. Medications can be used to relax the bladder muscle, although they can come with side effects. They work by preventing your bladder from contracting when it's not full.
8. If lifestyle changes and medication don't work, a healthcare professional may suggest other treatments. Small amounts of botulinum toxin (Botox®) injected into the bladder may prevent overactive bladder symptoms by paralyzing the bladder muscles and preventing them from spasming.
9. Treatments that stimulate the sacral nerve or the tibial nerve can be helpful for OAB as a third-line treatment option. Surgery to increase the size of the bladder or insert an ostomy bag is considered a last resort option.

Questions to ask your healthcare provider

Review the questions below, so you're prepared to discuss this issue with your healthcare professional:

• What may be causing my OAB symptoms?
• Can you see me for this condition, or should I see a specialist?
• What tests will you use to diagnose my condition?
• What treatments might work for me? Are these side effects from these treatments?
• What foods and drinks can trigger my symptoms?
• If it's not overactive bladder, what else could be causing my symptoms?