New Guidelines and Treatment Options
Overactive bladder (OAB) symptoms can be embarrassing, socially isolating and affect your quality of life. You may experience any combination of urinary frequency, urgency, nocturia (waking frequently at night to urinate) and urge incontinence. An estimated 9% to 43% of women and 7% to 27% of men may experience OAB symptoms. Many people find it difficult to perform daily tasks or sit in meetings at work because of their sudden urge to urinate. The nocturia caused by OAB leaves patients fatigued and – particularly for older patients – puts them at risk for falling in the dark when they get out of bed to use the bathroom.
The American Urological Association (AUA) developed guidelines for the evaluation and treatment of OAB. These guidelines recommend an initial evaluation that should include a history, physical and urinalysis. If the initial evaluation is normal, treatment can be initiated. Further evaluation may include a test to measure the amount of urine left in the bladder after urination. If symptoms persist after the initial treatment, further evaluation may include cystoscopy (a thin tube with a camera inserted into the bladder and urethra for visual checks) or urodynamics (a bladder study used to measured how well the bladder and urethra are working).
Keeping a 3-day voiding diary helps identify what and how much you’re drinking. Bladder irritants like caffeine, sodas, alcohol, and sugar substitutes can irritate the bladder, which can subsequently worsen OAB symptoms. You may also notice that you’re drinking more fluid just prior to bedtime, contributing to nocturia. Pelvic floor exercises with or without the assistance of a physical therapist can help you manage symptoms as well – track your progress with help from a coach or an exercise log.
Medications can also be added to behavioral modification/first-line treatment.
Anticholinergic medications block involuntary movement of muscles in the bladder and have been effective in treating OAB. These medications are available in both immediate and extended release varieties, although extended release is generally recommended due to fewer side effects. While it’s a standard treatment, some patients discontinue use because they experience common side effects, including dry mouth and constipation.
Note: If you have difficulty emptying your bladder, speak with your doctor before using anticholinergics. Also, if you have narrow (closed) angle glaucoma, consult your ophthalmologist before taking this medication.
Mirabegron, a b3-adrenoreceptor agonist, is a medication that can significantly reduce the symptoms of your OAB by causing the relaxation of smooth muscles in the bladder to help increase its capacity. Mirabegron does not have anticholinergic side effects (i.e. dry eyes, dry mouth and constipation), but some patients experience headaches or elevated blood pressure while taking this medication. Physicians may recommend that you keep an eye on your blood pressure while taking Mirabegron.
If your symptoms are not improving from first and second-line treatments, other options should be considered.
InterStim® therapy – otherwise known as sacral neuromodulation – has been available since 1997 and has become a common treatment option for OAB. InterStim® therapy involves a two-stage outpatient procedure for the treatment of OAB, urinary retention and fecal urgency/fecal incontinence. A great advantage of the therapy is that it involves a testing phase to identify if the therapy will improve your symptoms. This allows you to experience the therapy for 1-2 weeks prior to implanting the generator. The InterStim® generator is a small device, much like a cardiac pacemaker, that is surgically implanted and uses mild electrical pulses to stimulate the nerves that control your bladder and bowel. When these nerves are stimulated with electrical current, the bladder and bowel begin to function properly. Over the years, studies have shown more than 80% of the patients who test the therapy are satisfied with the outcome and want to move on to complete implantation of the device.
Botox injection into the bladder was approved for OAB in 2013. It involves injecting Botox into the bladder muscle in multiple locations to reduce the symptoms of OAB. The in-office procedure is fast with minimal discomfort. The Botox affects the nerves and muscles that control your bladder by blocking the signals that trigger the urge to urinate. The average frequency of injections is every 9 months. Complications from Botox are rare – 6% of patients may experience temporary urinary retention and require clean intermittent catheterization or an indwelling catheter.
Posterior Tibial Nerve Stimulation (PTNS)
PTNS is a minimally invasive way to stimulate the nerve to the bladder to reduce urinary frequency, urgency, and urge incontinence. Typically, you will receive 12 weekly office visits at which a small needle (the size of an acupuncture needle) is placed in the ankle and attached to a stimulator for 30 minutes. The needle and stimulator send an electrical pulse to the sacral plexus, the nerve that regulates the bladder. This pulsation works similarly to the pulsation delivered by the InterStim® therapy described above and reduces the number of times you will need to visit the bathroom. Often this will require monthly or quarterly booster treatments.
There are a variety of treatments that are recommended based on your specific set of circumstances and the severity of the OAB, but most patients find relief with treatment. Speak with your physician to talk through the best options for you.
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