Conditions and Treatments

Overactive Bladder

WHAT IS OVERACTIVE BLADDER (OAB)?

Overactive bladder (OAB) is a medical condition that results in an uncontrollable urge to pass urine and frequent need to urinate both during the daytime and night-time. It may also be associated with urine leakage and not getting to the bathroom in time because of an overwhelming urge, also know as urge incontinence.

OAB’s IMPACT ON QUALITY OF LIFE

OAB can greatly affect quality of life emotionally, socially, physically and financially. People find their lives revolving around the toilet and they plan their day around getting to a bathroom.  Some people avoid social situations due to fear of leaking, smell and embarrassment. Others rarely leave the house and become a “bladder hermit”. Suffers often feel tired all the time because they are waking up too many times during the night to go to the bathroom and not getting enough rest.  They are unable to enjoy a normal diet because they have to limit both foods and liquids so they do not trigger a bladder spasm.  Financially, the costs of pads and bladder medications can add up to a significant amount.  All these add up to a sense of loss of control over the bladder and eventually, one’s life.

QUESTIONS TO ASK YOURSELF IF YOU HAVE OAB

  1. Do you have a sudden need to rush to the bathroom to urinate?
  2. Is this caused by hand washing or turning the key in the door?
  3. Have you not made it to the bathroom fast enough and leaked urine?
  4. How often do you pass urine during the day?
  5. Do you always have to know where the bathroom is when you are out of the house?
  6. During the night, how many times do you get up to urinate? Is it your bladder which wakes you up?

WHAT CAUSES OAB?

Most commonly, there is no known cause for OAB.  Some cases are related to a neurological cause such as Parkinson’s disease, Multiple Sclerosis or stroke.  OAB can also happen as a result of a blockage f the bladder outlet such as prostatic obstruction in men.

WHAT OTHER CONDITIONS CAN BE MISTAKEN FOR AN OAB?

  1. Urinary tract infection
  2. Interstitial cystitis
  3. Bladder cancer
  4. Bladder stone
  5. Polyuria (excess production of urine by the kidneys)

HOW IS OAB DIAGNOSED?

  1. Urinalysis: A urine sample is tested for infection, traces of blood and other abnormalities.
  2. Bladder Diary: A useful tool that allows you to record and measure your liquid intake, urinary output, urinary frequency and leakages. A patient with OAB will show frequent, small urinations.
  3. Bladder Survery: Is done to evaluate the impact of OAB on quality of life.  It can also be done to measure how well the treatment is working.
  4. X-ray imaging is not done routinely, but a kidney ultrasound or CT scan can be useful if:
    1. History of a possible neurogenic bladder
    2. History of pain or blood in the urine
    3. Suspicion of anatomical abnormalities
    4. A urinary tract ultrasound can measure prostate size (in men)
    5. Cystoscopy is not done routinely unless:
    6. Suspect bladder cancer (history of blood in the urine)
    7. Bladder pain (rule out bladder pathology like stones or interstitial cystitis)
    8. Significant obstructive symptoms,(poor flow, straining)
    9. Significant incontinence is present
  5. Urodynamics: Bladder pressure studies that measure the function of the bladder. The indications are:
    1. Complex history
      1. Neurogenic bladder
      2. Mixed incontinence (both stress and urge incontinence)
      3. Previous pelvic or incontinence surgery
    2. When there is no response to medication or the diagnosis unclear
    3. Before invasive surgery

HOW COMMON IS IT AND IS IT TREATABLE?

OAB is very common. 1in 6 people over the age of 40 suffer from it, and the rate increases with age.  It is often thought to be more common in women but in reality, it is about as common in men. A lot of people do not seek medical attention and decide to “just live with it”.  This is unfortunate because there are now a lot of effective treatment options available.

WHAT ARE THE TREATMENT OPTIONS FOR OAB?

Treatments should always start with conservative ones before moving to invasive ones.

First line therapies:

  1. Lifestyle changes (reduce caffeine, alcohol)
  2. Behavioral therapy (bladder re-training)

Second line therapies:

  1. Pelvic Floor Therapy(Kegel) and Biofeedback
  2. Medications

Third line therapies:

  1. Percutaneous tibial nerve stimulation (PTNS)
  2. Botox Bladder Injection
  3. Sacral Neuromodulation (InterStim)

FIRST LINE THERAPIES

  1. Lifestyle changes include monitoring your fluid intake and paying attention to your diet. Foods and drinks that may worsen your OAB symptoms are alcoholic beverages, caffeine-containing foods and drinks, spicy foods, high-acid foods such as citrus fruits and juices, and carbonated drinks. If you notice symptoms of OAB worsen after you any of these foods or drinks, eliminating them or cutting back on them may make living with OAB easier. Weight loss and smoking cessation may also help to mange OAB symptoms.
  1. Behavioral therapy or bladder retraining is done with the help of a healthcare provider who sets up a urination or voiding schedule that helps you increase the length of time between bathroom visits.  Successful bladder retraining also requires you to distract and calm yourself until the desire eases. Biofeedback may be used to help you tell how well your pelvic muscles are contracting.

SECOND LINE THERAPIES

  1. Pelvic floor therapy and biofeedback is non-surgical form of therapy is used to retrain the pelvic floor muscles and/or bladder muscles. Typically, pelvic floor therapy consists of weekly sessions for six weeks. The first session will last about an hour, but the remaining sessions will be shorter.
    1. Using biofeedback and electrical stimulation techniques, a nurse or therapist will evaluate your muscle strength and instruct you on how to properly isolate and exercise these pelvic floor muscles.  A computer will be used to guide you and monitor your progress.
    2. The nurse will educate you in these techniques so that you can continue the exercises at home.

      Medications are the mainstay conservative treatment options.
      1. Anticholinergic drugs are most commonly used.  They act by “calming “down bladder activity.  Common side effects are dry mouth and constipation. Other side effects are confusion, dizziness, rapid heart beat, and urinary retention (unable to pass urine).  Patients with glaucoma should check with their ophthalmologist (eye doctor) before starting on these drugs.  There are now many drugs in this category. They differ in the number of times taken per day, mode of administration, side effects, profile, efficacy and cost.  Some medications have fewer side effects but are not subsidized by Medicare and hence, are more expensive. Your doctor will talk to you about which drug is best for you.
      2. Alpha-blockers are usedin men with OAB secondary to an obstruction from an enlarged prostate to improve the obstruction.  Sometimes, this will result in an improvement of the OAB symptoms over time.  In those that don’t, an anticholinergic drug can be added to treat the OAB symptoms.

For OAB patients who have tried medication(s) and still have symptoms of OAB or cannot tolerate the side effects, there are other effective treatment options available which are FDA approved and covered by Medicare and most insurance plans. They include:

  1. Percutaneous tibial nerve stimulation (PTNS)
  2. Botox bladder injection
  3. Sacral neuromodulation (InterStim)


THIRD LINE THERAPIES

Percutaneous tibial nerve stimulation (PTNS)

PTNS is a non-medication, non-surgery treatment for men and women with OAB. Also know as neuromodulation, PTNS stimulates the nerves that control your bladder. It is a combination of a hand-held stimulator, thin needle electrode and a lead set. The stimulator generates electrical impulses that are delivered through the lead set.

How Does PTNS Work?

It is done in our office while you sit comfortably in a chair. A slim needle electrode is temporarily placed near your ankle. The device delivers mild electrical impulses which travels up the nerves in your leg to the nerves that control the bladder. The treatment is generally well tolerated. You may feel a sensation in your foot or ankle. The treatment takes approximately 30 minutes and is done weekly for 12 weeks.

How effective is PTNS Treatment?

60-80% of patients see a satisfactory improvement in their OAB symptoms. PTNS may work even if other treatment options such as medications have failed.

How Long Does It Take to See Results?

It will probably take at least 6 treatments to see your symptoms change. It is important that you receive the full 12 treatments before you and your doctor determine whether this therapy is appropriate treatment for your symptoms.

Botox Bladder Injection

Botox (onabotulinumtoxinA) is a prescription medication that recently received U.S. Food & Drug Administration approval for use in the treatment of OAB symptoms in adults when other type of medication cannot be taken or did not work well.

How can Botox help OAB Symptoms?

Botox temporarily calms muscle contractions in the bladder by blocking transmission of nerve impulses to the bladder muscle.

How effective is Botox treatment for OAB?

Botox has been shown to reduce OAB symptoms in 75% of patients who were treated.

How is the Botox treatment done?

Botox is administered during an outpatient procedure in our ambulatory surgery center. A local anesthetic is administered and a sedative may be given. Once the bladder is numb BOTOX® is injected into the bladder muscle using a cystoscope or a specialized tube with an optical lens at the end that is used to see inside the bladder. A cystoscope is placed into the bladder via the urethra. Once the doctor is able to access the bladder and initiate the BOTOX® injections, the treatment takes approximately 15-20 minutes and then the patient is observed for approximately 30 minutes before they leave the ambulatory surgery center.

What are the side effects associated with BOTOX® treatment?

The most common side effects reported with BOTOX® treatment in the clinical studies included: urinary tract infection, difficult urination and urinary retention, which is a temporary inability to fully empty the bladder. Patients with diabetes mellitus treated with BOTOX® were more likely to develop urinary retention than non- diabetics.

Can Botox injections be repeated?

The effects wear off over time so a repeat injection may be needed every 6- 18 months.

What is The InterStim Therapy System?

InterStim Therapy is a treatment option that may relieve bladder or bowel control issues in people who have not had success with or could not tolerate other treatments.  It was created by Medtronic, the developer of the pacemaker, and has been FDA approved since 1997 for urge incontinence, and since 1999 for urinary retention and urgency-frequency.

How Does InterStim Work?

InterStim Therapy is a proven therapy that works by targeting the communication problem between the brain and the nerves that control the bladder and bowels. If those nerves are not communicating correctly, the bladder will not function properly.  InterStim uses mild, electric pulses to reduce the signals to the nervous system which may be causing the problems such as leaks, the sudden urge to go or going too often.

InterStim Therapy’s Peripheral Nerve Evaluation

You and your doctor may decide to try InterStim Therapy by going through test stimulation known as a peripheral nerve evaluation. With InterStim’s Therapy’s two- step process, you can test it out to see if it works for you before making a long term commitment. The peripheral nerve evaluation allows you to experience the effects of InterStim Therapy at home for a short period of time. Your doctor will discuss the peripheral nerve evaluation procedure with you and the options for using either a temporary lead or long-term lead for the test. One end of the lead is implanted near your sacral nerves and the other end is connected to a small external test stimulator that can be worn on a belt. The stimulator generates mild electrical pulses that are carried to the sacral nerve by the lead. While you wear the test stimulation system you will need to complete a diary to record how the stimulation affects your symptoms.

At the end of the evaluation period, you and your doctor will decide if an InterStim Therapy system is the right choice for you. Based on the results of the evaluation, you and your doctor will determine the next step that is right for you.

What Happens During The Evaluation Procedure?

The procedure is done in our Ambulatory Surgery Center (ASC), and usually takes less than 1 hour to complete.  You may want to bring a spouse, relative, or friend to provide support during the procedure. Your doctor will give you a local sedation so that you can provide feedback during the procedure. During the procedure, your doctor will insert a needle just above your tailbone to locate the appropriate sacral nerve. When the needle is in place, the test stimulation system will be turned on and your doctor will ask you to describe what you feel. Some people feel a “pulling” or “tingling” sensation in their pelvic muscles or big toe. Women may feel a sensation in the vaginal area; men in the scrotum.

The sensation of stimulation should not be painful. Most people describe it as a slight pulling or tingling in the pelvic area. If you experience any pain during the evaluation period, turn the test stimulator down or off and notify your doctor or nurse.

What to Expect After the Evaluation Procedure

  1. Take it easy; keep your activity level low to moderate during the test period.
  2. Avoid bending, stretching to much, or lifting heavy objects more than 5lbs.
  3. Sponge bath only. Avoid bath, showers, and hot tubs. Do not submerge your body in water.
  4. There will be small dressing over insertion areas. Do not remove. You can reinforce with another dressing. Keep bandages dry and intact. A small amount of blood is normal.
  5. If you experience any fever greater than 101.0 or severe pain, please call Georgia Urology and notify your doctor.
  6. You will receive a follow-up call from Georgia Urology staff member and a Medtronic Representative.
  7. Please be sure to call the office and make a follow up appointment as directed by your doctor.

Keeping a Diary during the Test Stimulation Period

You will be asked to keep a diary during the evaluation period to track your bladder control symptoms.  This history will help your doctor evaluate whether an InterStim Therapy system is right for you.

How Will I Know If InterStim Therapy Works For Me?

Generally, if your symptoms improved and you didn’t experience any problems during the evaluation period, then you and your doctor will discuss whether to proceed with a long-term InterStim Therapy system.

COMMON QUESTIONS ABOUT InterStim TEST STIMULATION

I’m not sure if the stimulation is working. What should I do?

Check the battery and the ON light to be sure the test stimulator is working. If it is, turn the amplitude dial to OFF and gradually turn up the stimulation to a comfortable setting. Call your doctor if you have any questions or are still unsure that the test stimulator is working.

What does the stimulation feel like?

Stimulation varies from person to person, but most people describe it as a slight “pulling” or a “tingling” sensation in the pelvic area. It should not be painful. If you feel any pain, turn off the test stimulator, and call your doctor.

Will the test stimulation cure my condition?

No. The test stimulation is temporary. It is a tool that helps determine whether an InterStim Therapy system is right for you. Once the lead is removed, your original symptoms will return. If you have had positive results with the test stimulation, then you and your doctor may decide to use a long-term InterStim Therapy system to treat your symptoms.

Will the stimulation change at all?

You may feel slight stimulation changes when you move from a sitting to a standing position or from a standing to a walking position. Check with your doctor; you may need to adjust the stimulation when that happens.

Will stimulation hurt my nerves?

No. Research has shown that the nerves are not harmed by the stimulation when used properly.

How long will the battery last?

Your test stimulator will have a new 9-volt battery when you go home. It should last for the entire test stimulation period. However, you can change the battery, if necessary, by opening the battery door on the back of the device. Turn off the test stimulator before removing the batteries (and do not leave the battery compartment of the test stimulator empty for any long periods of time). When the new battery is in place, close the battery door and slowly turn up the stimulation setting to a comfortable level.

Can I have sex during the test stimulation period?

No, you should avoid sexual activity during the test stimulation period because it could cause the lead to move. This restriction only applies to the test stimulation period, there are no restrictions on sexual activity during long-term InterStim Therapy.


SURGICAL OPTIONS

Augmentation cystoplasy

  1. A piece of small bowl is reflected and sutured onto an opened bladder to create an “augmented “or strengthened bladder.
  2. Overactive bladder contractions disappear over this larger area and become less symptomatic and less dangerous to the kidneys.
  3. Some patients may need to learn to do intermittent self catherization if the bladder does not empty well.
  4. The bowel segment of the augmented bladder will continue to produce normal mucous which will mix in with normal urine.
  5. There is an increased risk of bladder stone formation.
  6. Routine yearly cystoscopy is done as there is a very small risk of the augmented bowel segment undergoing malignant transformation over time.

Urinary diversion

  1. This is usually done as a last option.
  2. Urine can be surgically diverted by implanting the ureters (tubes draining the kidneys to the bladder) to a piece of small bowel. This then exits to the abdominal skin surface (stoma) into a bag.