What is Overactive Bladder?
Overactive bladder (OAB) is a common condition. It affects about 33 million Americans in total, and about 40% of women in the United States. Overactive bladder refers to a group of urinary symptoms. These include an urgent need to urinate, urinating frequently and the inability to hold your urine when a sudden urge hits. Loss of urine is called incontinence. Loss of urine associated with a strong urge is called urgency urinary incontinence. Waking up at night to urinate is called nocturia.
There are many causes of incontinence. Loss of urine while sneezing, laughing or doing other physical activities is called stress urinary incontinence (SUI). This is different from OAB.
Who Should See a Doctor?
Many people with overactive bladder don’t talk to their doctor about it. Some are embarrassed. Other people don’t ask for help because they don’t know that their symptoms can be treated. But you shouldn’t ignore symptoms of overactive bladder because they can really impact your life. People with OAB may need to make many trips to the bathroom throughout the day and night. This can interfere with their ability to work, exercise, socialize and sleep. It can put strain on their relationships with friends and loved ones. They may decide to avoid parties and activities out of embarrassment. Leaking urine is not only embarrassing, wet under garments can also cause skin problems and infections. These are all reasons to get help if you think you have OAB.
If I do see a doctor what will she do?
Your doctor will start by talking to you. She may ask you about your symptoms:
- How often do you go to the bathroom?
- Do you leak urine?
- Is your urine leakage associated with a strong urge to urinate?
- Do you wake up at night to urinate?
- Do you drink coffee or a lot of other liquids?
Your doctor will also do a physical exam. You will be asked to give a urine sample. This will be checked for infection and other things that may be causing your symptoms. Your doctor may want to check a post void residual. This means he will ask you to urinate and then check how much urine is left in your bladder. This can be done using an ultrasound or by putting a small tube in your bladder to see how much comes out.
There are more complicated tests that can be done for certain medical conditions or for patients who do not improve with treatment. Urodynamics is a test that involves filling your bladder through a tube and then monitoring how your bladder fills and empties, and if you leak urine. Cystoscopy involves looking in your bladder with a camera. An ultrasound is another test your doctor may order which can not only look at your bladder but can also look at your kidneys.
What is the treatment for OAB?
Your doctor will start by talking to you about OAB and normal urinary function. Next your doctor will talk about the benefits and risks of available treatments. OAB is bothersome, but it’s not a life-threatening condition. After making sure you don’t have something more serious, you and your doctor may decide to do no treatment. If you do decide to get treatment you may need to try a number of different treatments in order to successfully control your symptoms.
The first step is changing your behavior. This is called behavioral therapy. This may include limiting fluid, especially caffeine and especially before bed. Some patients think they must drink 8 glasses of water per day. This is not a strict rule and is not necessary. We recommend you drink if you are thirsty, and you may not need 8 glasses a day. Another thing you can do is called bladder training or timed voiding. This means going to urinate on a schedule. Some people hold their urine too long. Some people go to the bathroom every 15 minutes. We recommend you go every 2 – 3 hours. If you usually hold your urine for 8 hours just try to go to the bathroom after 3 hours whether you have to or not. If you usually go every 15 minutes try to distract yourself and hold it for at least a half hour every day this week, then try to make it to 45 minutes or an hour the following week. Keep stretching it until you are going every 2 – 3 hours. You can also do exercises to strengthen the muscles in your pelvis known as the pelvic floor. These are the muscles you would use to stop your stream if you had to stop urinating. If you have a strong urge to go and are afraid you might leak, do the “freeze and squeeze.” Stand still and squeeze your pelvic floor muscles until the urge goes away. Then you can walk calmly to the bathroom to urinate. Even if you decide to take medication for your overactive bladder, doing these behavioral therapies can help you go less frequently and leak less.
Medication is considered the second line of treatment. Most medications are in the family called anticholinergics. These medications relax your bladder but may cause side effects such as dry mouth, dry eye, constipation and confusion. Here is a list of some medications that are in this family:
- Darifenacin [Enablex]
- Fesoterodine [Toviaz]
- Oxybutynin [Ditropan]
- Solifenacin [Vesicare]
- Tolterodine [Detrol]
- Trospium [Sanctura]
Many of these medications come in immediate-release and extended-release formulations. The extended-release formulation is preferred because of lower rates of dry mouth. Oxybutynin also comes in a gel or patch form, which may have fewer side effects. The patch is available over the counter without a prescription, and the brand name is Oxytrol. If you do get side effects from these medications, your doctor may change your dose or give you tips about how to manage the side effects. For example, your doctor may recommend adding fiber to your diet if you have constipation. Your doctor may not offer you these medications if you are elderly, have narrow-angle glaucoma, impaired gastric emptying or a have been unable to urinate in the past.
There is another medication, called Mirabegron [Myrbetriq]. This works slightly differently and has fewer side effects. Your doctor may not offer this to you if you have uncontrolled high blood pressure.
If you are going through or already went through menopause you may have vaginal atrophy which often has symptoms of vaginal dryness. If you have this and either stress or urgency incontinence, your doctor may also recommend topical vaginal estrogen.
If medication and behavioral therapy don’t work for you, you may be referred to a specialist such as a urologist or urogynecologist. These specialists may do additional testing such as urodynamics or cystoscopy, described above. Then you may be offered third-line treatments.
Sacral neuromodulation involves an implant that looks like a pacemaker. This sends signals through your spinal cord to your bladder telling it to not squeeze too often. It can also be used if your bladder is not squeezing enough and you are unable to empty. Your doctor will put in a temporary stimulator to see if it helps you and if it does, the implant is then placed via a short surgery.
If surgery and a permanent implant doesn’t sound like it’s for you but you are still interested in a non-medication option, you can do peripheral tibial nerve stimulation treatment. This involves an acupuncture-type needle placed in your ankle which gets connected to a stimulator. This sends a signal up the nerve in your ankle to the nerves that go to your bladder. You have to get a treatment every week for 12 weeks. If it works for you, then we recommend coming back once a month for maintenance or a touch-up treatment.
Another option is onabotulinumtoxin A (Botox). Most people think of getting Botox to relax the wrinkles in your face, but it can also be used to relax your bladder. This is a procedure done in the office through a cystoscope which is a camera inserted in your bladder. The procedure usually needs to be repeated about every 9 months to a year. Sometimes the injection relaxes your bladder so much that you are unable to urinate. If this happens you may be at increased risk for urinary tract infection or you may need to empty your bladder by inserting a small tube every time you need to go. Although this would be an unpleasant situation, the Botox does wear off and so it would be short-lived.
In rare cases there may be patients who require complex surgeries to manage their OAB. But most patients can be managed with one or a combination of the above strategies. OAB is treatable and treatment can greatly improve quality of life.
Take Home Points
- Overactive bladder describes a group of symptoms including urinary urgency (rushing to the bathroom), urgency urinary incontinence (leaking urine when you have a strong desire to urinate) and nocturia (waking up to urinate at night). There are many reasons for leaking urine (incontinence) so it is important to discuss your symptoms with a doctor.
- Overactive bladder is more common as you age but it is not just part of the normal aging process and it is treatable.
- Initial treatment includes lifestyle modifications, pelvic floor muscle (Kegel) exercises and bladder training.
- If making these changes does not control your symptoms, your doctor may recommend a medication. These can have side effects such as dry mouth and constipation so it is important to discuss this with your doctor.
- If medications do not help, your doctor may refer you to a specialist who can offer you other treatments such as Botox injections in your bladder or treatments that affect the nerves going to the bladder to help the bladder relax.
Allison Polland, MD completed her undergraduate degree in Biomedical Engineering at Yale University and her medical degree at Columbia University College of Physicians and Surgeons. She completed her urology residency at Mount Sinai School of Medicine in New York before going on to fellowship in Female Pelvic Medicine and Reconstructive Surgery at Georgetown University/ MedStar Washington Hospital Center. She is currently an attending physician in the Department of Surgery, Division of Urology at Maimonides Medical Center in New York.
Disclosure: Dr. Polland has grant support from the International Society for the Study of Women’s Sexual Health and from the Sexual Medicine Society of North America for a study involving the effect of different treatments for primary overactive bladder on female sexual function. She does not have industry financial support from any particular treatment and all treatments for OAB were discussed equally in the article.