What is overactive bladder?
Overactive bladder is a compilation of symptoms, mainly urgency and frequency of urination. Meaning you go to the bathroom very frequently, and you can have urgent urination. You can even have leakage and need to wear a pad, and that can happen both day and night.
What causes it?
It's primarily a disease of aging. About 40% of women, as they age, can have signs and symptoms of OAB.
Overactive bladder is a multifactorial condition that can be caused by neurological disorders such as stroke and diabetes. It also increases in prevalence with the hormonal changes of menopause.
About 30% of men can have OAB as well. The biggest thing I see that causes OAB in men is prostate disease.
What are the most common treatments for OAB?
We usually start with behavioral modification — decreasing the amount of bladder irritants, such as caffeine and alcohol, stop drinking liquids a couple of hours before you go to bed, and pelvic floor physical therapy.
There are also two classes of medications for treating OAB. The first one, called anticholinergics, hit a receptor on the bladder to antagonize the release or the action of acetylcholine, which is a neurotransmitter that causes the muscles to squeeze. Those drugs, unfortunately, have a lot of side effects, including dry mouth and constipation.
The other class of medications, beta-3 agonists, relax the bladder by hitting a beta-3 receptor on the bladder. Those drugs are much better tolerated and have very few side effects. About 1% of patients can experience a rise in blood pressure. The problem with those drugs is they're expensive, and many times you have to fail a drug in the other class first. This can be a very frustrating process for patients.
What other treatments are there besides medication?
There are three procedural treatments we can do for OAB. One of them is called posterior tibial nerve stimulation, or PTNS. PTNS is a procedure we do in the office where we take an acupuncture needle, put it into the inner ankle, and electronically stimulate the tibial nerve for about 30 minutes. The tibial nerve has a downstream effect on the bladder. That procedure is once a week for 12 weeks. If you have a positive change in your symptoms, we then want you to do it once a month for a year or two to maintain the effects.
There’s a related device called an eCoin, which is implanted into the inner ankle and provides constant stimulation of that nerve so you don't have to keep coming into the office.
There's also Botox, which is an injection into the bladder wall, and we do that in the office as well. We take a small camera through the urethra, look in the bladder, and then use a needle to do 10 to 20 injections into the back wall of the bladder. That paralyzes the bladder muscle so it's not twitching all the time, making you feel like you need to go to the bathroom. Botox is highly successful in certain people, but it wears off over time, so we have to keep bringing you back.
Finally, there's something called sacral neuromodulation, which is like a pacemaker for the bladder. This is an implant that we put into the pelvis to stimulate a sacral nerve that affects the bladder. I use an X-ray machine to place a flexible metal lead, then we put a battery about the size of a USB port in the fat pad of your bottom. So you have constant stimulation of that nerve. It's a long-term solution, and the batteries last anywhere between 10 and 20 years. The newest version of the technology is also MRI-compatible, which is great, because many patients that need MRIs all the time also have overactive bladder. That was a big problem with the previous version of this implant.
How involved is the procedure to implant the sacral neuromodulation device?
It's really easy. We do a testing phase where we implant two temporary leads onto each side of the pelvis. We do that through a little pin-poke incision, and that stays in for a week. We're looking for at least a 50% improvement in your symptoms, and most people have that. Then we put in the full implant, and we do that in an operating room with twilight anesthesia, just like you have for a colonoscopy. It's all tunneled under the skin, so no one even knows you have it, and people go home the same day.
Are there any other effective treatments for OAB?
I'm a big proponent of hormone therapy. There are a lot of estrogen receptors around the urethra and bladder, so replacing estrogen, either through vaginal estrogen cream or hormone therapy with a patch, pill, or injection can really help. When women become perimenopausal or menopausal, the estrogen levels drop in the body, and those tissues in the pelvis, urethra, bladder, and pelvic muscles really suffer.
When you successfully treat OAB, what sort of difference do see you that make for patients in their quality of life?
It's huge. Patients can go to a movie; they can get out of their home. They don't have to know where a bathroom is every time they go someplace. I have known women who spent all of their Social Security money each month on pads. We give them their life back. They're not embarrassed anymore.
