Bladder Control Problems/ Overactive Bladder

Overview

In people with an overactive bladder (OAB), the layered, smooth muscle that surrounds the bladder (detrusor muscle) contracts spastically, sometimes without a known cause, which results in sustained, high bladder pressure and the urgent need to urinate (called urgency). Normally, the detrusor muscle contracts and relaxes in response to the volume of urine in the bladder and the initiation of urination.

People with OAB often experience urgency at inconvenient and unpredictable times and sometimes lose control before reaching a toilet. Thus, overactive bladder interferes with work, daily routine, intimacy and sexual function; causes embarrassment; and can diminish self-esteem and quality of life.

Urination 
Urination (micturition) involves processes within the urinary tract and the brain. The slight need to urinate is sensed when urine volume reaches about one-half of the bladder's capacity. The brain suppresses this need until a person initiates urination.

Once urination has been initiated, the nervous system signals the detrusor muscle to contract into a funnel shape and expel urine. Pressure in the bladder increases and the detrusor muscle remains contracted until the bladder empties. Once empty, pressure falls and the bladder relaxes and resumes its normal shape.

The Sudden Urge to Go: Is It Overactive Bladder?

Incidence and Prevalence 
Overactive bladder affects men and women equally. The U.S. Department of Health and Human Services has reported that approximately 13 million people in the United States suffer from OAB and other forms of incontinence.

Signs and Symptoms

Three symptoms are associated with an overactive bladder:

  • Frequency (frequent urination)
  • Urgency (urgent need to urinate)
  • Urge incontinence (strong need to urinate followed by leaking or involuntary and complete voiding)

Causes

A malfunctioning detrusor muscle causes overactive bladder. Identifiable underlying causes include the following:

  • Nerve damage caused by abdominal trauma, pelvic trauma, or surgery
  • Bladder stones
  • Drug side effects
  • Neurological disease (e.g., multiple sclerosis, Parkinson's disease, stroke, spinal cord lesions)

Other conditions can produce symptoms similar to overactive bladder, including urinary tract infection (UTI) and normal pressure hydrocephalus.

Diagnosis

The Sudden Urge to Go: Is It Overactive Bladder?

A complete medical history, including a voiding diary; a physical examination; and one or more diagnostic procedures help the physician determine an appropriate treatment plan for overactive bladder.

Medical history 
The medical history includes information about bowel habits, patterns of urination and leakage (when, how often, how severe), and whether there is pain, discomfort, or straining when voiding. The patient's history of illnesses, pelvic surgeries, pregnancies, and medications currently used also supply the physician with information relevant to making a diagnosis. In the elderly, a mental status evaluation and assessment of social and environmental factors may be performed.

Physical examination 
A physical examination includes a neurologic status evaluation and examination of the abdomen, rectum, genitals, and pelvis. The cough stress test, in which the patient coughs forcefully while the physician observes the urethra, allows observation of urine loss. Instantaneous leakage with coughing indicates a diagnosis of stress incontinence. Leakage that is delayed or persistent after the cough indicates urge incontinence.

The physical examination also helps the physician identify medical conditions that may be the cause of overactive bladder. For instance, poor reflexes or sensory responses may indicate a neurological disorder.

Urinalysis 
Examination of the urine may identify medical conditions associated with overactive bladder, such as the following:

  • Bacteriuria-presence of bacteria in urine; indicates infection
  • Glycosuria-excess glucose in urine; may indicate diabetes
  • Hematuria-blood in urine; may indicate kidney disease
  • Proteinuria-excess protein in urine; may indicate kidney disease, cardiac disease, blood disease
  • Pyuria-presence of pus in urine; indicates infection

Specialized Testing 
If overactive bladder persists after diagnosis and treatment, additional testing may be needed. Urologists perform urodynamic, endoscopic, and imaging tests to obtain a more extensive evaluation of the lower urinary tract to determine a new treatment plan.

Postvoid residual volume (PRV) 
This procedure requires catheterization or pelvic ultrasound. The patient voids just before the PRV is measured. This initial void should be observed for hesitancy, straining, or interrupted flow. A PRV less than 50 mL indicates adequate bladder emptying. Repeated measurements of 100 to 200 mL or higher represent inadequate bladder emptying. The clinical setting and the patient's readiness to void may affect the test result; therefore, repeated measurements may be necessary.

Urodynamic Testing 
Cystometry may be used to measure the anatomic and functional status of the bladder and urethra. The cystometer is an instrument that measures the pressure and capacity of the bladder; thus evaluating the function of the detrusor muscle. Simple cystometry detects abnormal detrusor compliance, but abdominal pressure is not included and the results must be evaluated with caution.

The multichannel, or subtracted, cystometrogram simultaneously measures intra-abdominal, total bladder, and true detrusor pressures. This allows involuntary detrusor contractions to be distinguished from increased intra-abdominal pressure. The voiding cystometrogram detects outlet obstruction in patients who are able to void.

Uroflowmetry identifies abnormal voiding patterns. Urethral pressure profilometry measures the resting and dynamic pressures in the urethra.

Endoscopic Tests 
Cystoscopy may be performed when urodynamic testing fails to duplicate symptoms, when the patient experiences new symptoms (e.g., cystitis, pain), or when urinalysis reveals a disease process (e.g., menaturia, pyuria). Cystoscopy identifies the presence of bladder lesions (e.g., cysts) and foreign bodies.

Imaging Tests 
X-rays and ultrasound may be used to evaluate anatomic conditions associated with overactive bladder. Imaging of the lower urinary tract before, during, and after voiding is helpful in examining the anatomy of the urinary bladder and urethra.

Treatment

Treatment may include one or more of the following:

  • Bladder retraining
  • Medication
  • Oxybutynin transdermal system
  • Sacral nerve stimulation
  • Surgery

Bladder Training with Timed Voiding 
This treatment is used for urge and overflow incontinence. The patient keeps a voiding diary of all episodes of urination and leaking, and the physician analyzes the chart and identifies the pattern of urination. The patient uses this timetable to plan when to empty the bladder to avoid accidental leakage. In bladder training, biofeedback and Kegel exercise help the patient resist the sensation of urgency, postpone urination, and urinate according to the timetable.

Medication 
Drugs such as oxybutynin chloride (Ditropan XL®) and tolterodine (Detrusitol®, Detrol LA®) are taken orally, once a day, for overactive bladder. These medications are antimuscarinics, which affect the central nervous system and muscarinic receptors in smooth muscle. They relax the smooth muscle of the bladder, reducing detrusor contraction and subsequent wetting accidents, usually within 2 weeks. Newer drugs indicated for OAB include trospium chloride (Sanctura®), derifenacin (Enablex®), and solifenacin (Vesicare®).

Side effects, including dry mouth, constipation, headache, blurred vision, dry eyes, hypertension, drowsiness, and urinary retention occur in approximately 50% of those who use these medications. They should be used with caution in patients with narrow-angle glaucoma or certain types of kidney, liver, stomach, and urinary problems. Women who are pregnant should not take these medications without consulting a physician.

Oxybutynin Transdermal System 
The oxybutynin transdermal system (Oxytrol®) is a thin, flexible, clear patch that is applied to the skin of the abdomen or hip, twice weekly, to treat overactive bladder. This treatment delivers oxybutynin continuously through the skin into the bloodstream and relieves symptoms for up to 4 days allowing twice a week dosing.

Patients who have urinary or gastric retention, uncontrolled narrow-angle glaucoma, and those with hypersensitivity to oxybutynin should not use the oxybutynin transdermal system.

Side effects are usually mild and include adverse reactions at the site of application, dry mouth, and constipation.

Sacral Nerve Stimulation 
InterStim® therapy is a reversible treatment for people with urge incontinence caused by overactive bladder who do not respond to behavioral treatments or medication. InterStim is an implanted neurostimulation system that sends mild electrical pulses to the sacral nerve, the nerve near the tailbone that influences bladder control muscles. Stimulation of this nerve may relieve the symptoms related to urge incontinence.

Prior to implantation, the effectiveness of the therapy is tested on an outpatient basis with an external InterStim device. For a period of 3 to 5 days, the patient records voiding patterns that occur with stimulation. The record is compared to recorded voiding patterns without stimulation. The comparison demonstrates whether the device effectively reduces symptoms. If the test is successful, the patient may choose to have the device implanted.

The procedure requires general anesthesia. A lead (a special wire with electrical contacts) is placed near the sacral nerve and is passed under the skin to a neurostimulator, which is about the size of a stopwatch. The neurostimulator is placed under the skin in the upper buttock.

Adjustments can be made at the doctor's office with a programming device that sends a radio signal through the skin to the neurostimulator. Another programming device is given to the patient to further adjust the level of stimulation, if necessary. The system can be turned off at any time.

Possible adverse effects include the following:

  • Change in bowel function
  • Infection
  • Lead movement
  • Pain at implant sites
  • Unpleasant stimulation or sensation

Surgery 
Surgical augmentation of the bladder is reserved for people who do not benefit from bladder retraining or medication.

Those who cannot take medication due to medical conditions or intolerance may find incontinence management devices helpful.

DEPEND® Adult Incontinence Products. Encouragement and information for people with incontinence, and those who care for them.

Elimination and Challenge Diet

Bladder control problems that are not the result of neurological damage, poor muscle tone, or hormone deficiencies may result from irritability within the bladder or urethral tissues caused by chronic inflammation and/or food sensitivities. An elimination and challenge diet can help determine a food sensitivity. Symptoms that can occur on a food challenge include the following:

  • Headache (may be brief or prolonged)
  • Nausea, stomachache, sharp abdominal pain
  • Sore throat, stuffy nose, runny nose, itchy nose or eyes
  • Skin rash or itching, facial flushing, red ears
  • Sleepiness, insomnia, fatigue, apathy
  • Irritability, depression, anxiety
  • Excitability (feeling hyper or "buzzed")
  • Aching or twitching muscles

Symptoms associated with food challenges may not be the same symptoms experienced before the elimination process. For example, before the elimination and challenge diet began, a patient's symptom was chronic sinus pain, but a stomachache occurred during the challenge. This does not mean that the food group being challenged was not causing the sinus pain. It is just that the body and immune system react differently when the offending agent is removed and then reintroduced.

Option 1 
For 2 to 6 weeks, eliminate all suspect foods and focus diet on fresh fruits, vegetables, potatoes, yams, animal protein (fish, poultry, lamb), and nonglutenous grains (rice, buckwheat). Eat organic foods whenever possible.

After 2 to 6 weeks of maintaining a strict elimination diet, there should be relief from symptoms. Weight may also be lost. Now begin the challenge. Start with the food group that is least problematic. Challenge a specific food group for one day only. Eat several servings of that food group throughout the day. Then do not eat that food again for at least 48 hours while continuing to eat only elimination diet foods. If symptoms do not return after 48 hours, go on to the next suspected food group. However, feel free to wait more than 48 hours. Waiting a week between food group challenges is optimal. This increases the accuracy of the diagnosis. Remember to challenge only one food group at a time.

Continue this process until the problematic food group is determined. In most cases, reactions occur within 48 hours. Rarely do symptoms appear several days or weeks later.

Option 2 
Maintain a regular diet and eliminate only the food group that is believed to be causing the symptoms. Eliminate all items in that food group for at least 1 month. If the symptoms disappear before the end of the month, continue to abstain from that food group for another week before starting the challenge.

To do the challenge, eat several servings of the suspect food group during a 24-hour period. Then return to the elimination diet and do not eat the suspect food group for at least 48 hours. More often than not, immediate reactions occur if there is a sensitivity.

  • Herbal Support
  • Anti-inflammatory Support
  • Homeopathic Support

Herbal Support 
Soothing urinary tract tonics may help heal the bladder and related nervous irritation. Also drink 2 - 3 quarts of water daily.

Herbs to use as tea:

  • Cleavers (Galium aparine) - traditional urinary tonic
  • Marshmallow root (Althea officinalis) - soothing demulcent properties, best in "cold infusion" (Soak herb in cold water several hours; strain and drink.)
  • Buchu - soothing diuretic and antiseptic for the urinary system
  • Corn silk (Zea mays) - soothing, diuretic
  • Horsetail (Equisetum arvense) - astringent, tissue-healing properties, mild diuretic
  • Usnea lichen - very soothing and antiseptic

Anti-inflammatory Support

  • Flax oil: 1 tablespoon daily
  • Vitamin C: 500 mg, 2 to 3 times daily with meals
  • Bromelain 400 mg or Wobenzyme 5 tablets: 3 times a day away from meals
  • Vitamin E: 400 IU daily

Homeopathic Support 
A trained homeopathic practitioner is needed to diagnose and prescribe a deep acting, constitutional remedy. For acute, symptomatic relief, the following remedies may relieve some of the symptoms associated with incontinence.

  • Causticum for stress incontinence associated with frequent urging and difficulty urinating.
  • Natrum muriaticum for stress incontinence associated with the menopausal symptoms of vaginal dryness, painful intercourse and a history of emotional grief.
  • Pareira for difficulty urinating due to prostate enlargement.
  • Sepia for stress incontinence with sudden urging, especially associated with vaginitis or prolapsed uterus.
  • Zincum for difficulty urinating while standing up (must sit to initiate flow), associated with prostate problems.

Standard dosage for acute symptom relief is 12c to 30c, 3 to 5 pellets taken 3 times a day until symptoms resolve. If you have chosen the right remedy, you should experience improvement shortly after the first or second dose.

Warning: Most homeopathic remedies are delivered in a small pellet form that has a lactose sugar base. If you are lactose intolerant, be advised that a homeopathic liquid may be a better choice.