Bladder Control Problems/Overactive Bladder

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Questions to Ask Your Doctor about Overactive Bladder (OAB)
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Overactive Bladder Treatment

Treatment may include one or more of the following:

• Bladder retraining
• Medication (e.g., oral medicines, transdermal medicines)
• 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®) 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®).

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.

Side effects, including dry mouth, constipation, headache, blurred vision, dry eyes, hypertension, drowsiness, and urinary retention occur in approximately 20% 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.

In October 2008, the U.S. Food and Drug Administration (FDA) approved fesoterodine fumarate (Toviaz™) to treat overactive bladder in adults. This prescription medication is administered once daily and is available in extended-release tablets. Toviaz reduces OAB symptoms by relaxing smooth muscle of the bladder.

Side effects of Toviaz include constipation, dry mouth and/or eyes, and difficulty urinating. The usual dosage of the drug is 4 mg, which can be increased to 8 mg if necessary. Toviaz should not be used in patients with uncontrolled narrow-angle glaucoma, urinary or gastric retention, or severe liver disease. It should be used with caution in patients with severe constipation and dosages above 4 mg should not be prescribed for patients who have reduced kidney function.

In January 2009, oxybutynin chloride gel (Gelnique™) received FDA approval to treat overactive bladder. This gel is applied once daily to the skin of the thigh, abdomen, or shoulder and delivers a consistent dose of oxybutynin through the skin for 24 hours.

Side effects of Gelnique include adverse skin reactions, dry mouth, and urinary tract infection (UTI). This medication should not be used in patients who have uncontrolled narrow-angle glaucoma or urinary or gastric retention. It should be used with caution in patients with liver or kidney disease, urinary tract obstruction, myasthenia gravis (MG), and gastrointestinal obstructive disorders, such as ulcerative colitis, esophagitis, and GERD (gastroesophageal reflux disease).

Sacral Nerve Stimulation (also called sacral nerve neuromodulation [SNM])
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 (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.

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