If you are a coffee drinker and you suffer from symptoms of overactive bladder (OAB) such as frequent urination or urgent urination, it is a very safe bet that someone (very often your health care provider) has told you to cut out the caffeine. Caffeine can serve as both a stimulant, an irritant, and a diuretic so it should follow that it must lead to overactive bladder, right? That has been the conventional wisdom for years, though we should always be careful to check that our wisdom is really based on facts.
A recent review article by Palma and Staak provides an overview of the most recent studies about the effects of caffeine on the bladder. When taken together, these studies demonstrate that drinking more than 2 cups of coffee per day (>200mg caffeine) is associated with worsening symptoms of overactive bladder. The effect does depend on the dose and more than 4 cups of coffee per day may result in developing symptoms of OAB even in patients with no symptoms before.
One bit of good news is that the small amount of caffeine found in decaffeinated coffee does not appear to have a negative effect on OAB symptoms.
In this case, the conventional wisdom, dispensed for years by friends, family and even your health care provider appears to be spot on. You may want to skip that extra cup of coffee tomorrow if you have a long meeting in the morning.
Colin M. Goudelocke, M.D.
In a digital world that provides endless distraction, we tend to focus on those things that directly affect us or those we care about. We are drawn to the local news, the posts of our friends, or just tomorrow’s weather forecast. Judged by this standard, for most of us, Overactive Bladder (OAB) doesn’t always seem to have that personal impact. But whether we realize it or not, almost all of us know someone well who suffers with OAB (or we suffer ourselves). And the impact of these symptoms – financial, social, personal – is immense.
A recent review article by Reynolds et al. is an eye-opening reminder not only of how prevalent OAB is but also what an out-sized impact it has on the lives of those who live with it. The authors note that the development of a precise and easily-used definition of OAB based on patient symptoms rather than invasive testing has allowed a better sample of how common OAB really is in the United States. Though there is some variation among the larger studies looking at the prevalence of OAB, it seems likely that around 30% of women and 16% of men report symptoms of urinary frequency or urgency at least some of the time. Up to 11% of women report urinary incontinence associated with OAB. This means that about 37 million women in the United States have overactive bladder with 14 million of them experiencing urinary leakage. To put this in perspective, more people have OAB than diabetes, asthma, or arthritis.
The individual impact of OAB on daily life can be enormous. Much of this effect can be attributed to the embarrassment and distress that urinary leakage can cause. OAB isolates, forcing people to avoid friends, family and many of the activities that they may enjoy. For someone who has to rush to the bathroom every 30 minutes, worshiping at church, seeing a movie with friends, or going to a basketball game is virtually impossible. The authors in this review note studies finding that over 1/3 of people with OAB report their daily activities curtailed by OAB symptoms and 12% even report staying at home because of their OAB. It is not surprising that many people with OAB gain weight when they are not able to exercise regularly due to their symptoms.
Even if you don’t personally have overactive bladder or know someone who does (though you almost certainly do), as a society we pay a heavy price for OAB. Overactive bladder costs each of us the equivalent of $426 per year in lost productivity and more than three times that in pads, medications and other treatments. The review by Dr. Reynolds and collegues cites a study estimating that by 2020 OAB may cost us over $82 billion. That is more then the US government spends on education each year.
For those who personally experience OAB, there is little question of its enormous impact on everyday life. But for the rest of us, there is no denying that overactive bladder should demand our attention.
Colin M. Goudelocke, M.D.
The diagnosis of overactive bladder (OAB) depends on identifying urinary symptoms of frequency, urgency or urgency incontinence. Diagnosing OAB is not like checking for high blood pressure or diabetes. The symptoms that identify OAB are typically reported by patients rather than being directly observed by the health provider. It seems natural to question what would be the best way to identify and measure these symptoms.
Short questionnaires of a dozen or so questions about urinary symptoms are often used to classify bladder symptoms as well as to measure their severity. These are attractive because they can be completed quickly and easily and do a very good job of characterizing OAB.
The bladder diary is a written log that may include information about how frequently urination happens, how much urine is produced with each void, how much liquid is consumed, whether any urine leakage occurs, and what was happening when leakage occurred. A recent review article by Dixon and Nakib expertly summarizes the important studies that show the usefulness of voiding diaries in bladder care.
The authors begin by pointing to several studies that demonstrate that voiding diaries are completed by the vast majority of patients asked to do so. Furthermore, most patients find these diaries easy to complete and they report that completing a diary was helpful to them. We often find that patients gain significant insight about how frequently they void and the relationship of their symptoms to behaviors such as how much they may be drinking. It is not unusual to see improvement from the first to the last day of a diary as the patient begins to modify her behavior in response what she sees in the diary.
Voiding diaries can be very useful for identifying specific problems. Patients who consume too much fluid will quickly be identified and can be given very specific recommendations as to how much to reduce intake. A voiding diary showing an excess of urine produced at night can give a clue to medical problems including sleep apnea or congestive heart failure. Finally, a voiding diary can be a very useful way to distinguish between stress incontinence and urgency incontinence.
In modern medicine, we frequently focus on complex, sophisticated and often expensive tests that often do provide useful information. But, when evaluating OAB, we would do well to remember a very simple study that costs just pennies in copy costs but can provide a wealth of information.
Colin M. Goudelocke, M.D.
Urinary tract infections (UTI) affect up to 60% of women over the course of their lifetime. These infections result in bothersome symptoms including frequent, painful urination, they lead millions of people to seek medical care and they cost billions of healthcare dollars each year. Is it any wonder then that we would hope to find some way to prevent recurrence of these infections? For many, that hope has been placed in the tart little berry that makes its appearance each Thanksgiving. But how effective are cranberries at preventing infection? What about all of the cranberry extracts that we see? As with so many aspects of medicine, the answers may not always be as simple as we would like.
First, let’s talk about cranberry juice. Early on, several studies indicated that cranberry juice was effective in preventing recurrence of urinary tract infections. A class of chemicals called proanthocyanidins (PAC) found in cranberries are thought to keep E. coli (the most common cause of urinary tract infections) from binding to bladder cells. It seemed to make sense that drinking cranberry juice would prevent infections from recurring. However, PAC breaks down after 10-12 hours meaning people would need to drink cranberry juice twice daily to maximize the benefit. Furthermore, many studies show a lot of people just don’t like the tart taste of cranberry juice and stop drinking it (sorry, the sugar-sweetened 10% juice cocktail won’t cut it here). Finally, as more and more studies have been done, fewer of them have shown a benefit and, overall, the evidence for cranberry juice has been questioned. When taken as a whole, it seems more likely that cranberry juice doesn’t make much of a difference in preventing infections.
What about cranberry extracts? There are studies that show benefits from capsules containing extracted PAC, especially in certain populations that are at high risk of getting new infections. Unfortunately, these extracts suffer from a lack of standard make-up. By that, I mean that the amount of PAC from one supplement to another varies greatly. For example, one study found that the amount of PAC across 7 different cranberry extracts varied by 30 times. So, one brand of extract contained 30 times the amount of PAC compared with another. With so much variability, it is very difficult to know whether these capsules can prevent infections. So, again, when we look at all of the studies together, it seems less likely that there is much of an effect.
What to do? Well, there are studies ongoing for both cranberry juice and cranberry extract supplements that may find particular doses are effective or that certain types of people may benefit, so stay tuned. There are other compounds such as d-mannose sugar that may prove to be useful as well. Women with recurrent urinary tract infections may benefit from a medical evaluation to see if there is an underlying urologic problem that may be causing recurrent infections. I often find in my practice issues such as complications from previous surgeries that can explain recurrent infections. It may even be that our over-use of antibiotics may precipitate infections by killing of normal, beneficial vaginal bacteria. There is at least some evidence that probiotics (essential doses of healthy bacteria) may provide benefit, though these studies are ongoing.
Colin M. Goudelocke, M.D.