When we think about overactive bladder (OAB) treatments, many of us inevitably focus on the many medications that we can use to treat the symptoms of urinary urgency, frequency or urgency incontinence. Or perhaps we might even think of more advanced therapies such as botulinum toxin, sacral neuromodulation or percutaneous tibial neuromodulation. However, patients and health providers should be careful not to dismiss everyday changes that can be made without ever going to the pharmacy or visiting the doctor’s office. In fact, because behavioral changes can be so important, the current American Urological Association guidelines on OAB urge providers to offer these as first-line therapies. Even better, behavioral treatments are as effective as medications with few if any side effects. For those people who may eventually require medications or more advanced therapy, multiple studies confirm that these treatments are made more effective if combined with behavioral treatments.
Behavioral treatments for OAB include fluid reduction, diet changes, weight loss, and pelvic floor exercises. Bladder training (BT) is another means of behavior therapy for OAB that can be effective in a properly motivated or dedicated person. BT begins with education about overactive bladder often accomplished with brochures, websites or videos. Completing a record for several days of how often one voids (and whether there is an urgency to void) helps to identify a time interval of typical urination. The goal becomes to gradually increase that interval, usually by 30 minutes every 1-2 weeks. There are numerous distraction techniques (pelvic contractions, relaxation techniques) that can be used to ignore any urinary urgency that comes in between the interval.
How effective is bladder training? Trials comparing BT to the most common medications used to treat OAB show that it is as effective as medications with fewer side effects. Perhaps more encouraging, other therapies including medications, are more effective if you add bladder training. So, not only can behavioral therapies be used to treat OAB on their own, but they should be continued even if you move on to other therapies.
It should be remembered that bladder training can be difficult. It requires time and attention that some people are not able to devote. The number of patients remaining adherent to bladder training tends to be low in many of these studies. We certainly could use better tools to make this therapy more successful. Yet, for the determined patient who wants a successful therapy without the cost or side effects of medication, BT can be a wonderful therapy.
Colin M. Goudelocke, M.D.
I suspect that if you ask most people (including most health providers) whether it is normal to have bacteria in the bladder, you would hear an emphatic “NO!”. The conventional wisdom has long been that the bladder is a sterile environment. But for many years there has been mounting evidence that this simply is not true. A recent review article written by Thomas-White et al provides an excellent history and summary of our developing understanding of normal and beneficial bacteria found in the bladder. These authors also detail their own research which is helping to lead to a radical new understanding of what constitutes a healthy bladder.
This enlightening paper begins by pointing out that our misunderstanding of urine as sterile dates back to the 19th century when we were just beginning to grasp the nature of bacteria. This idea of a sterile bladder delayed one of the most important advancements in our treatment of patients with neurologic injuries of the bladder: self-catheterization. Prior to the 1960’s, patients with urinary retention were not told to self-catheterize out of fear that it would lead to infections. Unfortunately, the opposite is true and infections are actually prevented by catheterization in these patients.
Most importantly, the authors detail their ground-breaking new work that is advancing our understanding that not only are healthy bladders full of bacteria but that some of these bacteria may be very beneficial for bladder health. Their research identifying bacteria that are clearly alive and present in the bladder suggests that patients with overactive bladder (OAB) may lack an abundance of certain Lactobacillus species. These are the same types of bacteria thought to be protective of infection in the intestine and vagina. It may be that these types of bacteria are also protective against developing urinary tract infections.
For decades we have been guided by an overly simple understanding of the bladder and urine that today seems just plain wrong. This may even influence our current over-use of antibiotics, particularly as it relates to bladder bacteria. Perhaps our abundant use of antibiotics may predispose some patients to recurrent urinary tract infections by killing beneficial and protective bacteria in the vagina and bladder. It is wonderful to see such cutting-edge scientific study that may one day revolutionize the way we approach our bladder health.
Colin M. Goudelocke, M.D.
Many people blame their frequent visits to the bathroom every night on an overactive bladder (OAB) or, for men, an enlarged prostate. While these may be frequent causes of nocturia (waking up to urinate more than one time per night), an often overlooked cause is obstructive sleep apnea. If you wonder how sleep apnea could cause you get up multiple times at night to urinate, a recent study by Miyauchi et al confirms both the relationship between nocturia and sleep apnea as well as the improvement seen with treatment.
We begin by noting that many patients who get up frequently at night do so because they make too much urine at night. The bladder is simply filling up more quickly than it should. Normally for young people, no more than 20% of your daily urine production should come while you are asleep. In older patients, less than 33% is more normal. Patients who exceed this are said to have nocturnal polyuria, meaning they make too much urine at night. This is easily diagnosed by having patients keep a diary for several nights to measure how much urine they make during the night compared to the day.
While there are several causes of nocturnal polyuria, an often overlooked one is obstructive sleep apnea. Blockage of your airway in sleep apnea results in a lot of negative pressure in the chest as you try to breathe (try closing your throat and taking a breath). This causes more blood to return to the heart. When this part of the heart expands from the extra blood, it releases a hormone (atrial natriuretic peptide) that makes you make more urine. It’s as if the body thinks there is too much blood volume (maybe you drank a lot of fluid) and tries to get rid of the excess fluid. So, patients with obstructive sleep apnea make too much urine at night.
The encouraging news is that treatment of the sleep apnea such as with a mask providing continuous airway pressure (CPAP) not only treats the sleep apnea but also will reduce the urine production and the nocturia. So next time you find yourself getting up that 3rd or 4th time at night, consider having an evaluation of whether you are making too much urine at night. If so, a test for sleep apnea may be in order.
Colin M. Goudelocke, M.D.
Voiding difficulty in women may include difficulty starting or maintaining the urine stream or the need to push or strain to empty the bladder. Often this voiding dysfunction results in incomplete emptying of the bladder. While it can result from more easily identified causes such as a previous incontinence surgery or advanced bladder prolapse, quite often the reason for the voiding dysfunction is not clearly known. Often, patients are treated for this voiding difficulty by undergoing a procedure to stretch the urethra (the urine tube that exits the bladder). This is called urethral dilation. And though this may be a commonly performed therapy, this review by Basu and Ducket accurately points out that there is little evidence to support the continued use of routine urethral dilation in the treatment of voiding dysfunction.
The authors detail the history of urethral dilation beginning in a time when very little was known about normal voiding. Dilation of the urethra emerged as a treatment for numerous problems including urinary tract infections and bladder pain. The assumption was that these issues resulted from a urine tube that was too narrow to permit proper emptying of the bladder. However, it is now known that spontaneous narrowing of the urethra (urethral stenosis) is uncommon and probably represents only 1-2% of patients with voiding dysfunction. This is much less common than the frequency of urethral dilation would suggest. One concern is that repeated urethral dilation can even be the cause of narrowing of the urethra due to fibrotic healing.
Perhaps the popularity of urethral dilation is because it can produce a short-term effect, making voiding easier and relieving some symptoms such as incomplete bladder emptying. This is likely due to the temporary malfunction of the urethra and surrounding muscles caused by the stretching. This temporary benefit disappears in over 80% of patients by 6 months. And this may cause new urine leakage in nearly 20% of patients. Even patients with improvement are likely to be subjected to repeated urethral dilation to maintain this temporary effect.
There are treatments for voiding dysfunction that is either more effective or at least do not carry the risk of new urinary incontinence or development of urethral stricture. Patients may benefit from pelvic floor physical therapy using biofeedback, which may help to train patients to relax the muscles that constrict the urethra when voiding. Medications may help to relax these muscles as well. Finally, in patients who do not improve with biofeedback or medications, neuromodulation or botulinum toxin may be useful. These treatments rely on a better understanding of the complex interaction between the bladder and urethra that produces normal urination.
Outside of a small percentage of patients with urethral stricture (who often need a more extensive surgery rather than urethral dilation), urethral dilation provides, at best, a short-term fix that may carry significant risks. With little evidence to support its use, urethral dilation should become a rare treatment, not a common one.
Colin M. Goudelocke, M.D.
Thanks in no small part to the marketing efforts of companies that produce treatments for overactive bladder (OAB), the term “OAB” has become relatively well known among health providers and the general public alike. The fact that the term has become so common and well accepted has been a source of criticism by some who feel that it doesn’t adequately describe the symptom complex it is associated with it.
But where does the term even come from? A review of the history of the term “Overactive Bladder” by Cardona-Grau and Spettel is a fascinating exploration of how this term came to be commonly used. They point out the very interesting way in which the name OAB has been influenced by the syndrome it describes, but also how thinking about these symptoms as “overactive bladder” has influenced the way we approach and treat it.
The authors of this review note that the origin of the name overactive bladder is credited to Drs. Wein and Abrams, two giants in the field of urology, particularly bladder health. It reflects their understanding of how the symptoms of urinary urgency, frequency and sometimes incontinence are perceived by patients. It also was a term they were already using with their patients to make their condition more understandable. It took away the stigma that was attached to previous terms such as “unstable bladder” that may have made patients feel that their mental stability was being questioned.
But the term also has had an influence on the way we think about and study OAB. Prior to the introduction and later acceptance of a standard definition for OAB that is based on symptoms reported by a patient, previous definitions relied on the findings of an invasive test called urodynamics. In contrast, the definition of OAB can be applied without the need for expensive and invasive testing. It can be used by specialists and general practioners alike. I like to point out that patients are generally able to self-identify all of the symptoms we associate with OAB (even if they can’t always rule out other causes of those symptoms). The change to using the term overactive bladder largely coincided with the development of recommendations that the initial evaluation of OAB should not involve advanced testing, with a history and physical exam largely sufficing.
And while it is often noted by critics that the term OAB has been used effectively for marketing purposes by the pharmaceutical industry, the term was not invented by marketers or for marketing. Rather, it has served as a useful starting point for an understanding, by both patients and physicians, that can lead to a better and more thorough understanding of just what is this thing we call “OAB”.
Colin M. Goudelocke, M.D.