Urinary incontinence affects millions of men and women. Unfortunately, this is not often openly discussed, leading to common misconceptions that stand in the way of people seeking and receiving treatment. We explore and hopefully dispel some of these common incontinence myths.

1. Urinary Incontinence only happens to older women.

Urinary incontinence certainly becomes more common in older populations, with over one-half of women aged over 65 reporting at least one episode of incontinence. But even younger women still experience urinary leakage at fairly significant rates. Nearly 1 in 5 women aged 20-25 also report urinary incontinence, proving this is not simply a disease of older women. In addition, younger women seek treatment for urine leakage at much lower rates than they report symptoms, suggesting that this myth may be creating barriers to younger women asking for help for their incontinence.

2. Urinary Incontinence is a normal part of getting older.

While incontinence is more likely to occur as men and women age, that does not make it a “normal” part of aging. We see many diseases (heart disease, diabetes, high blood pressure) that are more common as we get older but do not then conclude that it is something to just be accepted and accommodated. Not only does urine leakage have immense impact on the lives of men and women but there are so many treatments that can provide real benefits. This myth, unfortunately, seems to keep many people from talking to their health care provider about diagnosis and treatment of their urine leakage.

3. Men never experience Urinary Incontinence.

While men certainly experience incontinence less often than women, it is still fairly common in men. As many as 11% of men overall report incontinence, with much higher rates than this in older men. Men with urinary incontinence most often report urgency incontinence. Unlike women, men report stress incontinence much less frequently and this is often related to prior surgeries or treatments for the prostate (such as for prostate cancer).

4. Surgery is the only treatment for Urinary Incontinence.

Not only is surgery not the only treatment for urinary incontinence, it is not even the most common treatment for incontinence. Stress incontinence may be treated with surgery (such as a mid-urethral sling) in men and women who have failed to see improvement with more conservative therapy such as pelvic floor exercises (Kegel exercises). However, urgency incontinence, is treated first with behavioral changes (such as dietary modification and bladder training) and medications (such as oxybutynin, VESIcare or Toviaz). Only patients with moderate to severe symptoms of urgency who cannot take or do not see improvement with earlier treatments consider more invasive therapies (Interstim, Urgent PC or Botox).

5. Diagnosis of Urinary Incontinence requires expensive and invasive testing.

The vast majority of patients with overactive bladder (OAB) are evaluated very simply in the office with a thorough history and physical exam. At The OAB Clinic, we do find that questionnaires and a voiding diary help us in our evaluation, but even these are not necessarily required. More expensive or invasive tests are reserved for the few patients with difficulty such as failure to improve with prior therapy or complications such previous pelvic surgeries or blood in their urine. Similarly, most patients with stress incontinence are diagnosed with a history and physical exam and often a questionnaire and voiding diary.

Conclusion

By some estimates, only 1/3 of patients reporting symptoms of urinary incontinence may seek treatment. This may be due to relatively mild symptoms, but is likely also influenced by many of the myths that surround the evaluation and treatment of incontinence. By dispelling these myths, we hope to remove barriers to patients who desire treatment for bothersome incontinence.

-Colin M. Goudelocke, MD, FPMRS

Overactive Bladder (OAB) is a syndrome that is characterized by sudden urges to urinate that are difficult to postpone. This commonly also results in frequent trips to the bathroom (both day and night) and may even cause some patients to leak urine.

Overactive Bladder (OAB) affects millions of men and women of all ages. There is no “typical” person with OAB and so there is no one treatment for this syndrome that is right for all patients. Proper therapy for OAB means tailoring the treatment to the patient not the patient to the treatment.  Today, we discuss some of the various therapies that can be used to treat OAB.

Behavioral Modifications

These should be the first choice in treating overactive bladder and can be undertaken on your own, before you even see a provider. A bladder diary may help you see patterns that may explain your symptoms, such as drinking a lot of fluids at night. It may be helpful to identify and then reduce or eliminate foods or beverages that may be irritating to your bladder. Some of these possible irritants include caffeinated drinks, carbonated drinks, acidic foods (tomatoes, citrus fruits and juices), spicy foods, artificial sweeteners or dyes. Reducing the total fluid intake may improve symptoms for some people. This is best done after reviewing your bladder diary, because excessive fluid intake is not the cause of OAB symptoms for most people. Timed voiding involves urinating on a set schedule (for instance, every two hours) which can then be gradually increased to train the bladder. Finally, pelvic floor exercises can help to control urinary leakage associated with OAB.

Medications

Medications (such as VESIcare, Toviaz, Myrbetriq, etc) are often prescribed for patients who are not improved enough with behavioral changes, though it is not necessarily wrong to try both medications and behavioral changes as initial therapy. Medication therapy will be more effective if combined with behavioral changes as above. Medications can be very effective but may have side effects in some people. In addition, some people with certain diseases (such as glaucoma) or who are taking medications (such as potassium supplements) may have to be cautious with some OAB medications. This is why these should be used only after consulting a care provider familiar with treating OAB.

Percutaneous Tibial Nerve Stimulation (PTNS)

PTNS (Urgent PC) is a form of neuromodulation. In neuromodulation, we use tiny electrical signals to change the way the bladder sends signals to the brain that it is full and even how the brain responds to that message. In PTNS, that signal is sent via a very small needle placed under the skin near the ankle. There is a branch of the nerve to the bladder located there and stimulating this nerve can significantly improve the urinary frequency, urgency and urgency incontinence that occurs with OAB. There are few complications or risks, other than mild irritation at the site of needle placement, so this may be a good option for patients who are not able to undergo any type of surgical therapy for their OAB. The treatment takes place in the office and is usually administered once a week (it takes about 40 minutes) for 12 weeks and then about every 4 weeks thereafter (to maintain the effect).

Sacral Neuromodulation

Another type of neuromodulation stimulates the nerve to the bladder further up the nerve. Again, tiny electrical signals change the way that the bladder and brain communicate. However, in sacral neuromodulation, (Interstim) we are able to place a small wire beneath the skin just above the buttocks. Because the wire is underneath the skin, there is no need to come into the office for treatment. The wire is placed in the operating room under sedation (much like a pacemaker for the heart), so patients should be able to tolerate minor surgery. Also, this type of treatment is appropriate for those patients with moderate or severe symptoms who have not improved on multiple medications or are unable to take medications (because of side effects, for instance). This type of treatment should also be performed by specialists with knowledge and training in how to properly place the wire.

Botulinum Toxin

For some patients, it may be appropriate to use botulinum toxin (Botox) to help to treat OAB symptoms which do not respond to medications and behavioral changes. Small doses of botulinum toxin (Botox) are injected into the wall of the bladder through a small scope. This may be done in the office (though I find that most of my patients prefer this done in the operating room with some sedation). This will typically need to be repeated after 6-9 months to maintain its effectiveness. In some patients, botulinum toxin may make it difficult to empty the bladder completely, something that is very important to discuss before treatment.

Conclusion

Patients with OAB are very diverse often have different symptoms, lifestyles, or other medical problems. An ideal approach to OAB involves finding the best treatment (or even treatments) for that individual patient instead of treating all patients as if they were the same.

At The Overactive Bladder Clinic a part of UT Erlanger Urology in Chattanooga, Tennessee, we specialize in the evaluation and treatment of all forms of urinary incontinence. For more information, contact us at 423-778-4OAB (4622).

-Colin M. Goudelocke MD, FPMRS