Trust your body.

 Discover the many ways to improve OAB.

cultures

OVERACTIVE BLADDER (OAB)

Patients with OAB feel a sudden urge to urinate, which can be followed by leaking. Some people leak on the way to the bathroom or while they are trying to pull their underwear down. Sometimes the entire bladder empties causing an embarrassing accident and expensive pads are often worn to prevent wet clothing.  Many of those suffering from OAB will feel the urge to go even though their bladder is not full.

 

The bladder holds urine and expands to hold fluid like a water balloon. The muscles around the  urethra tighten to hold in urine while the bladder muscle relaxes. When you urinate, the brain signals the urethra and pelvic floor muscles to relax. The bladder muscle squeezes which pushes urine out of the body. Normal frequency of urination is under 8 voids per day and 1 per night. In people with OAB, the bladder muscle is overactive and squeezes too often. These bladder spasms cause urgency, frequency and uncontrolled leakage even when the bladder is not full. 

It can feel embarrassing to have uncontrollable bladder leakage but OAB effects 40% of adults.  You are not alone. It is important to find an OAB provider who can guide you to improvement.  During your first visit a thorough voiding history will be obtained. A pelvic exam will often be performed to help identify other conditions that influence the bladder, such as prolapse or leakage with straining.

 

Additional tests might include:

    • Urinalysis to check for a urinary tract infection and blood in your urine.
    • Ultrasound or placement of a small catheter to assess how much urine remains in your bladder.
    • Urodynamics are sometimes performed to obtain objective data to help decide treatment options.

Treatments range from behavioral changes and physical therapy to procedural and surgical options:

 

Lifestyle Changes

  • Mange medical issues such as diabetes, hypertension, poor mobility and obesity
  • Reduce fluid intake (i.e. consume under 64 ounces)
  • Avoid bladder irritants (i.e. citrus, artificial sweeteners, carbonation, alcohol, caffeine and spicy foods)
  • Perform timed voiding and urinate prior to activities where bathroom access will be limited (i.e. shopping, meetings, driving and flying)
 

Pelvic Floor Physical Therapy

  • Working with a specialized therapist will maximize this option.
  • We have our own physical therapist at Sansum Clinic who is specifically trained in Pelvic Floor Dysfunction ( Taisa Skovorodko, DPT).
  • This option might help improve OAB symptoms and has no side effects.
 
 Medications
  • Anti-cholinergics (Vesicare, Detrol, Ditropan, Toviaz, Enablex& Sanctura)
  • Beta Agonists (Myrbetriq& Gemtesa)
 

Neuromodulation Therapy 

  • Percutaneous Tibial Nerve Stimulation
  • Botox Bladder Injections
  • Sacral Neuromodulation Implants

Typically, medications regardless of class are not a successful long term management strategy for OAB due to to poor compliance, side effects, high cost and/or ineffectiveness (refer to lists below). Medication samples are great to try when available to see if OAB symptoms improve while using the drug.  In some patients medications might be a reasonable option if tolerated, affordable and efficacious. Most patients will be candidates for OAB therapies beyond medications.

 

 

Anti-cholinergic Drawbacks:

  • 80% quit by year 1
  • Commonly cause dry mouth, dry eyes, constipation & effect the central nervous system (i.e. linked to dementia)
  • Still the predominant class of OAB medication prescribed due to lower price 
 

Beta Agonist Drawbacks:

  • 60% quit by 1 year
  • Mybetriq sometimes cause headaches and hypertension
  • Usually costly and often require prior authorizations
  • Only two non-generic options approved: Myrbetriq& Gemtesa
  • Neuromodulation is a therapy in which the nerves of the bladder and pelvic floor are targeted in order to improve symptoms.
  • There are several types of neuromodulation that have been shown to be safe and effective in treating OAB:

The electroceutical coin (eCoin) is being studied for urge urinary incontinence. The eCoin OAB device is a nickel-sized, pacemaker-like device implanted into the lower leg to stimulate the tibial nerve.

 

  • Peripheral Tibial Nerve Stimulation or PTNS (also called Urgent PC) is an FDA approved form of neuromodulation for patients with urinary urgency, frequency, and urgency incontinence in which the posterior tibial nerve near the inside of your ankle is stimulated once a week for 12 weeks in the office and monthly thereafter.
  • A thin acupuncture needle is placed near the nerves and the electrical stimulation is applied for 30 minutes in the office.
  • The stimulation of the posterior tibial nerve travels up the leg and connects with the nerves of the bladder to provide the therapy.
  • In clinical trials, 55% of patients had improvement in symptoms.
  • It often takes 6 weeks for an effect to be noticeable. After the 12 week treatment, maintenance therapy is needed monthly to maintain the effect.
  • Patients must have the ability to make frequent office visits because treatment effects decline once treatment stops.

  • Botox is the trade name for onabotulinum toxin A, which is injected into the wall of the bladder to treat patients with overactive bladder symptoms (urinary urgency, frequency, urgency incontinence and bladder pain) .
  • This procedure is performed using cystoscopy and is done in the clinic usually.
  • 5 to 10 injections are delivered after the bladder has been flushed with lidocaine to reduce discomfort.
  • Blood thinners do not need to be held prior to the procedure. 
  • The effects of Botox are not permanent and generally last between 6 and 11 months depending on the dose and the patient. Repeat injections are needed to maintain the symptom improvement.
  • In clinical trials, approximately 80% of patients had at least a 50% improvement in their symptoms and about 20% were dry.
  • Risks include, but are not limited to bleeding, infection, urinary retention requiring catheterization (<5% of patients), and lack of efficacy. Generally, symptoms are transient.
  • Patients considering Botox treatment should be willing to accept the possibility of performing self-catheterization or needing a bladder catheter for 40 days on average if retention were to occur (<5%).

  • Sacral neuromodulation (Axonics or lnterstim Implants) is a therapy for patients who have urinary urgency, frequency, urgency incontinence, urinary retention, fecal incontinence, fecal urgency or bladder pain.
  • The therapy is initially delivered with a testing procedure or initial outpatient surgery. Subsequent outpatient surgery follows to place the final implant.
  • In order to determine whether this therapy works for your symptoms, the process to a full implant occurs in phases. The first phase is a trial to see if your symptoms improve.
  • This can be done with a testing procedure with wires or a surgery to implant the tined lead for therapy (PNE test procedure versus stage 1 tined lead outpatient surgery).
  • In the first stage option, we insert a thin electrode wire with fixation features (also called a tined lead) near the nerves of the bladder and connect it to a pacemaker outside your body which stimulates the nerves to function better. If you have a greater than 50% improvement in your symptoms during the test period (usually 2 weeks), then we proceed to stage 2 battery placement (or we remove the lead if not enough improvement).
  • We offer both Axonics and Medtronic PNE testing based on implant preference. This test procedure may be ideal for some patients prior to a surgery. 
  • During the trial period, we test to see if the stimulation works in controlling your symptoms. The signals may have to be adjusted during this testing period. If it works in improving your symptoms, then we proceed to the next phase of surgical implant.
  • If you are a therapy responder, subsequent surgery is performed under your skin. If a PNE test was performed a tined lead is placed with the battery. If a prior tined lead was surgically placed the battery is connected to provide the therapy. There is a remote control (also called the patient programmer) so you can adjust the stimulation so it is comfortable.
  • Please see the OAB care pathway for the details on the differences between the Axonics and Medtronic SNM devices. I offer both brands. After placement, the device adjusted over time to maintain efficacy.  The Medtronic recharge-free battery generally lasts 4 to 7 years while the Axonics battery lasts 15 years by using a rechargeable battery. Batteries are surgically replaced when needed.
  • This procedure has been approved by the FDA since 1997.  Approximately 88% of patients have over a 50% improvement in their symptoms at 24 months (Axonics Pivotal Trial Data).
  • All offered devices allow for an MRI of the entire body, but the Axonics device provides less limitations when perfoming MRI scans (See Comparison in tab below).  Other imaging tests such as CT scans and X-rays can be performed.  
  • Risks include infection of the device requiring removal, pain at the lead site, pain at the stimulator site, lead migration, electric shock, need for surgical revision, and lack of efficacy. If this occurs, the device can be turned off, surgery can be performed to correct the problem or the device can be removed.