Between 8 percent and 17 percent of American adults—up to 34 million people—suffer from symptoms of overactive bladder: frequent, sudden urges to urinate that disrupt work and sleep and are sometimes accompanied by involuntary urination. Men and women seem to be about equally affected, and the condition is estimated to cost the economy about $12 billion a year in lost productivity, money spent on protective products and treatment costs.
“It’s age-related and wickedly prevalent,” says Dr. Kevin McVary, professor of urology at the Feinberg School of Medicine at Northwestern University. Although men’s symptoms were formerly believed to occur primarily because of an enlarged prostate, researchers now believe that men, too, are affected by urgency and frequency that has little to do with that gland.
McVary and colleagues recently published a study finding that 76 percent of people over 45 diagnosed with the overactive bladder went untreated.
Affected people don’t seek help for many reasons. Some try medication and find it too expensive or the side effects too bothersome; others prefer to deal with it by modifying their lifestyles. “Those are all legitimate reasons,” McVary says. “What’s not OK is saying ‘Oh, I’m getting older and I have to accept wetting and urgency.’ Acceptance only [makes sense] if you know your options and have weighed them.”
Coping with overactive bladder
So how can you best deal with overactive bladder? Most people prefer to start with lifestyle changes. The simplest technique is drinking fewer liquids, particularly in the evening. Not drinking for two hours before bed can sometimes prevent sleep interruption. Caffeine can irritate the bladder for some; in these cases, reducing coffee and cola intake can help.
Exercising can also reduce sudden urges—and for people who are overweight, losing weight can have a big impact. “When they lose weight and keep it off, urination decreases,” McVary says. “And it’s not that fat is pushing down on bladder—it’s not clear why it changes.”
Bladder training
“Bladder retraining” is another technique, usually done with the guidance of a urologist and typically used to reduce episodes of involuntary urination accompanied by sudden urges or by coughing or sneezing. Kegel exercises—yes, those linked with more intense orgasms in women—are one part of the process.
But they aren’t just for women. Men can do Kegels, too. Practice by starting and stopping the flow of urine to locate the correct muscles; don’t use your abs. Then build up to increased time contracting the muscles and increased numbers of repetitions, just like with weight lifting. (No word on whether this improves male orgasm, but it can’t hurt.)
Another aspect of bladder retraining involves gradually learning to wait to urinate when feeling a sudden urge and incrementally increasing the time you can manage comfortably.
“If you start off by trying to hold it for two to three hours, that will be bothersome; it’s not going to work,” says Dr. Matthew Rutman, assistant professor of clinical urology at Columbia University Medical Center, “But if you do it in small increments—for an hour, then an hour and 15 minutes, then an hour and a half, it can help significantly.”
An alternative method puts urination on a schedule. You go at specific times whether you need to or not and gradually become conditioned to the schedule. These methods can take weeks to produce results, and it’s important to track episodes of incontinence and urges to see if they are starting to work.
“That’s a totally legitimate way to try to control it,” McVary says. “I like it because it’s not pushing medications. It’s not clear how successful it is in the long term, but if the person is willing to try, it’s certain something to consider.”
Medication options
If lifestyle changes don’t work, there are about half a dozen medications that may be helpful—and more in the pipeline. Most work by affecting the muscarinic acetylcholine receptor. This is a receptor on nerve cells that affects the activity of muscles in the bladder. “These pills inhibit that [nerve] transmission. They mute it,” McVary says, noting that this relaxes the bladder and reduces contractions associated with urges.
Options include Vesicare (solifenacin) Detrol (tolterodine), Ditropan (oxybutynin), Sanctura (trospium) and Enablex (darifenacin). Oxytrol is a skin patch form of oxybutynin. A new drug in this class, Toviaz (fesoterodine) was approved at the end of last year.
"They all function the same way," McVary says. “The only way to try to differentiate between them is by side effects, which are variable.” The most bothersome side effects are dry mouth and grogginess, which many people find worse than overactive bladder.
McVary’s research shows that generic drugs are associated with worse side effects in this class of medications, so this is a case in which it may make more sense to pay for the brand name. Notes Rutman, “You can try five medications and the sixth is the magic one,” adding that no one knows why different people get such varied results.
A medication that works on a different receptor mechanism—which could have fewer, or at least different, side effects—is in phase III clinical trials, the final step required for approval by the Food and Drug Administration. It is not yet clear when or whether the drug, YM178, will be approved and marketed.
Nerve stimulation, Botox and surgery
If all else fails and the problem is troublesome enough to restrict activities or cause repeated embarrassment, there are other options. The least invasive is percutaneous or posterior tibial nerve stimulation (PTNS). This involves the temporary insertion of a needle into the ankle to run electric current through a nerve that affects the bladder. Sessions last 30 to 45 minutes and are done once a week for eight to 12 weeks and sometimes monthly afterwards if needed. Nothing is permanently implanted in the body.
“It’s like an acupuncture needle behind the ankle,” Rutman says, noting that PTNS is often associated with “significant improvement,” for example, reducing incontinence from occurring five times a day to once. “Patients are typically very happy,” he says. Unfortunately, it is sometimes difficult to get insurance coverage for this treatment.
Botox injections into the bladder, given under anesthesia, are another alternative. “It works well,” Rutman says, noting that the drawbacks include the fact that the results last only six to nine months. Also, because Botox is not specifically FDA-approved for this use, insurance may not cover this, either.
Additional surgical options are available, including implantation of a device that is like a pacemaker for the bladder and other types of surgery. However, Botox and these options all carry the risks associated with surgery and should be reserved for severe cases.
The bladder and the brain
Recent research on rats suggests that overactive bladder may involve and affect the brain, not just the bladder. “As the bladder fills, it has to send signals to brain,” explains Rita Valentino, Ph.D., professor of anesthesiology at the University of Pennsylvania, who published a recent paper on the topic in the Proceedings of the National Academy of Sciences. In Valentino’s research, rats with damage to the bladder similar to overactive bladder in humans had measurable changes in their brains, affecting regions involved with attention.
“What we have to do is change our behavior. If we’re sleeping, we have to wake up. If we’re awake, we have to change the focus of our attention, and we even see this in rats. Because it’s a bladder problem, urologists study it and the focus is on [that] organ,” Valentino says. “Psychiatrists focus on the brain, and rarely do people bring the two things together."
Valentino’s work suggests that targeting the brain regions associated with bladder control might help. Indeed, certain antidepressants—like Cymbalta (duloxetine) or older tricyclic antidepressants—that affect this area can also be used to treat overactive bladder.
This research also suggests that social stress may exacerbate the problem. “We have a paper that shows that stress actually impacts on bladder to produce something that looks like overactive bladder,” she says, explaining that the rats in the study are exposed to a big, threatening male rat, which causes the condition. It’s not yet known how social stress affects human bladders, but in many other conditions, social support is known to reduce levels of stress hormones associated with the brain areas that Valentino found to be affected. More work on these connections could lead to better treatment approaches, both medical and psychosocial.
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