Urge Incontinence / Overactive Bladder

What is Overactive Bladder and Urge Incontinence?

Urge incontinence is the involuntary loss of urine that is associated with a sense of urinary urgency.  Patients often say “when I gotta go, I gotta go…and I don’t quite make it to the bathroom.”  Patients may also have urgency without incontinence.  Another common symptom in these patients is frequent bathroom trips.  Overactive bladder (OAB) is the term that has been introduced to encompass patients with both urgency and frequency, and patients may have or not have urge incontinence with it.  All of these conditions are all related.

Urge urinary incontinence is extremely common, affecting an estimated 13 million people in the United States, and OAB is equally common.  The exact cause of these disorders is unknown, although it is thought that the bladder becomes overactive and spasms during filling with urine. When this spasm occurs, you feel urgency and possibly leak urine at the same time.  If the bladder is empty during a spasm, you will still get the sense of urgency.  This is why patients often report visiting the bathroom frequently, but not urinating much.  Over activity of the bladder muscle is unfortunately something that happens to varying degrees with aging.  However, many factors can influence the bladder, including diet, medicines, and even the outside temperature.  Patients of all ages present with this problem, and it affects both men and women.

Treatment Options

There are a variety of treatments for urge incontinence available including both non-surgical and surgical options. Most surgical options are minimally invasive and do not require an overnight hospital stay.

Non-Surgical Treatments

Bladder Retraining
Just like training other muscles, you can retrain your bladder muscle.  Bladder retraining is a program that changes the way you urinate to help decrease the problems of urgency, frequency, and incontinence.  Bladder retraining involves various techniques that include modifying your diet to avoid bladder irritants, and keeping a bladder diary to record various things about your bladder function.  In addition, you are taught different ways to urinate, including urinating on a schedule and double urination techniques. Together, these steps can be very effective.

While this option is not suitable for everyone, studies have shown that it can be helpful.  One study showed that bladder retraining resulted in 75% of patients seeing improvements in their symptoms, with 12% being completely cured. These are very encouraging results as bladder retraining does not require patients to take any medications or undergo any surgeries.

Pelvic Floor Exercises
Pelvic floor exercises are designed to strengthen the pelvic muscles, more specifically the urinary sphincter.  This exercise strengthens the muscles, thereby improving stress incontinence (incontinence with coughing or sneezing).   Also, these exercises can improve the strength of the overall pelvic floor, thus helping to prevent these muscles from shifting and causing prolapse (cystocele, enterocele and rectocele).  The best known pelvic floor exercises are called Kegel exercises.  Pelvic floor exercises are not the gold standard for incontinence therapy; however, they are a wonderful initial therapy and are non-invasive. In some cases, they can provide great relief.  While most patients do not experience complete relief of incontinence, pelvic floor exercises have provided significant improvement in many patients.  Many patients say they have already tried these exercises. However, it is important to note that the excercises used to control overactivity are different. Patients do much better in performing these exercises when they have been taught the proper technique by a professional.

What does this treatment involve?

Pelvic floor exercises are taught by a physical therapist that is part of the Virginia Urology team.  The physicians and our patients have found that this provides a relaxed atmosphere where patients can focus on learning the pelvic floor exercises. Initially, appointments are generally held once per week. Once you feel comfortable with the exercises, you and your physical therapist may decide to decrease the number of visits.

Drug Therapies
Medicines are often used to treat OAB/urge incontinence.  In general, these medicines are all part of the same family, with only minor differences.  You may be familiar with one or all of them: Detrol, Ditropan, Enablex, Vesicare, Sanctura.  Their primary function is to the calm down the bladder.

What are the success rates and side effects?

These medicines are very effective in improving patients’ symptoms.  It is important to note that it may take up to 4 weeks before you begin to see the medications working.  Approximately 60-80% of patients will have significant improvement from these medicines. However, these medicines can often cause dry mouth and constipation, and many patients stop taking the medicine for this reason.  When one medication does not work, sometimes another one may work better.

Surgical Treatments

Interstim (Sacral Neuromodulation)

Interstim, sacral neuromodulation, is a new technique performed where a wire is placed close to the nerves that control bladder function. The wire then emits a signal that is delivered by the Interstim device to help calm down the bladder.  This wire is placed through a small incision in the back, and passes through a natural opening in the hip bone to get close to the targeted nerves.  

What does this treatment involve?

Interstim is a 2-stage procedure. Both stages are performed in a surgery center and you may go home the same day. In the first stage, the wire is placed in and exits from a small incision in the back. It is connected to a small controller that you can attach to your belt. This controller is turned on, which begins to emit signals to the bladder nerves.  You then return home, and wait for 1-2 weeks to see how well the Interstim calms down the bladder.  If it is helping, then you will return for the second stage where the temporary controller is replaced by a permanent one that is placed beneath the skin on your back (just above your hip). If it is not helping, then the wire is completely removed.

What are the success rates?

One of the best studies available examined patients 18 months after their surgery. All of these patients had failed conservative treatments before Interstim.  This study found that 77% of patients were benefiting from the Interstim. 

What are the possible complications?

Your doctor will review and discuss the potential complications with you. Interstim is a minimally invasive procedure.  Rare number of patients may have bleeding or discomfort at the incision site.  In a rare occasion that an infection develops, then the device will be removed.

What does this all mean?

Interstim is a significant treatment advancement for urge incontinence.  Until recently, if medications did not work for patients, then there were few remaining options.  Interstim allows many patients with more severe symptoms to lead a normal life.

Botox

Botox is a new technique where the substance is injected into the bladder to help calm it. Yes, this is the very same Botox that is used to help wrinkles! Botox is a chemical that can paralyze muscles, which is how it decreases wrinkles.  It also makes sense that it would help with a spastic bladder. This is why it was tried for OAB/urge incontinence.

What does this treatment involve?

Injections are done in the clinic first using a numbing liquid that is placed in the bladder by a catheter, and no anesthesia is required.  Injections are performed with a small camera that is inserted into the bladder so your doctor can see where to place the injections.  This is the same camera that many of you had when you were first seen in the clinic.  The entire procedure takes about 5 minutes. In general, patients are surprised by how fast the procedure takes and how little discomfort they experience. You may go home the same day. Botox does not last forever, and just like people who use it for wrinkles must go in periodically for more injections, the same is true for the bladder injections.  Botox lasts approximately about 9 to 12 months in most patients.  Importantly, Botox is currently considered an off-label therapy. That means that it is approved by the government for another use (ex: wrinkles), but not yet for the bladder.  This does not mean it is not safe or effective.  There are many studies that have shown how safe it is.  However, this currently means that most insurance carriers will not cover this procedure.  This is unfortunate because it is one of the most promising treatments currently available for treating OAB/urge incontinence.  Sometimes, our patients have been successful in applying to their insurance carriers for approval, but often patients must pay out-of-pocket for the procedure.

What are the success rates?

Dr. Rapp was involved in many of the earliest studies examining the use of bladder Botox injections.  These studies showed that 70-80% of patient benefited from Botox, either patients were cured or saw significant improvements in their condition. This is a wonderful result considering most of these patients had failed other available therapies.

What are the possible complications?

You doctor will review and discuss potential complications with you. Botox injections are a minimally invasive procedure.   Some patients may experience light bleeding in the urine or a urinary tract infection after the injection.  One possible complication is urination difficulty due to the medication partially paralyzing the bladder.  A dose strong enough to help with the bladder spasms is used, but low enough to try and prevent urination difficulty.  However, this balance is sometimes difficult to achieve.  When patients have difficulty urinating, this is almost always a very short term issue.  About 2% of patients need help emptying their bladder for several days. This can be done by wearing a catheter or, if you are comfortable, by teaching you how to catheterize yourself several times daily so that a catheter does not need to be left in. Very rarely, bladder difficulties persist longer. Because the medicine will eventually wear off, permanent urination difficulty is not a common concern.

What does this all mean?

Botox is an extremely promising advancement in the treatment for urge incontinence. Until recently, if medications did not work for patients, there were few remaining options.  Botox injections allow OAB/urge incontinence patients to be treated using a 10 minute procedure that may be performed without any anesthesia or incisions.  For this reasons, urologists are very excited about this new treatment option.