Brunilda Nazario, MD
Do you have frequent, sudden urges to urinate and problems holding your urine while sleeping or drinking? Then you may have urge incontinence, which is a symptom of overactive bladder (OAB).
Do you find yourself suddenly leaking urine when you cough, sneeze, laugh, or lift your groceries? Then you may have stress incontinence.
The vast majority of people -- most of them women -- who have trouble making it to the bathroom in time have one or both these types of incontinence. “The problem is, we don’t have a single treatment that takes care of both,” says Linda Brubaker, MD, a professor in the department of obstetrics & gynecology and urology at Loyola University Chicago Stritch School of Medicine, and director of the division of female pelvic medicine and reconstructive surgery at Loyola University Health System. “We could give you medications that help with urge incontinence, but you might still be bothered by stress.”
Or even more frustrating, you might have a urethral sling surgically placed to combat stress incontinence, only to find that you’re still running to the bathroom three or four times a night -- and not always making it.
There are a number of treatments for OAB, and researchers are studying more in clinical trials in Europe and North America.
If you have symptoms of more than one type of incontinence, it’s likely that you’ll need more than one treatment, Brubaker says. “And incontinence is also a chronic condition that tends to get worse as people age. This means we need a lot of options.”
Many of the most common OAB treatments -- medication, nerve stimulation, and surgery -- have been helpful for people with OAB. If you’re frustrated by overactive bladder or other continence problems, you might want to learn more about the newer OAB treatment options.
One way to treat urinary incontinence is through nerve stimulation, in which mild electrical impulses cause contractions of specific muscles that help control bladder function. These therapies have proven to be very successful in treating many cases of urge incontinence and overactive bladder. Nerve stimulation therapies can also be used along with techniques such as behavioral therapy and pelvic muscle exercises, or Kegels.
During posterior tibial nerve stimulation (PTNS), the doctor inserts a fine-needle electrode into the nerve just above your ankle. A mild electrical impulse is passed along the needle to nerves that control bladder function. This regulates the function of your bladder and pelvic floor.
“It’s a fairly simple procedure, done in the office,” says Ross Rames, MD, associate professor of urology at the Medical University of South Carolina. Rames works with the university'sBladder and Pelvic Health Center. “Often, we’ll see improvement within the first couple of weeks after the patient starts PTNS treatments.”
With PTNS, you have to go to the doctor’s office more frequently. “It’s more intensive to receive, and you have to get more frequent, smaller doses,” Brubaker says. “Some studies suggest that it works, but we don’t yet know how often we need to deliver it to be most effective.”
Sacral nerve stimulation is a treatment in which mild electrical impulses are sent to the sacral nerves that control bladder function. A device -- implanted in the upper buttocks under the skin -- is used to provide these electrical pulses. The procedure to implant the device is minimally invasive. The device will signal your bladder to regulate itself until the batteries run out. Batteries last from three to seven years, depending on the device being used and the programmed limits for stimulation.
While sacral nerve stimulation can be an effective treatment, it’s still more or less a permanent surgical implant. And surgery is not an option for everyone.
Botulinum toxin injections may offer some promise for people with overactive bladder. You might be wondering, “Botox? Like movie stars use on their forehead?” Yes, the same substance that dermatologists use to smooth out wrinkles can also be used to teach an uncooperative bladder to behave.
To treat incontinence, doctors inject botulinum toxin into the bladder muscle. This is done with a needle that is inserted via a long tube called a cystoscope that goes up into the bladder. “The goal is to reduce the over-activity of the bladder muscle so that the patient has better control, but still allow enough muscle contraction to empty the bladder,” Rames says.
Experts are still trying to determine exactly how botulinum toxin treats overactive bladder. “We have good evidence that it may be helpful in blocking sensations you don’t want to have. It may be blocking the signal that tells the muscle to contract,” Brubaker says.
It’s a fine line to walk: Too much botulinum toxin and the bladder is temporarily paralyzed. This means that the patient has to have a catheter placed until he or she can urinate again.
The National Institutes of Health is enrolling participants in a clinical trial that will compare nerve stimulation with botulinum toxin when treating challenging incontinence. “This is for people who’ve been very difficult to treat, not those just stopping to see their doctor for the first time,” Brubaker says. “Over the next couple of years, they’re hoping to find out which therapy offers that type of patient better control.”
Several drugs are being studied in clinical trials for treatment of OAB. These drugs include:
SOURCES:Linda Brubaker, MD, professor, department of obstetrics & gynecology and urology, Loyola University Chicago Stritch School of Medicine, Chicago.Ross Rames, MD, associate professor of urology, Medical University of South Carolina, Charleston.UpToDate: "Treatment of Urinary Incontinence."
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