Overactive Bladder

Don’t let your bladder run your life. Control your bladder. If you’re one of the 33 thousand women who experience bladder control problems, don’t let embarrassment keep you from getting the help you deserve. Involuntary leakage of urine, having to urinate frequently and experiencing other symptoms of urinary incontinence affect your quality of life and are not necessarily a natural part of aging.

Many health care providers do not routinely ask about urinary function during a clinic visit. It’s up to you to take control and make the first step in treating your problem. If you have bladder control problems, tell your doctor about them and ask for help.

Bladder control problems require medical attention for several reasons.

Several serious underlying medical conditions, such as multiple sclerosis, neurologic conditions, diabetes or kidney problems
Cause you to restrict your physical activities leading to weight gain
Lead you to withdraw from social interactions and feel isolated
Increase your risk of falling if you have balance or mobility problems and you often rush to the bathroom to avoid leaking urine ( urge incontinence )
Can lead to nursing home admissions
When to seek help

A few rare and isolated incidents of urinary leakage don’t necessarily require medical attention. However, if the problem continues or affects your quality of life, consider getting these symptoms evaluated.

You may opt to see a bladder control specialist if you are experiencing any of these problems.

You’re embarrassed by urine leakage, and you avoid important activities because of it.
You often feel urgency to urinate and rush to a bathroom, but sometimes don’t make it in time. Urge incontinence
You urinate much more frequently than you used to, such as at night (nocturia), even when you don’t have a bladder infection.
You often feel the need to urinate, but you’re unable to pass urine.
You notice that your urine stream is getting progressively weaker, or you feel as if you can’t empty your bladder well.
In most circumstances, symptoms can be improved.

Many clinicians can treat bladder control problems without referring you to a specialist. However not all health care providers have the necessary training to properly guide you or offer state of the art treatments. In spite of better understanding and treatment of urinary incontinence, some providers consider it an inevitable consequence of childbearing, menopause or normal aging — a belief that makes them unlikely to consider you for evaluation or treatment.

If you feel that you are not getting the evaluation or treatments you deserve consider visiting Dr Angelo E Gousse.

Urinary incontinence or the involuntary leakage of urine is one of the most common problems treated in female urology. It is important for the clinician to realize that there are several different types of urinary incontinence, each with a different cause and potential treatment options. These include stress incontinence, urge incontinence, and overflow incontinence, mixed incontinence (simultaneous stress and urge incontinence), total incontinence and functional incontinence.

Improper diagnosis of the type of urinary incontinence is probably the most common reason for treatment failure. A detailed history and physical examination is of paramount importance in the proper diagnosis and sub typing of urinary incontinence. In select cases, Urodynamic testing or cystoscopy may be useful. A neurologic history and physical examination should be obtained in order to rule out neurogenic bladder.

Patients with “pure” stress urinary incontinence report activity–related urinary leakage which interferes with their quality of life. The disorder is unrelated to psychologic stress. Any increase in abdominal pressure such as coughing, sneezing, laughing, exercising, jumping, running, or event sexual activity may precipitate urinary leakage. Stress incontinence may or may not co-exist with pelvic organ prolapse. In most cases urethral hypermobility is noted with rotational descent of the urethra upon straining. The need for treatment is largely dictated by the degree that it affects the quality of life of the patient. Pad usage and pad weight are sometimes used to gauge disease severity

The current most popular surgical treatment to treat stress urinary incontinence is the sub-urethral sling. Transurethral bulking agent is another less successful and shorter duration treatment option.

The suburethral sling can be performed using a synthetic mesh (mono-filament macroporous Type I mesh) or biologic allograft, autologous rectus fascia. Abdominal procedures such as Burch urethropexy are effective but remain more invasive than the transvaginal sling procedures.

Currently, there is no approved medication for stress urinary incontinence. There is no evidence that estrogen therapy is effective in the management of stress urinary incontinence.

Patients with urge urinary incontinence report involuntary urinary leakage with bladder spasm and strong urges to void. Urge incontinence is one of the symptoms associated with overactive bladder. Overactive bladder is not necessarily related to aging or prior surgery. Most cases of overactive bladder and urge incontinence are idiopathic. Urge urinary incontinence is often associated with urinary urgency and frequency. However, a neurologic cause should always be ruled out especially in younger patients. The treatment algorithm of urge is very different from that of stress incontinence.

Behavioural therapy, fluid management, timed voiding, avoiding bladder irritants, pelvic floor exercises; Kegel exercises are useful in many cases. In more severe cases, anticholinergic medications can be used. Anticholinergics are plagued with adverse side effects such as dry mouth, constipation, cognitive side effects, and potential for urinary retention. The newest anticholinergic drugs have a better safety profile but yet remain far from being free from side effects. The newly developed beta-adrenergic agonists are promising. They are effective free from anticholinergic side effects but are associated with hypertension.

In cases refractory to oral medications, intradetrusor injection of Onabotulinum toxin A (Botox) offers new hope to affected patients. Pic III The procedure is minimally invasive and can be performed in the office without general anaesthesia. A urinary retention rate of 6 % and poor bladder emptying are potential side effects of Botox. Urinary retention is rare in our personal practice and in well selected patients with a post void residual of less than 100 ml pre-Botox- procedure. Botox should be re-injected every 3-6 months to remain effective. Few patients with urge incontinence require Botox re-injection yearly. The usual dosage is 100 Units of Botox in patient with idiopathic urge incontinence refractory or intolerant to medications. This option is FDA approved in the USA.

Another option is implant of a sacral nerve stimulator (looks like a pacemaker). It is possible to stimulate the third (S3) sacral nerve via an implantable neuro-stimulator. Medtronic (Axonics) manufactures the most popular device. The procedure is performed under local anaesthesia with the patient awake. A staged procedure (First –stage lead implant) and second stage (implantable pulse generator- IPG) implant is often required to obtain the best results. The device is expensive and the battery (IPG) half-life is 3-7 years. Patients who require infra-cranial MRIs can’t have the procedure performed. A few long term studies have documented the safety and efficacy of Axonics Sacral Nerve Modulation. Recently, posterior tibial nerve stimulation (PTNS) has been added to the armamentarium of urge incontinence treatment with very reasonable outcome data. Long term studies are needed. No implant is necessary for PTNS but multiple weekly office visits are required.

Patients with mixed urinary incontinence have a combination of stress and urge incontinence. Often, the most dominant symptom is treated first. Some clinicians treat both symptoms simultaneously. Mixed incontinence can be stress predominant, urge predominant, or balanced. Many (up to 50%) mixed incontinence patients with stress predominance become dry of both subtypes of incontinence after sub-urethral sling (synthetic, allograft, autologous rectus fascia).

Patients with overflow incontinence have impaired bladder emptying associated with an elevated post void residual. Impaired bladder emptying can be associated with bladder outlet obstruction (urethral stricture, severe pelvic organ prolapse, urethral diverticula). Other causes include detrusor muscle underactivity ( acontractile ) or neurologic disorders. Patients with overflow incontinence are best treated by intermittent self-catheterization or relieving the bladder outlet obstruction.

Patients with functional incontinence are unable to reach the rest room because of functional difficulties associated with body mobility. Elderly patients with cognitive impairment and or orthopaedic problems are most commonly affected by functional incontinence. Nursing care and physical therapy are the most effective treatment options.

If you have questions about Bladder control or pelvic organ prolapse, contact Angelo E Gousse MD, urologist and board certified in Female Pelvic Medicine and Reconstruction, (305)-606-7028, Dr Gousse, Voluntary Professor of Urology at the University of Miami Miller School of Medicine, is associated with Memorial Hospital System, Aventura Hospital, University of Miami Hospital and Clinics, Jackson Memorial Hospital. Web site www.bladder-helath.net