WOMEN’S HEALTH
Ralph Zipper, MD
Many women are plagued on a daily basis by frequency of urination, excessive nighttime urination, urgency of urination, and urinary incontinence associated with the sensation of needing to urinate. These symptoms are the result of the inability to control the bladder muscle thus causing inconvenient accidents. The media calls this Overactive Bladder (OAB) while your doctor calls it Detrusor Overactivity (DO) or Detrusor Instability, named for the muscle that surrounds the bladder.
As the bladder fills with urine, the detrusor muscle should stay at rest with no significant change in bladder pressure. This bladder control muscle should only contract when one consciously allows it. When the relationship between the brain and the bladder is compromised, the detrusor muscle may escape brain control resulting in involuntary contractions of the bladder.
TREATMENTS OPTIONS
Drug Therapy: The majority of drugs used in the treatment of DO fall into the Anticholinergics class. Acetylcholine is the main neurotransmitter responsible for contraction of the bladder muscle. Anticholinergic drugs block the receptors for acetylcholine on the bladder muscle and help weaken contractions. When used in the correct dose, patients will have significant improvement in their symptoms and still be able to urinate. Unfortunately acetylcholine is responsible for many other body activities including brain function, bowel function, heart function, vision and salivation.
THE INTERSTIM® IMPLANT is about the size of a book of matches and is implanted well beneath the skin of the upper buttock providing up to five years of continuous sacral nerve stimulation and bladder control for patients who haven’t had success with urinary control medications.
Newer drugs are more selective and therefore may have less unwanted side effects. The most commonly used drugs are Ditropan® (Oxybutynin), Detrol® (Tolteradine), Vesicare® (Solifenacin), Oxytrol® (Oxybutynin Patch), Sanctura XR® (Trospium) and Enablex® (Darifenacin). All of these drugs are quite safe and may be prescribed with most other medications.
Nerve Stimulation Therapy: Nerve stimulation therapies are a more precise method of treating DO if medical management fails and are not associated with adverse effects to other organ systems. Stimulation to the sacral nerves may block some of the signals traveling from the bladder to the brain. A technique called Interstim® was FDA approved in 1997 and has been extensively used since.
The Interstim® procedure is comprised of two steps. The first is a test that involves placing a tiny wire into the appropriate nerve and attaching this wire to a small stimulator worn on your belt for up to one week. Based on improvement from the test, patients continue on to the second step, implant. The Interstim® implant is about the size of a book of matches and is implanted well beneath the skin of the upper buttock providing up to five years of continuous stimulation and bladder control for patients suffering from urinary urge incontinence, urinary urgency-frequency, and non-obstructive urinary retention.
Tibial Nerve Stimulation Therapy (TNS): TNS is a newer and indirect approach to stimulation of the nerve impacting the need to urinate. The Urgent PC® device was FDA approved in 2007 and provides stimulation by sending an impulse through the tibial nerve. The tibial nerve is located just beneath the skin of the ankle and travels up inside the sciatic nerve to the nerves of the sacrum.
TNS is an office-based procedure, administered in a series of thirty-minute treatments utilizing an acupuncture type needle and a small computer. The computer sends gentle impulses up the tibial nerve to the sacral nerve complex.
Electrical Stimulation Therapy: (E-Stim): E-Stim is the oldest of the nerve stimulation therapies and is administered by placing a probe with electrodes into the vagina. A painless current causes stimulation of the pelvic nerves and muscles. Typically done at home, not all devices are created equal and many yield inferior results.
E-Stim is one of the least effective treatments for DO. However, as there are no significant side effects, it is sometimes used in combination with other therapies.
Bladder Retraining: This is a form of behavioral modification that has been shown to improve DO. A diary is kept to determine urination frequency. Following very specific rules, the patient is forced to increase time between urination every 3-5 days by 15-minute intervals. Compliance with the rules and weekly office visits are essential to successful bladder retraining. When performed correctly, the brain’s ability to control the micturation reflex can improve. The time considerations and limited effectiveness of this therapy have caused it to fall out of favor.
Pelvic Floor Physiotherapy: Physical therapy can be used to help patients with DO strengthen and gain control over the muscles of the pelvis. Intuitively it would seem that this would only help patients with stress incontinence. However, a strong contraction of the pelvic muscles can stop a bladder contraction. The mainstay of pelvic floor physiotherapy is called biofeedback therapy. Small pad electrodes (EKG type pads) are placed on the skin of the abdomen and anus. These pads are typically connected to a computer screen that displays easy-to-see messages when the patient contracts the correct or incorrect muscles. Hence, the patient learns to exercise and control the pelvic muscles without contracting the abdominal muscles.
Intacystic Botox® Injection: Botox® causes temporary muscle paralysis and has gained notoriety and popularity in the aesthetics world to treat unwanted wrinkles of the face. Botox has also been used “off-label” in the treatment of DO for over 10 years, and seems to provide a viable therapy option for patients who either did not benefit from medical treatment or who could not tolerate their side effects. Botox is injected into the wall of the bladder during cystoscopy (visualization of the lining of the bladder using a scope), a 10-15 minute office procedure that requires only local anesthesia. When used correctly, it weakens the bladder muscle just enough to prevent OAB symptoms, but not enough to cause urinary retention. Unfortunately, Botox will wear off and in 3-5 months, most patients will need another injection.
Diet and Lifestyle: Certain foods and beverages have been associated with overactive bladder symptoms such as spicy foods, tomato based foods, fruit juice, carbonated beverages, caffeinated beverages and decaffeinated coffee and tea. Water is not irritating to the bladder and certainly does not cause DO, but many patients drink too much water. Although water is certainly one of the safest beverages, there is no data to show that people drinking two glasses of water each day are less healthy than those drinking eight glasses. However, those drinking eight glasses will be hurrying to the bathroom.
With the wide variety of treatment options available, those with DO no longer need to suffer. Finding a qualified urogynecologist is the first step in any treatment plan. There is no need to hide secret discomfort and embarrassment anymore.
Dr. Zipper is a national leader in the field of urogynecology and vaginal surgery. His Zipper Urogynecology Associates is one of the nation’s top centers for the treatment of pelvic floor dysfunction; overactive bladder and urinary incontinence; and vaginal rejuvenation. For information please log on to www.Zipperurogyn.com or call 321-674-2114.
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