Overactive bladder is a common problem in which a frequent and intense urge to urinate may be accompanied by incontinence (wetting accidents).
Approximately 33 million Americans are affected by overactive bladder, and the risk increases with age. Contrary to popular belief, men are just as likely as women to develop the problem, although women are more likely to experience incontinence.
In men, the symptoms of overactive bladder can be mistakenly attributed to benign prostatic hyperplasia (BPH)—also called benign prostatic enlargement, or BPE—that can cause bladder outlet obstruction.
Some men suffer from both overactive bladder and BPH. Bladder control problems may also be caused by stress incontinence, a leakage of urine brought on by activities such as coughing, sneezing, laughing, or exercising.
Because stress incontinence can overlap with both overactive bladder and BPH, proper evaluation by a physician is essential for an accurate diagnosis. If overactive bladder is the problem, a variety of effective treatments are available.
How the urinary tract functions
Urine is produced by the kidneys and transported to the bladder via two tubes called ureters. Urine leaves the bladder and exits the body through another tube, the urethra. Urination is primarily controlled by two types of muscles: the detrusor and the sphincters.
The detrusor is a large smooth muscle in the wall of the bladder that squeezes urine out of the bladder at the time of urination. The sphincters are muscles located at the bladder neck (smooth muscle sphincter) and below the prostate (skeletal muscle sphincter). Sphincter tone prevents urine from passing through the urethra when voiding is not taking place during toileting.
As the bladder fills, the sensation to urinate becomes evident, and through coordination with the voiding center in the brain, urine is squeezed out of the bladder when the sphincters relax and the detrusor contracts.
How overactive bladder develops
When nerves carrying messages to and from the bladder don’t work properly, the detrusor muscle can become overactive and squeeze the bladder before it has filled adequately. In many cases, the reason for this overactivity is unclear.
Experts speculate that overactive bladder may be related to aging. Damage to the nerves in the pelvic area during surgery, and disruption of the inhibitory signals coming from the brain (for example, with a stroke or Parkinson’s disease) may be other contributing factors.
Medications, such as some sedatives, diuretics, and sleeping pills, can contribute to overactive bladder. Products found at your local supermarket also can irritate the bladder and cause problems. For example, concentrated citrus products are a common cause of bladder problems.
Other items that may exacerbate overactive bladder in some people include:
• Carbonated beverages (with or without caffeine)
• Milk or milk products
• Tomatoes or tomato-based products
• Highly spiced foods
• Sugar, honey, and corn syrup
• Artificial sweeteners
If any of these products increases urinary symptoms, they should be eliminated from your diet.
A stepwise approach to managing overactive bladder
The initial approach for managing any patient with overactive bladder involves eliminating bladder irritants, drinking four to eight glasses of water a day (because restricting fluid intake results in concentrated urine that can irritate the bladder), strengthening the pelvic floor muscles, retraining the bladder and, if needed, taking medication or undergoing a procedure to reduce or eliminate side effects.
A complete bladder-training program can take as long as 60 days to produce results. The goals of the program are to be able to hold about 1 pint of urine in the bladder and to urinate every two to four hours during the day.
To begin the program, keep a detailed bladder control diary for at least 72 hours. The diary helps you keep track of what you drink, how much you drink, how many times you urinate and how much each time (a minimal, moderate, or large amount), whether you felt a strong, sudden urge to urinate, and what activity was interrupted by the need to urinate. Wetting accidents should also be noted in the diary.
Kegel exercises, special exercises to strengthen the pelvic floor muscles, are performed daily. These exercises help reconnect the transmission of nerve impulses between the bladder and the brain.
To retrain the bladder, when you feel the urge to urinate, try to hold the urine for five minutes before going to the bathroom. The pelvic floor exercises will help with this. Each week, add five minutes to the length of time the urine is held before going to the bathroom.
Pharmacotherapy can play a major role in the management of overactive bladder. Prescription drugs relax the bladder muscle and decrease its sensitivity to irritants. By reducing the sensation of urgency, the drugs also provide more time to get to the toilet.
Medications for overactive bladder include darifenacin (Enablex), fesoterodine (Toviaz), oxybutynin (Ditropan, Ditropan XL, Gelnique, Oxytrol), solifenacin (Vesicare), tolterodine (Detrol, Detrol LA), trospium (Sanctura, Sanctura XR), and Myrbetriq (mirabegron).
When behavioral therapy and medication do not relieve the symptoms of overactive bladder there are still therapy options for patients not responding to standard conservative therapy.
Intravesical injection of onabotulinumtoxinA (Botox), percutaneous tibial nerve stimulation (PTNS), and sacral neuromodulation (InterStim therapy) are available for patients who are resistant to pelvic floor retraining and medication.
• Botox. If you are still dealing with frequent urination problems and have not benefited from the traditional therapies, onabotulinumtoxin, more commonly called Botox, could possibly be a minimally invasive solution to consider.
Approved by the U.S. Food and Drug Administration in 2013, injections of this drug directly into the bladder have offered some patients a reduction in overactive bladder symptoms.
This is an outpatient procedure. After applying a local anesthetic, the doctor will inject the drug directly into the detrusor muscle of the bladder, which causes the muscle to relax, reducing its overall contractility 24 to 72 hours later. The injections will eventually help increase the storage capacity of the bladder while decreasing both urinary incontinence and frequency episodes.
Treatment with Botox can be repeated when the benefits of the drug from a previous treatment have decreased. However, there should be at least three months between treatments.
• Percutaneous tibial nerve stimulation (PTNS). This is a non-surgical, low-risk treatment to consider if Kegel exercises and medication have failed to relieve urinary symptoms.
PTNS works by indirectly providing electrical stimulation to the nerves responsible for bladder and pelvic floor function.
During this office procedure, the patient’s foot will be elevated and supported, and a slim needle electrode will be placed near the tibial nerve at the ankle.
A device is then connected to the electrode that sends mild electrical pulses to the tibial nerve. These impulses then travel to the group of nerves at the base of the spine—the sacral nerve plexus—that are responsible for bladder function.
This treatment stimulates the nerves through gentle electrical impulses, and this can lead to gradual changes in bladder activity over time.
Typically, patients will undergo a series of 12 weekly, half-hour sessions. Improvements with PTNS are typically noted five to six weeks later. Studies have reported that upwards of 80 percent of patients benefit from the procedure.
• Sacral neuromodulation. InterStim therapy is a proven neuromodulation therapy that targets the communication problem between the brain and the nerves that control the bladder.
Bladder function is regulated by a group of nerves at the base of the spine called the sacral nerve plexus. When those nerves are stimulated through gentle electrical impulses similar to that in a heart pacemaker, bladder overactivity can be calmed or eliminated.
The implantation of the InterStim device sends continuous impulses to the sacral nerve plexus, which inhibits urgency and spontaneous uncontrolled bladder activity.
The gentle electrical impulses dampen these wayward reflexes while letting the normal signals get through.
Learn more about how to fight incontinence.