Imagine this – your bladder controls your life. Actually, it controls your life and the lives of those around you as well. It controls your every activity – where you go, what you do, what you wear, what you drink, how much you drink. In truth you hardly drink anything for fear that it’s going to make you want to go to the loo YET AGAIN!!! (that whole not drinking thing doesn’t actually help – but more of that later)
Those apps you can get on your phone which tell you where the closest public toilet is – you don’t bother with them. You KNOW where those toilets are and what the quickest routes to them are. You are very well acquainted with ALL the public toilets at your favourite haunts. In fact you don’t need to memorise that many toilets because your bladder is so in control that your social outings have become less and less ambitious to the point where you don’t go out much at all any more. These days a trip to the supermarket IS a social outing. Work is difficult. You know you go to the toilet lots. You don’t need the sniggers and rolling eyes to remind you of that. You’ve made changes to your wardrobe. You don’t wear light coloured pants or skirts anymore – just in case.
Women who don’t have overactive bladder (OAB) have gentle nudges from their bladder as it fills to remind them that they need to go to the toilet. Women who have OAB get messages from their bladder akin to someone yelling at them with a megaphone from about 6 inches away – “OMG!!!!!! YOU NEED TO GO TO THE TOILET NOW!!!!!!!!” Subtlety is not a word that can be used for the call of the OAB. This is a message which cannot be ignored. Women with REALLY bad OAB are jealous of other women with OAB who have to squat in their garden because they don’t think they can get to the loo in time. Why? – because they have the time to squat and have a pee instead of having it run down their legs.
Normally, the bladder is a floppy bag of muscle that gradually fills as urine flows into it from the kidneys. As it fills, it sends message back to the brain…..
“Got some wee collecting”….. (and the brain replies – okay, no probs)
“Need to start looking for a loo soon”…. (and the brain replies – yes, yes just a little bit longer)
“Need to find that loo in the next 5 minutes or so”….. (and the brain replies – okay, calm down we’re almost there)
Then, once the person finds a loo, they sit down, the brain tells the bladder to contract and urine is passed.
Now imagine that whole process happening in one of those old black and white movies where everything is sped up. The amount of urine that is able to be collected in the bladder of someone with OAB is a fraction of the capacity of a normal bladder and the urge to go to the toilet is so overwhelming that sometimes the bladder just says to the brain – get lost!, I don’t care what you say, I’m just going to contract – that contraction is a result of and also a cause of severe urinary urgency. That contraction is also the cause of the incontinence that some women with OAB suffer from.
So how is OAB defined? OAB is the combination of urinary urgency and frequency which may or may not be associated with incontinence. Simple to define but not always so simple to treat.
So what IS normal as far as urgency and frequency goes? Obviously urgency is a relative symptom but it’s usually obvious to both the doctor and the patient when the degree of urgency is abnormal. It is a sudden compelling desire to urinate. Frequency is more easily quantified. If the number of times that you pass urine between when you wake up and when you go to bed is more than seven – then that is increased. Rising more than once overnight is also usually abnormal.
For some women the causes of OAB can include nerve damage caused by abdominal trauma, pelvic trauma, or surgery; bladder stones; drug side effects; neurological disease (e.g., multiple sclerosis, Parkinson's disease, stroke, spinal cord lesions) – all of these causes are relatively uncommon. For many women the cause of OAB is never found – it just happens.
Some common disorders can mimic the symptoms of OAB. Urinary tract infection (“cystitis”) has symptoms very similar to OAB – a urine test needs to be taken to test for infection. Vaginal prolapse can cause urinary urgency and frequency and so therefore a physical examination is also necessary. You will often get homework in the form of a bladder diary. Every wee over the course of 24 hours is recorded – day or night – and the volume passed. This can give clues to other possible causes of what appears to be OAB.
Other more invasive investigations may be necessary if initial examination or investigations highlight other possible causes for the symptoms.
Diet and lifestyle modifications
I once saw a patient who to all intents and purposes suffered from OAB. She was voiding more than 20 times a day and up to 6 times during the night. Everything was pointing towards OAB until I got to the part of the consultation where I asked her about caffeine. It turned out she was drinking about 15 cups of coffee a day!! She was a little miffed when I told her that it was her coffee consumption that was causing the problems. I advised her about gradually decreasing her consumption and planned for her to return for review in 6 weeks. At her 6 weeks checkup her bladder was completely back to normal. She’d gone and quit her coffee cold turkey after she had left our last appointment!! The withdrawals during the first week were like hell but she was extremely pleased with the effect on her bladder.
There are many other dietary intakes which can exacerbate OAB by increasing urine output - carbonated beverages, chocolate and alcohol. Other intake can irritate the bladder- coffee, tea, cola, chocolate, alcohol, citrus fruits and juices, tomato-based products, artificial sweeteners, and spicy foods.
You need to drink normal amounts of water, about 6 to 8 glasses, spread out evenly throughout the day. Don’t avoid drinking because this can worsen symptoms by irritating the bladder because the urine is more concentrated. However, you may can restrict fluids before bedtime so you're less likely to have to use the bathroom in the middle of the night.
If you smoke – try and QUIT! Smoking irritates the lining of the bladder.
Constipation can worsen OAB symptoms so watch your diet and include natural fiber from sources like whole grains, fresh vegetables, beans and prunes. Benefibre is a great fibre supplement.
Excess weight puts pressure on the bladder, which may contribute to OAB. If you're overweight, talk to your doctor about a diet and exercise program.
One of the challenges of OAB is keeping the affected area clean and dry. If you are using an absorbent product, make sure you change it often. To avoid developing a rash or irritation, cleanse yourself with gentle, deodorant-free, soap-free cleanser and dry off thoroughly. Some women find using a hair dryer for this purpose is gentler than a towel.
Pelvic floor physiotherapy
Any of you that have seen me previously for any issues related to the bladder or vaginal prolapse or bowel or pelvic pain or…or…or…. will know that I am a HUGE fan of pelvic floor physiotherapists. This is not your run of the mill physio that you would see with your calf strain or back stiffness. This is a physio that has decided to specialise in all things related to the pelvic floor. Some women are not keen to see a pelvic floor physiotherapist (PFP) and I have never quite figured that out. These girls (there are no guy PFP’s) can work wonders. Instead of resorting to medications or surgery (for prolapse issues – another topic) many women are able to manage their own symptoms without going to the next step. They are able to achieve this through a combination of pelvic floor exercises and bladder retraining. I hear you saying “What’s the point of pelvic floor exercises. I’ve done them for years and they don’t work.” The point is that many, many women are doing those pelvic floor exercises WRONGLY! Often, just a single visit to a PFP will get you on the road to success. Bladder retraining is a specialised program individualised for each woman in order to increase the length of time between bathroom visits. It’s about deferring that URGE sensation using a number of techniques.
Medications are a common, safe way to control OAB or to treat the underlying cause of urinary problems. Several factors must be considered in selecting an appropriate medication. Your doctor will need to consider the cause of bladder symptoms and the type of urinary incontinence, as well as factor in your age, general health and any medication you may already be taking.
The most common type of medication used to treat OAB is a class of drugs called “anticholinergics”. These act on the bladder to relax the muscles in the bladder wall and therefore decrease urgency, frequency and leakages. The most common anticholinergics that are used are Ditropan and Vesicare. The reason that we don’t rush into using these medications is that they all have side effects. The commonest side effect is dryness of the mouth but constipation can also be a problem. Other side effects include headache, blurred vision, hypertension, drowsiness, and urinary retention.
Vesicare is one of the newer anticholinergics and comes in a once daily dosage and tends to give less in the way of side effects. However, it is expensive. It’s not on the PBS and it costs up to ~$50 a month. Ditropan is much cheaper. It has been around a lot longer. It does tend to have more in the way of side effects but the dose can be adjusted so that symptom control can be balanced against side effects.
Neotonus Magnetic Chair
The Neotonus Chair can be an effective treatment of overactive bladder. It is also used in the treatment of urge, stress and mixed urinary incontinence.
The Neotonus Chair is an effective, painless and non-invasive treatment utilising Extracorporeal Magnetic Innervation (ExMI) technology. The Neotonus system directly stimulates the pelvic floor muscles and sacral nerves without pain or the insertion of invasive needles or devices within the vagina. No active participation by the patient is required. Whilst the Neotonus Chair helps restore control, long term benefit is also dependent on the patient’s willingness to change behavioural habits (diet, weight loss, medications, exercise, etc.). It is essential that the use of the Neotonus Chair is integrated within a program of functional pelvic floor exercises with a trained pelvic floor physiotherapist.
A course of between 16 and 20 sequential treatments is normally prescribed. Treatments can be effective for up to 12 months or more. Some patients may need to repeat treatments periodically to maintain symptom control. Results vary from patient to patient; symptoms of urgency are often reduced after the 2nd or 3rd treatment. An improvement in stress incontinence may be seen by the 8th treatment, and in most cases, a patient will see improvements by completion of the course of 16-20 treatments. Patients affected with urge symptoms are most likely to show a significant improvement.
While sitting in the magnetic chair, patients feel a small vibration or tapping and will feel their pelvic floor muscles contracting. They may also see the muscles in their thighs contract or twitch. In some cases the pelvic floor muscles may feel tender or fatigued afterwards but only for a short time.
Some patients report soreness in the pelvic floor muscles after their first few treatments. In most cases, the pelvic floor muscles have not been used for quite a while, and can become “sore” and fatigued after being contracted during Neotonus treatment just as is normal after exercising. As the muscles being to build strength and endurance during repeated treatments, they will no longer experience soreness. Some patients also report an increase in leakage after the first few treatments – this is due to the fatigued muscles. This should resolve by the fourth or fifth treatment.
There are other more invasive treatments available for the treatment of the very severe OAB. These can include sacral nerve stimulators or Botox injections into the bladder wall. It is very uncommon that patients require these sorts of treatments and if they are necessary then referral onto a urologist that specialises in these techniques is necessary.
OAB is life changing. Treatment of OAB is life changing. Each and every patient’s treatment for OAB is individualised in order to best improve their bladder function whilst taking into account other issues which may be impinging on their general health and welfare.
If you think you have OAB you should see your GP soon. If left untreated it tends to worsen over time. If you think it can’t get any worse than what it is now – think again!