An overactive bladder (OAB) results in urgency to pass urine, often frequently which can be both during the day and night. Some women will leak urine if they do get to the toilet in time, which is called urge incontinence.

  • How is an overactive bladder treated? Open or Close

    Despite our limited understanding of the overactive bladder, there are a number of effective treatments. These include:

    Lifestyle Changes

    Adequate fluid intake.



    Tea, coffee and fizzy drinks contain caffeine which can irritate the bladder, so try and keep them to a minimum or cut them out altogether. As an alternative you may want to try caffeine-free tea or coffee. Similarly, if alcohol causes your bladder to misbehave, avoid it. 

It is important to drink enough fluids overall. A daily intake of 1.5 to 2 litres per day is usually adequate, but you may need to drink more in hot weather or if exercising. 

Many women avoid drinking fluids of any type because “as soon as I have a drink I want to go to the toilet”. This simply should not happen. The reason it does is that these women have developed and association between drinking and going to the toilet and this has become habit. The fluid you drink does not go straight to your bladder. Think about the journey fluid takes through your body. Fluid first settles in your stomach and is then transported through your intestine (bowel) where some of it is absorbed for your bodily needs. The fluid enters your bloodstream and it is the blood that is filtered by your kidneys to produce urine which is stored by your bladder. As you have probably worked out by now this takes time and there is no reason why you should automatically have to go to the toilet to pass urine after having had a drink.

     

    Physiotherapy

    What is the pelvic floor?
    The pelvic floor is the layer of muscles at the base of your pelvis that supports your pelvic organs, bladder, womb and back passage, and controls the passage of urine. The muscle layer forms a hammock or sling from the pubic bone in front to the coccyx (tail bone) behind. These muscles help to prevent urine leaking when coughing, sneezing or straining. Pelvic floor exercises, therefore, are contractions of these muscles. You can increase the strength of these muscles and hence the pelvic floor by regularly exercising these muscles.

    How to contract the pelvic floor muscles
    This can be done in two ways: imagine you are trying to stop yourself from passing wind. This squeezes the muscle around the back passage. Secondly, imagine that you are trying to stop your urine stream. This tightens the vagina. Do not use your tummy muscles or your bottom. If you are not sure you are exercising the right muscle, put two fingers gently into the vagina and try to squeeze around them.

    To increase the strength of your pelvic floor muscles, you should perform fast and slow exercises.

    Slow exercises
    Sit or stand comfortably with your knees slightly apart. As described above, squeeze your pelvic floor muscles as tight as you can, and hold for as long as you can. Try and hold the contraction for 10 seconds. You may not be able to hold it for more than two or three seconds at first. Repeat this as often as you can, up to ten times, but have a rest in between each one for five seconds.

    Fast exercises
    Fast exercises are done in the same way as slow exercises, but when you squeeze the muscles, let go immediately so that you only feel a very quick lift in your pelvic floor. You should repeat these exercises up to 10 times.

    You should do both fast and slow exercises six times a day.

    Not all women will be able to perform pelvic floor exercises. Those who cannot may benefit from instruction and supervision from a continence advisor or specialist physiotherapist. For those women who cannot contract their pelvic floor muscles, it may be possible to simulate contractions using a special probe. This is called electrical stimulation and is a technique that women can administer themselves following instruction.

    There are alternatives to performing pelvic floor exercises as described above such as biofeedback and vaginal cones.

    Women are often advised to practice contracting their pelvic floor muscles by trying to stop the flow of urine mid-stream. Whilst this is useful to help you identify which muscles you should be contracting, it is not advisable to be doing your exercises this way.

    Bladder retraining

    Bladder retraining is an educational and behavioural process used to re-establish the control of your bladder if you suffer with urinary urgency, frequency, urge incontinence, etc.; in other words if you have an overactive bladder. It consists of several key elements:

    • Understanding the mechanisms of continence and incontinence
    • A scheduled voiding regimen with gradually increasing intervals between voids
    • Urgency control strategies using distraction and relaxation techniques
    • Self-monitoring of voiding behaviour
    • Positive re-inforcement from a health professional.

    Bladder retraining may be taught by a physiotherapist or continence advisor. Before starting to retrain your bladder, it is helpful if you keep a bladder diary for a few days, recording the following:

    • type and amount of fluids drunk
    • time of each drink
    • time and volume of urine passed (you can use a plastic measuring jug)
    • any incontinence episodes

    This will give you a baseline from which to work. In many cases, bladder retraining is a matter of breaking bad habits, which are often longstanding. So go to the toilet only when you need to. If you go 'just in case' then the bladder will become used to holding less urine. Try and distract yourself with other things and try not to panic. If you begin to feel the strong urge to pass urine, you can try and contract your pelvic floor muscle. Often the urge will subside.

    One of the aims of bladder retraining is to increase the volume of urine you allow it to hold. Voiding regimes are tailored to each individual. If you void every hour, try and increase the interval between voids by 15 - 30 minutes each week, until you are voiding every 2-3 hours, If you can manage 3-4 hours, even better. It is important you continue to do your pelvic floor exercises at the same time and drink appropriate amounts and types of fluid. Bladder training takes time but it does get easier, so persevere.

    Sometimes it may be necessary for you to take drug therapy to relax your bladder at the same time.

    Drug Treatment

    Overactive Bladder (OAB)
    Drugs have been used to treat overactive bladder symptoms very effectively for many years. The selection of available drugs is growing all the time but the majority act in a similar way. In simple terms they stop the bladder from contracting inappropriately, which is what causes urinary urgency, frequency and urge incontinence. As drugs go, they are very safe.

    Although the drugs are effective, their main drawback is side-effects which are more of a nuisance and rarely serious. The drugs work on certain receptors in the nerve endings which make the bladder muscle contract. These receptors are found throughout the body. The drugs are unable to target just those receptors in the bladder, hence the side-effects. The side-effects most commonly reported include dry mouth, heartburn or acid reflux, bloating, headaches and constipation. It is impossible to predict who will get side-effects, but once again treatment is a balance between side effects and the benefits. If one drug does not work or gives you side effects you can try another.

    All the drugs bar one come in tablet form which you take daily. The exception is a patch which is changed twice a week. One of the most commonly prescribed drugs is oxybutynin which comes in both tablet and patch form.

    There are no hard and fast rules as to how long you should take drug treatment, but it is advisable that you should continue therapy for a minimum of two or three months, or at least until your symptoms are under control. Some patients need to be on treatment for much longer. You can then try stopping treatment. If your symptoms return you can restart treatment.

    If drug treatmnent is unsuccessful, you will probably require further investigation such as urodynamics or cystoscopy. Other treatments such as nerve stimulation and injection of botulinum toxin A may need to be considered.

    Nerve Stimulation

    Some women will continue to have symptoms despite having tried bladder retraining, pelvic floor muscle training and drug therapy. Other treatment options are available, including nerve stimulation, or ‘neuromodulation’ as it is otherwise known.

    There are two forms of neuromodulation in used in this country:

    SACRAL NERVE STIMULATION (SNS)

    This treatment involves the stimulation of a nerve at the lower end of your spine with electrical impulses generated from an implant which is placed beneath the skin of your lower back. This therapy only available in specialist centres.

    PERCUTANEOUS TIBIAL NERVE STIMULATION (PTNS)

    PTNS works similarly to SNS, but the nerve stimulated is in your ankle rather than your back. A fine needle is inserted in your ankle close to the posterior tibial nerve, which has its root in the same area as the nerves supplying the bladder. The needle is attached to a battery-powered stimulator which sends impulses to stimulate the nerve and hence the bladder. Each treatment lasts 30 mins and is administered weekly for 12 weeks.

     

    Injection of Botulinum Toxin

    What is botulinum toxin?

    Botulinum toxin is neurotoxin produced naturally by certain bacteria. Type A neurotoxin is the one used most commonly. It is commercially available as Botox and Dysport.

    How does it work?

    The toxin paralyses muscles by blocking the nerve impulses to those muscles to prevent them from contracting excessively. It is given by injection.

    What is botulinum toxin used for?

    It is licensed to treat muscle spasms in the eyelid, face, neck and shoulders caused by certain neurological conditions. Its use, in the form of botulinum toxin A, has been extended to treat excessive sweating of the armpits and the overactive bladder. It has gained much attention for its cosmetic use in reducing facial wrinkles.

    Botulinum toxin is not licensed for the treatment of the overactive bladder. However, many drugs are used to treat conditions outside their license. Sometimes a medicine has been licensed for a certain use and later experience or research shows that it works for a different condition. It is legal for a doctor to prescribe a medicine that does not have a UK license and a pharmacist can legally dispense that drug. This applies to botulinum toxin A. You doctor must inform you of this.

    In an overactive bladder, the symptoms are caused by sudden, uncontrolled contractions of the bladder muscle. Paralysis of the bladder muscle with botulinum toxin has been shown to decrease the symptoms associated with this condition.

    Who can have botulinum toxin?

    This therapy is usually only considered when overactive bladder symptoms persist despite bladder retraining and drug treatment.

    There are people with certain medical conditions who should not have botulinum toxin.

    How is botulinum toxin A given?

    Botulinum toxin is administered by injection directly into the bladder wall using a telescope which is passed through the urethra (the tube through which you pass urine). This can be done under local or general anaesthetic.

    Are there any side-effects from botulinum toxin?

    · Some women experience pain in the bladder following injection.

    · Treatment can cause you to retain urine in the bladder, in which case you may have to self-catheterise. This a technique which you will have to learn before treatment just in case it becomes necessary.

    · Allergic reactions in the form of a rash do occur occasionally.

    It can take up to a week for you to notice the benefits of treatment.

    How long do the effects of botulinum toxin last?

    The majority of women do notice some improvement in their overactive bladder symptoms. In my experience, the benefits of treatment last from four to 14 months. Repeat injections may be given.

     

  • What causes an overactive bladder? Open or Close

    Although the bladder is structurally a relatively simple organ (it is essentially a reservoir for urine), it is under the control of a more complex system of nerves and chemicals extending down from the brain, through the spinal cord and ending in the pelvis. We still do not fully understand why in the majority of cases the bladder becomes overactive. 

Sometimes a bladder may become overactive due a disease process either inside or outside it. The following conditions can result in an OAB:

    • Urine infection or cystitis
    • Bladder stone
    • Interstitial cystitis (a chronic inflammatory condition of the bladder)
    • Bladder cancer (a rare cause)
    • Neurological disease – e.g. Parkinson’s, multiple sclerosis
    • Stroke
    • Back problems
    • Pelvic surgery – e.g. hysterectomy
    • Psychosocial problems – e.g. dementia, physical disability

    In most cases of overactive bladder, the bladder itself is healthy.

    The following may be associated with an OAB:

    • Caffeine consumption (tea, coffee, carbonated drinks)
    • Constipation
    • Smoking