Overactive Bladder - Severe Overactive Bladder

Introduction

Overactive bladder can be very inconvenient and uncomfortable.  Overactive bladder causes an extreme sudden urgency to urinate, frequent urination, and the need to urinate at night (nocturia).  Some people experience unexpected urine loss as well.  The problem occurs when muscles in the bladder send out “false alarms” to urinate before the bladder is even full.  Fortunately, medications and lifestyle changes are helpful for most people.  Surgery may be recommended for people with severe symptoms.

Anatomy

Your urinary tract system consists of your kidneys, bladder, and urethra.  Your kidneys are a pair of bean shaped organs located in the lower back area.  The kidneys filter waste products and extra fluid from your blood, creating urine.  Urine is composed of mainly water and metabolic waste products.  From the kidneys, urine travels through two tubes (ureters), to the bladder.

Your bladder holds and collects the urine that arrives from the kidneys.  When a certain level of urine has accumulated in the bladder, your bladder sends signals to your brain so you know that it is time to urinate.  Urination is a voluntary action.  When you are ready, the bladder walls (detrusor muscle) contract and the pelvic floor muscles relax.  A valve-like muscle on the bladder (urinary sphincter) opens and allows urine to empty from the bladder.  Urine is carried from the bladder to the outside of your body through a tube called the urethra.  The female urethra is short and ends above the vaginal opening.  The male urethra is longer and ends at the tip of the penis .  When you have finished urinating, the urinary sphincter closes to hold urine in the bladder.

Causes

The exact cause of overactive bladder is not known.  It occurs when the muscles in the bladder wall contract at the wrong time or too often.  The muscle wall contraction signals the brain that it is “time to go to the bathroom,” although the bladder is only partially full.

There are several underlying conditions that appear to be associated with overactive bladder.  Conditions that affect the urinary tract may contribute to overactive bladder, for example urinary tract infections, inflammation, structural abnormalities, an enlarged prostate in men, bladder cancer, and bladder stones.  Neurological conditions including Parkinson’s disease, stroke, and multiple sclerosis can contribute to overactive bladder.  People with diabetes or those who consume excess alcohol or caffeine may develop overactive bladder. 

Researchers suspect a chemical (serotonin 5-hydroxtryptamine) imbalance in the brain that disturbs the nerve signal process may be linked to overactive bladder.  The chemical is associated with depression, anxiety, attention deficit disorder, irritable bowel syndrome, and pain.  Further, people with both fibromyalgia and a bladder condition known as interstitial cystitis experience higher incidences of overactive bladder and irritable bowel syndrome. 

Symptoms

The main symptom of overactive bladder is the very sudden urgent need to urinate.  You may urinate frequently, more than eight times during the day and more than two times at night (nocturia).  Following the urgent feeling, you may have the unintended loss of urine (urge incontinence), known as “overactive bladder, wet”.  About two thirds of people with overactive bladder do not experience urge incontinence, which is termed “overactive bladder, dry”. 

Diagnosis

Your doctor can diagnose overactive bladder by conducting a physical and neurological evaluation, reviewing your medical history, and conducting lab tests.  Make sure to bring a list of your medications to your appointment.  Some people may feel embarrassed about discussing “private” matters, but rest assured that your doctor respects and appreciates the information that you provide, as it helps in the process of diagnosing your problem.  It is beneficial to write down your symptoms before your appointment and bring them to discuss with your doctor. 

Common tests include blood tests and urine tests.  Your doctor may ask you to keep a record of how much you drink and urinate and episodes of incontinence over several days.  The information can help your doctor diagnose factors that may contribute to your symptoms.

Specialized tests may also be conducted.  A uroflowmeter is used to measure the amount of urine and speed of your voiding.  A post void residual (PVR) measurement helps to find out if you have a problem with emptying your bladder.  After you have urinated, your doctor will use a catheter or ultrasound to assess how much urine is left in your bladder.  A catheter is a soft thin tube that is carefully inserted into your urethra to your bladder to remove remaining urine for measurement.  An ultrasound is a painless imaging test that uses sound waves to create a picture of the bladder and remaining urine.  With either test, a large amount of remaining urine indicates a blockage in the urinary tract or a bladder problem.

Urodynamic testing is another test to learn more about bladder function.  Urodynamic testing evaluates the muscle strength in the bladder walls and sphincter.  For this procedure, a catheter is inserted into the bladder and then the bladder is filled with water via the catheter.  A pressure monitor records the pressure within the full bladder.  Pressure in a healthy bladder increases slightly while filling.

Bladder pressure can also be measured with cystometry.  For this procedure a catheter is inserted into the bladder and the bladder is filled with water.  A small pressure monitor is inserted through the anus and into the rectum.  The device measures pressure changes in the bladder and surrounding areas while the bladder is filled to various capacities. 

Video urodynamic testing is frequently performed at the same time as cystometry.  Video urodynamic testing uses X-rays or ultrasound to show what the bladder looks like while it is filling and emptying.  A special dye may be used to enhance the images.

Your doctor may use a cystoscope to view the inside of your lower urinary tract.  A cystoscope is a thin tube with a viewing instrument.  It is carefully inserted through your urethra.  The bladder is expanded with air or water to open the bladder folds and provide a better view.  The procedure (cystoscopy) allows your doctor to check for problems inside of the bladder and urethra.  Narrow instruments can be inserted through the cystoscope to allow your doctor to remove tissue if necessary.

In some cases, electromyography is used to assess the way that nerves conduct signals to the bladder muscles or sphincter.  The evaluation involves placing sensors on the skin, in the bladder, or in the rectum.  The sensors transmit a record of how coordinated specific nerve signals are with each other.

Treatment

The type of treatment that you receive depends on the cause of your overactive bladder.  Medications are commonly used in combination with behavioral interventions.  Surgical procedures may help people with severe overactive bladder.

Prescription medications (anticholinergics) are used to relax the bladder wall muscles to prevent episodes of overactive bladder.  Medications can help treat urge incontinence as well.  Prescription medications are usually an effective treatment for most people. 

Your doctor may recommend behavioral changes, such as limiting fluids, avoiding alcohol and caffeine, losing weight, and quitting smoking.  It can be helpful to go to the bathroom more often or do so on a regular schedule.  Bladder training involves holding urination for increasing minutes after feeling the urge to go to the bathroom to help lengthen the time between urinating.  Another strategy, double voiding, is to wait for a few minutes after you have urinated, and then try again.  Additionally, there are a variety of disposable or washable protective pads and briefs on the market today that can be worn to protect clothing.

It is common for people with incontinence to learn Kegel exercises to help strengthen the muscles that control urination.   You may be referred to a physical therapist that specializes in pelvic floor strengthening.

Surgery may be recommended for people with severe overactive bladder that fail to have symptom relief with other types of treatment.  Sacral nerve stimulation is used to help regulate the nerve signals between the bladder tissues and spinal cord.  It involves surgically placing a small device under the skin in the abdomen.  Wires from the device are placed near the nerves.

Another surgical option, augmentation cystoplasty, is used to enlarge a bladder that is too small or has very high pressure.  This is a major surgery that uses sections of your bowel to reconstruct the bladder. Following augmentation cystoplasty, you may need to use a catheter to empty your bladder.

Neurolysis is a surgery to cut the nerves that supply the bladder.  This prevents nerve signals from reaching the muscles in the bladder that cause it to contract.  Neurolysis is rarely used, but may be an option for people with severe overactive bladder.

Prevention

If you have overactive bladder, it is important to follow your doctor’s treatment instructions carefully.  Performing Kegel exercises, not smoking, and avoiding alcohol and caffeine can all be helpful.

Am I at Risk

Overactive bladder is most frequently experienced in men over the age of 65 and women in their mid-40s.  It is fairly common in the United States, affecting about one in six people.

Risk factors for overactive bladder:
___ Certain neurological disorders
___ Diabetes
___ Enlarged prostate in men
___ Bladder cancer
___ Urinary tract infection
___ Urinary tract inflammation
___ Bladder stones
___ Bladder tumors
___ Excess caffeine or alcohol consumption
___ Certain medications

Complications

Overactive bladder may be embarrassing for some people.  Others may feel depression, anxiety, or a loss of dignity.  In some the “false alarms” from overactive bladder can lead to reduced social interaction and social isolation.  Make sure to discuss your concerns with your doctor.  Your doctor is happy to offer suggestions or recommendations for assistance and support.

If you experience urine incontinence with overactive bladder, you may be at risk for skin infections or sores (ulcers).  Additionally, chronic urine incontinence increases the risk for repeated urinary tract infections.  Ask your doctor to recommend preventive measures that are appropriate for you.