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Physicians Update


Physicians Update

Fall 2011

Treatment Options Available to Control Overactive Bladder


Bladder Care“Many women are forced to curtail their social and physical activities, as well as intimacy,” says Christopher Tarnay, M.D., director of female pelvic medicine and reconstructive surgery for the Department of Obstetrics and Gynecology. “Overactive bladder can lead to lowered self-esteem and is associated with an increased risk for depression.”

Both behavioral changes and medications can be effective in alleviating the problem. But for many women, at some point they prove not to be enough. “It can be very frustrating,” says urologist Shlomo Raz, M.D., head of UCLA’s Division of Female Urology, Reconstructive Surgery and Urodynamics. “However, patients who are resistant to behavioral changes and medications should know that there are effective options available.” These options include botulinum toxin (Botox) and two forms of nerve stimulation.

Behavior modification, the first line of therapy for women experiencing urgency or frequency incontinence, typically falls into two categories: dietary changes such as fluid and caffeine restrictions, and pelvic-floor-muscle strengthening exercises. “There is good evidence that both of these approaches help approximately 60 percent of women,” says Dr. Tarnay, though he notes that compliance with pelvic-floor strengthening tends to be more difficult for women as they age.

Pharmacotherapy targeted toward bladder relaxation can also be effective. But Dr. Raz notes that more than half of patients stop taking medications within three months. “Some patients stop because they aren’t able to tolerate the side effects, which can include dryness in the mouth, constipation and vision issues,” he says. “Cost can also be a factor, and some women don’t want to have to take a drug every day. And others are just not responding to medication and require further help.”

For patients who are resistant to behavioral modification and pharmacotherapy, one effective option is neuromodulation through stimulation of sacral root 3, the nerve the controls the bladder. The procedure, known as InterStim therapy, starts with the percutaneous insertion of a small electrode near the sacral nerve roots. Patients use an external pulse generator for up to a week to determine the response level and optimal intensity; if there is a positive response, they undergo placement of permanent electrodes, along with an implantable device often referred to as a “bladder pacemaker.” Both procedures are outpatient and performed under local anesthesia.

“This device delivers an electrical frequency that can ablate and suppress urinary urgency and frequency,” says Larissa Rodriguez, M.D., co-director of the Division of Female Urology, Reconstructive Surgery and Urodynamics. “This is a skin surgery — nothing deep — and is reversible. It has been demonstrated to be effective in women who are resistant to traditional therapies.”

A different form of neurologic-stimulation therapy, also performed by both UCLA physicians, is percutaneous stimulation of the tibial nerve. Typically administered through one or more sessions per week for approximately six weeks, the procedure employs a small electrode to stimulate the nerve that runs just posterior to the ankle, using an acupuncture-like methodology. Pioneered in Scandinavia, the approach has come to the United States in the last two years.

“Through the same neuromodulation effect that we see in sacral-nerve stimulation, this has been demonstrated to be as effective as drug therapy in reducing the overactive bladder symptoms,” says Dr. Tarnay, “and it is particularly exciting because it can be done without an implanted device.” Although the need for multiple sessions is a disadvantage, they can be done in the home, he adds.

Another relatively new option for patients whose overactive bladder is resistant to behavioral and pharmacotherapy approaches involves the intravesical injection of Botox into the bladder muscle through an outpatient procedure approximately every six months. This treatment has the effect of blocking the muscle overactivity of patients with urgency or frequency incontinence. “Botox is easy, well tolerated, reversible, and it improves urgency and frequency symptoms in a great number of patients,” says urologist Ja-Hong Kim, M.D.

Kidneys and BladderOn the other hand, Botox has not yet been approved for refractory overactive bladder, so patients may have to pay out of pocket. In the absence of longterm data, it is also unclear whether patients will eventually develop resistance to the injection’s effects. “Neuromodulation is more of a long-term solution,” Dr. Raz says.

The most significant downside to Botox is the risk of urinary retention, which occurs in approximately one in four patients. “Botox is a viable option, and we see dramatic improvement in up to two-thirds of patients,” says Dr. Tarnay. “However, it’s not surprising that if you’re blocking the release of neurotransmitters to reduce the involuntary smooth-muscle activity of the bladder, the rates of retention will be high, requiring many patients to catheterize themselves at home.”

It’s important to counsel patients on this risk, Dr. Tarnay notes. But even after being counseled, many decide it’s worth going ahead, calculating that the prospect of self-catheterization is preferable to chronically being wet and in a diaper, or having to stay home and toileting as many as 20 times a day. “Many women describe being a slave to their bladder, or that they are shackled to the toilet,” Dr. Tarnay says. “They are looking for something to change that.”

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