Overactive bladder

Most of us expect to relinquish control over some things in life, but the bladder isn't one of them. For 17 million Americans with overactive bladder, most of whom are women, the struggle to maintain control can grow to dominate their existence.

Overactive bladder is characterized by the sudden, uncontrollable urge to urinate. The need is so strong that it may not be possible to get to a bathroom in time. In that case, urine floods out involuntarily -- a condition known as urge incontinence.

THE ORIGINS OF THE PROBLEM
The bladder is a fairly simple organ -- a muscular sac resembling an inverted balloon that can store up to a pint of liquid for hours. The bladder expands as it fills, and nerve endings within the bladder wall transmit a "fullness" message to the brain as it nears capacity. One sphincter -- or ring of muscle -- at the bladder neck and another surrounding the urethra keep urine from leaking out. Even though the bladder may be uncomfortably full, it won't empty until it gets a signal from the brain, enabling us to get to a bathroom in time. When we sense that it's okay to void, the bladder wall contracts, squeezing urine into the urethra, and the sphincters relax, allowing urine to pass.

In women with overactive bladder, the muscular wall contracts well before the bladder reaches capacity. The condition may be due to a problem in one of three principal areas -- the central nervous system (brain or spinal cord), the bladder nerves, or the bladder wall. It may be exacerbated by bladder infections, weakness in pelvic floor muscles, or loss of tone in the urethra, or by substances in food, drink, and medications. The result is usually an excessive number of bathroom visits, in which only small amounts of urine are passed.

Managing overactive bladder can be a full-time occupation that imposes severe restrictions on all facets of life. It may mean a wardrobe limited to loose, dark clothing, social venues dictated by the availability of restrooms, and a sex life hampered by the fear of losing bladder control during intercourse.

DIAGNOSING THE PROBLEM
If you find that you are planning your life around access to a bathroom, you should talk to your clinician. You can help the discussion by composing a 2-day diary of your urination history. The diary should be divided into 2-hour periods in which you note whether you have urinated or have had an episode of incontinence, what triggered each event, and the amount of urine passed. (If possible, void into a measured container.)

Also jot down your fluid consumption during the same period, paying special attention to tea, coffee, carbonated drinks, alcohol, and acidic juices. Note when and how much of each you drank. Also list all prescription and nonprescription medications taken, specifying the dose and the time you took them.

Your clinician may want to conduct a physical exam and do some tests to determine whether you have a bladder infection or nerve damage that may be responsible. Most bladder infections can be successfully treated with antibiotics. If the doctor suspects nerve damage, you may be referred to a urologist, gynecologic urologist, or neurologist for further testing.

TREATMENT
There are a number of behavioral and drug treatments that can be effective in treating overactive bladder. They include:

Dietary changes. Eliminating substances that provoke bladder contractions can reduce the number of trips to the bathroom. These include all beverages containing caffeine or alcohol, which are diuretics, and acidic and spicy foods, which are irritants.
Behavioral conditioning. The bladder can often be trained to resist a premature signal to void. One method is to make an effort to hold urine 5 minutes longer than you ordinarily would and to add 5 minutes each week until 4 hours elapse between urination.
Urethral plug. A disposable plug may hold back urine long enough to make it possible to get to a bathroom. The Reliance Urinary Control Insert is a thin plastic tube that is placed in the urethra. A tiny balloon at the tip inflates on insertion to hold the device in place. The balloon is deflated and the device removed before urinating.
Drug therapy. The medications that are most effective work by blocking certain nerve receptors both in the bladder and in salivary glands. Ditropan (oxybutynin), the drug with the best track record, has enabled patients to hold urine longer, but it also causes dry mouth. A newer drug, Detrol (tolterodine), is as potent as Ditropan in the bladder and less powerful in salivary glands. As a result, it is less likely to cause dry mouth.

Nerve stimulation. The one device approved for bladder control, InterStim Therapy, works something like a heart pacemaker. A generator implanted in the abdominal wall sends impulses to the nerves that control the bladder. Although the device was very effective in reducing trips to the bathroom and incontinent episodes in clinical trials, a third of the patients had to have a second operation to reposition the generator. Surgery is still considered a last resort.

FOR FURTHER INFORMATION
The Simon Foundation for Continence: 1-800-237-4666

The National Institute of Diabetes and Digestive and Kidney Diseases: wwww.niddk.nih.gov

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