What to Know About Overactive Bladder

Overactive Bladder (OAB) is a syndrome that is diagnosed by its symptoms. Patients with OAB usually experience urinary frequency. How frequent is too frequent? Most guidelines say 8 or more trips to the bathroom to urinate per day. Urinary frequency can result from drinking excess fluids, but in patients with OAB, the frequency has more to do with how much the bladder can comfortably hold. While most people can easily hold between 10 and 20 ounces, those with Overactive Bladder often feel like they have a very full bladder with as little as 2-3 ounces. This results in more frequent trips to the bathroom, even if you decrease your fluid intake.

Another feature common in OAB is urinary urgency. Urgency is described as a an uncomfortable need to urinate, a feeling that urinating is very difficult to postpone. Urinary urgency can lead to urinary frequency. It can make you feel like you are chained to the bathroom. We often describe the “warning time” for urination. That is the time from when you have a first desire to urinate until you feel like you can’t control your urination. That warning time can be minutes or hours in a normal bladder but patients with Overactive Bladder sometimes have only seconds. One goal of treatment for OAB is to increase your warning time. That helps you regain control over your life.

Related to warning time and urinary urgency is Urgency Incontinence (often abbreviated UUI - the extra “U” is for urinary). This is the most common type of bladder leakage in patients with OAB and can result in large amounts of incontinence. Many patients describe this as losing control of their bladder or just urinating when they don’t want to, so the term leakage can be confusing. Some people may not even notice this as a strong urge because they have become accustomed to it. But incontinence that occurs when you are not doing something strenuous, such as sleeping, watching TV, washing dishes or walking to the bathroom, is usually Urgency Incontinence.

While OAB is, by far, the most common cause of these symptoms, there may be other bladder diseases that produce similar symptoms. It is important to be aware of certain warning signs that may indicate another underlying cause. Presence of these warning signs should prompt a visit to a bladder health specialist.

It is not really clear why any particular person develops an Overactive Bladder. There are numerous factors suspected of worsening OAB symptoms but none of these, on their own, fully explains OAB. Some of these factors include obesity, smoking, advanced age and consuming irritating foods or beverages. Particularly with irritating foods and beverages such as caffeine or acids, reduction can improve bladder symptoms. But plenty of people have continued symptoms of OAB even without eating or drinking anything irritating. There may even be some genetic component to Overactive Bladder, though this has not been clearly demonstrated.

While, unfortunately, there is no cure for OAB, numerous treatments are available. The first group of therapies are called behavioral therapies, or sometimes first-line therapies. This group of therapies is more conservative, meaning that they are unlikely to cause significant side effects and are not invasive in any way. They can also be undertaken largely on your own and can give you a lot of control over your own therapy. Because they do not require taking a medication or having a procedure done, they can sometimes be mistaken as being less effective. In fact, several studies suggest that, if taken seriously by a dedicated patient, these therapies can be at least as effective as taking a medication for bladder symptoms. But success depends heavily on how much work someone is willing to put into these therapies. Explore more in this helpful guide that details behavioral therapies for OAB including handouts that you can download.

Second-Line Therapies

The next group of treatments are often called second-line therapies and are medications that you take to treat Overactive Bladder. There are numerous medications approved for OAB and most of them work in a similar way. The bladder has nerve endings (called receptors) within its wall that are responsible for sensing when the bladder is full and communicating this to the brain. A full bladder should trigger the urge to urinate. In Overactive Bladder, these nerve endings are “overactive” and send signals that the bladder is full, long before it is. These messages result in frequent, urgent urination and, in some people, urine leakage. Most medications try to block the receptors. However, the bladder is not the only location for these receptors and blocking them elsewhere can lead to side effects including dry mouth, dry eyes, constipation and even memory/thinking impairment. There is an OAB medication, mirabegron (Myrbetriq), which works in a different way. It stimulates a different receptor to try to calm the bladder and its nerve endings. While it has not been shown to be more effective at controlling the symptoms of OAB, because it works in a different way, it does not cause the same side effects. We do have to be watchful because Myrbetriq may raise your blood pressure. View our more detailed guide to medications for OAB for more information.

Third-Line or Advanced Therapies

Finally, the last group of treatment for OAB are called advanced therapies (or third-line therapies). These are typically used in patients who have refractory Overactive Bladder. Refractory OAB which has not responded to first and second-line therapies or OAB in patients who cannot take medications due to side effects or other medical problems. They are also generally used in patients with moderate to severe symptoms of OAB (though a lot of patients have these kinds of symptoms). Read this brief summary of advanced therapies or follow the links to access a detailed guide for each therapy.

Two of the advanced therapies are types of neuromodulation. This simply means that we are stimulating a nerve (neuro) in order to change (modulation) the way the bladder tells the brain how full it is. Sort of like turning up the TV so you can’t hear an annoying relative at Thanksgiving. Peripheral Tibial Nerve Stimulation (or Percutaneous Tibial Neuromodulation - they are the same thing) is one type of neuromodulation that stimulates a branch of the nerve to the bladder in the leg near the ankle. Stimulating this nerve can help to decrease the signals of urgency going from the bladder to the brain, helping to control symptoms. Currently it is delivered in the office and uses a very tiny needle under the skin. This allows PTNS to be used in patients who may have too many other medical problems to tolerate other therapies.

Sacral Neuromodulation

The second type of neuromodulation is Sacral Neuromodulation (SNM). Like PTNS, this therapy stimulates the nerve to try to “drown out” the annoying signals coming from the bladder. However, SNM stimulates the nerve before it reaches the bladder, rather than a branch of the nerve. Also, it is implanted under the skin permanently so that patients do not have to return to the office regularly for the therapy.

Botox for Bladder

Botulinum toxin (Botox is the brand that is used) is the final type of advanced therapy for OAB. Similar to medications, Botox can block the nerve endings responsible for sending signals of urgency to the brain that result in OAB. Unlike medications, Botox is injected directly into the bladder wall and has an effect mostly in the bladder with few side effects outside of the bladder. It also lasts much longer so while medications are taken once or more per day, Botox treatments occur about every 6 months. Botox therapy does require looking into the bladder with a small scope (cystoscopy) but anesthesia can numb the bladder for this or patients may choose to be lightly sedated.

Not really. In fact, there are many things that you can do to control OAB without seeing any kind of doctor at all. Behavioral therapies such as avoiding bladder irritants (for example caffeine), bladder training with timed voiding, or pelvic exercises do not require a physician visit. If you find that you need more help, such as an OAB medication, your primary care provider should be able to help with this. However, if you have any concerning or complicating factors, you may need to see someone who specializes in bladder health. Or, if you have been frustrated by previous efforts with medications and behavioral therapies, a specialist can provide additional options.

Because OAB (like many other diseases) becomes more common as we get older, it is tempting for some patients and even health providers to think of it as “just a normal part of aging”. But the symptoms of OAB are never normal and if they are bothersome you deserve to have them diagnosed and treated. It is not uncommon for younger men and women to experience symptoms of urinary frequency, urgency and incontinence associated with Overactive Bladder and this is certainly not “a disease of older people”. However, as we age, the rates of OAB do increase (especially in men) and it can seem like these symptoms are something to be expected and just tolerated. This can lead to frustration on the part of people who are tired of suffering with these bladder symptoms but may not feel like they are being taken seriously. If this is the case, it may be helpful to meet with a provider who has a focus or an interest in bladder health.

Many people are concerned that being evaluated for OAB means expensive or invasive tests. In fact, most of the diagnosis is obtained simply by asking questions about your symptoms and taking a history to rule out other potential causes. An office test of your urine and a physical exam are often all that is required. It may be appropriate to perform a painless ultrasound scan of your bladder to see if it is empty. Unless there are complicating factors, it is not necessary to perform more in-depth testing to first diagnose OAB. Only patients who have concerning bladder warning signs or who do not see improvement with therapy need to have a more extensive evaluation.

Both Overactive Bladder (OAB) and Interstitial Cystitis (often also called Bladder Pain Syndrome) can cause symptoms of frequent urination. So, it can be difficult, at times, to tell them apart. It can add to the confusion when patients have both of these syndromes at the same time. But what are the differences? First, the frequent urination that we see with Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is usually driven by pain. In contrast, patients with OAB more often report voiding because of a strong urge or fear of incontinence. The presence of pain is an indication the patient may have IC/BPS.

Medications used to treat the two syndromes are also quite different. Overactive Bladder is often treated with medications that attempt to block the nerve endings responsible for sending messages about bladder fullness. These medications are called antimuscarinics. Another type of OAB medication stimulates a different nerve receptor that helps to relax the bladder. Neither of these OAB medications is indicated for use in IC/BPS. I have even noted that some patients with BPS/IC who report that their symptoms became worse with OAB medications, possibly because their bladders were able to hold more urine (which can increase pain with IC/BPS). Medications to treat Interstitial Cystitis/Bladder Pain Syndrome target different nerves of the bladder, attempt to decrease inflammation in the bladder or try to restore the normal lining of the bladder.