Alternative approaches to overactive bladder

September 15, 2006
Peter L. Rosenblatt, MD
Peter L. Rosenblatt, MD

Dr Rosenblatt is Director in the Division of Urogynecology, Department of Obstetrics and Gynecology, Mount Auburn Hospital, Cambridge, Massachusetts, in the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachuset

,
Gouri B. Diwadkar, MD
Gouri B. Diwadkar, MD

DR. DIWADKAR is a Resident, Beth Israel Deaconess Medical Center, Cambridge, Mass.

Although traditional drugs work for most patients, potential side effects turn some patients off. Examining the evidence, two experts argue for trying approaches like magnetic and electrical stimulation, acupuncture, or Botox.

We think it's increasingly important for ob/gyns treating patients with overactive bladder (OAB) to first try alternative approaches instead of traditional anticholinergic drugs. Seventeen percent of American women suffer from this condition, and half of them have incontinence.1 A patient with OAB has symptoms of urgency with or without incontinence and the condition is usually associated with frequency and nocturia, according to the International Continence Society.2 Urgency is defined as feeling the need to void immediately for fear of leaking urine, while frequency is defined as urinating more than eight times during working hours. Detrusor overactivity is a urodynamic diagnosis in which detrusor contractions are recorded on filling cystometry.3 While anticholinergic drugs do alleviate symptoms in up to 70% of patients with OAB, they can cause side effects such as dry mouth, constipation, and nausea, which could lead patients to stop taking them.4 In addition, symptoms of OAB are apt to return once the drugs are discontinued, unless they're combined at the start with treatments such as behavioral modification.

For years, timed voiding, bladder retraining, biofeedback, and pelvic floor muscle exercises-either alone or combined with drugs-have been frequently recommended. And much data support their use. [But there are also studies that advocate less common or alternative treatments such as magnetic and electrical stimulation, hypnosis, botulinum-A toxin, bladder injections, acupuncture, vanilloid substances, and diet combined with weight loss in the treatment of OAB and urinary urge incontinence (UUI).]

Our goal here is to look at the effectiveness of these less common alternative treatments, based on recent data. Many of these haven't been widely accepted due to a lack of adequate studies and design quality or because they're supported only by case studies. We'll focus on these less common approaches, rather than drugs or the more popular biofeedback and pelvic floor exercises.

First a word about the behavioral methods of timed voiding, bladder retraining, and prompted voiding. Timed voiding prevents incontinence episodes by creating a fixed time interval between micturitions. In contrast, for bladder retraining, the time interval is not fixed and therefore can be gradually increased to "train" the bladder to resist the urge and drain less frequently.5 Bladder retraining is based on the hypothesis that conscious efforts to suppress sensory stimuli will reestablish cortical control over an overactive bladder.3 Finally, prompted voiding, often used in institutionalized, cognitively impaired patients, requires a caregiver who reminds a patient to void periodically, to make her aware and prevent leakage accidents.5

A retrospective review of 50 patients with OAB with or without UUI who underwent timed voiding found that 80% said they were cured or improved at discharge.6 Another investigator looked at prompted voiding in a prospective cross-over study of 19 cognitively impaired homebound adults. The group treated had a 60% reduction in daytime incontinent episodes (vs. a 37% reduction for controls). After the controls crossed over to the treatment group, there was an additional 22% reduction.7 However, not all studies are this positive. One retrospective study revealed that bladder retraining may not be as successful as once thought, due to poor patient compliance: Of women recommended for telephone-based bladder retraining, 55% failed to complete the training.8

Electrical stimulation

Discovered in 1963 when an electrode was first implanted into the periurethral muscles, electrical stimulation for incontinence is thought to work by stimulating the pudendal nerve afferents, with the efferents causing the striated pelvic muscles to contract. It's believed that the striated muscle action inhibits inappropriate detrusor activity. [Implantable and nonimplantable devices can be applied to the legs, vagina, anus, and pelvic muscles to treat stress, urge, and mixed incontinence. Since 1977, a number of US trials-including randomized controlled trials (RCTs)-have supported this therapy.9 ]