By Jennifer Miles-Thomas, MD, FPMRS:
Anyone who watches television has seen an explosion in commercials for medications to treat urinary incontinence. However, therapy options for patients who don’t respond to these drugs remain much less familiar.
Multiple types of incontinence affect millions of Americans every year, with a higher prevalence in women. Risk factors for the two most common forms, stress and urge incontinence, include age, pregnancy and childbirth, obesity, and diet and activity levels.
In the past, physicians have prescribed a pill to virtually everyone suffering from leakage, frequent urination, bladder-emptying problems or lack of bladder control, a constellation of symptoms referred to as overactive bladder.
But as we have learned more about the various causes of incontinence, several new modalities have appeared. For instance, we know FDA-approved medications won’t be effective for stress incontinence, as that involves a weakening of the urinary sphincter and pelvic floor muscles.
For all patients, the first step is typically introducing pelvic floor exercises and lifestyle changes that can reduce bladder irritation. Many foods and beverages have higher acidity levels that can trigger bladder contractions; a short list includes coffee, soda, cheeses, nuts and lemons.
Patients also should stay well hydrated to dilute those acidity levels. While people assume that drinking more water will force them to urinate more often, they’re more likely to maintain control by avoiding dehydration.
Should behavioral modifications and two types of medications fail to relieve symptoms, we can perform urodynamic testing to better pinpoint root causes and rule out issues such as undiagnosed infections or bladder tumors.
This procedure places tiny sensors inside the bladder via slim catheters – smaller than the inside of a pencil – to measure nerve and muscle function, flow rates and pressure in and around the bladder.
Several “third line” treatments can significantly improve quality of life when medications fail, and they are usually covered by insurance:
• Percutaneous tibial nerve stimulation (PTNS): This form of neuromodulation involves inserting a fine needle electrode into the ankle – like acupuncture – site of a nerve that runs to the sacral nerve plexus that regulates bladder and pelvic floor function. This delivers adjustable pulses that can decrease bladder contractions, although patients won’t feel anything inside the bladder. Treatments are weekly, about 20 minutes apiece, for three months. By eight to 10 weeks, most patients see a significant benefit.
• Sacral Neuromodulation: An electrical stimulation therapy that implants a programmable, battery-operated device – similar to a pacemaker – just beneath skin in the buttocks. This stimulates sacral nerves leading directly to the bladder, again aiming to slow contractions. It often works for five to seven years and can be removed or replaced; it is also invisible to others (and doesn’t set off metal detectors!).
• Botox injections: Guided by a cystoscope, physicians administer 100 to 300 units of Botox into the bladder after numbing the wall to relax the muscle and block some nerves that generate contractions. It typically lasts for six months.
Patients who have suffered embarrassing symptoms for years – whether leakage or frequent dashes to the restroom – have found great relief with these treatments. I encourage others to discuss these issues with your primary doctor and if you have tried medications without benefit, consult a urologist.
Dr. Miles-Thomas, a urologist, is Board certified in Female Pelvic Medicine and Reconstructive Surgery. She serves as President of Urology of Virginia. urologyofva.net