New Treatments for Overactive Bladder

More confidence for women in mid-life

Amy Rosenman, MD

June, 2004

Leaky bladder is a common complaint for women in mid-life, especially for those who've had children. A long or difficult labor puts women at an even higher risk of developing this problem by age 50. The good news is that clinicians now have more and better ways to deal with their discomfort and distress.

About 15 million American women are incontinent or have a prolapsed uterus that can lead to this condition. The problem only grows worse with age. Thirty percent of women over 60 suffer incontinence that limits their day-to-day activities. [1]

But younger women are affected, too. A Scandinavian study published in the February 2004 issue of BJU International [2] showed that 35 percent of European women over 18 report some form of incontinence. (This study was based on self-reports and participants had different definitions of incontinence, so these numbers may be high.)

The majority of pre-menopausal women suffer from "stress" incontinence. Leakage results from giggling, sneezing or coughing and the sudden impact of these explosive events on the bladder muscles. Most women experience stress incontinence from time to time and need to be concerned only once the leakage increases and becomes more problematic.

For post-menopausal women the statistics are different. By then, at least 50 percent are suffering from "urge" incontinence, which produces a compelling need to urinate and more frequent contractions of the bladder muscle, regardless of how full the bladder actually is.

All women, however, complain about the effects of incontinence on quality of life. Some avoid high-impact sports because the strain on the bladder region causes leaking. Eventually, they may even cease exercising altogether even though staying active can help alleviate the symptoms of stress incontinence.

Other women say they have to change clothes frequently or use several protective pads a day. At some point, it becomes easier to stay home than deal with potential embarrassment. If they don't speak up and ask for help, women over time may become isolated and even reclusive. A University of Virginia Health Sciences Center study found that when urge incontinence is linked with a chemical imbalance (low serotonin), patients are more prone to depression. [3]

The good news is that there are several things we can do to cure incontinence—or at least control it more effectively.

Dealing with Stress Incontinence

Women who have given birth tend to have higher rates of stress incontinence. We found in researching our book, The Incontinence Solution, that delivery is responsible for much of the injury to the muscles and nerves of the pelvis.

Women who have C-sections aren't immune: Carrying a child to term can also stress the pelvic floor, and so can the labor before a Caesarian is performed. An elective Caesarian section, however, reduces the damage that leads to stress incontinence.

Often patients can be cured in a week using Kegel exercises. Kegel exercises are vaginal isometrics; they tense and release the pelvic floor muscles and basically build up one's ability to control urine flow.

If a woman has difficulty isolating these muscles or performing these exercises on her own, we may recommend biofeedback. (See The Controversy over Kegels: Are women doing them correctly?)

Or we may use a computerized monitoring device to more fully investigate the problem. Urodynamic testing measures bladder pressure, urinary flow, and sphincter muscle strength. These tests are virtually painless.

If Kegel exercises and biofeedback don't produce the desired results, there are two second-line treatment options.

The drug duloxetine (Cymbalta), developed as an antidepressant and now under FDA review, effectively reduces stress incontinence, according to a 2004 study. [4] Duloxetine is a dual reuptake inhibitor acting on the neurotransmitters serotonin and norepinephrine. It stimulates the nerve connected to the urethral sphincter that keeps the urine from spilling out. [5]

Transvaginal electrical stimulation also helps curtail both stress and urge incontinence, according to a 2004 Brazilian study. [6] A vaginal probe sends a weak electrical current to the pelvic floor muscles. The current causes the muscle to contract, thereby strengthening it. This approach also teaches patients how to identify and activate this muscle. Brazilian researchers found that 88 percent of women had a noticeable reduction in symptoms or went into remission six months after treatment.

The last line of defense for stress incontinence is surgery. The object is to put the bladder and urethra back into their normal positions. Studies show [7] that inserting tension-free vaginal tape to correct bladder position is an effective treatment for stress incontinence. This technique was imported from Europe, and since 1995, 20,000 American women have signed up for this sling-like procedure; the success rate is 90 percent after a three-year follow-up. [8] The surgery itself takes 30 minutes.

For more information on surgical approaches, see chapter 6 of The Incontinence Solution, available online and see the American Urogynecologic Society web site.

Coping with Urge Incontinence

Urge incontinence (overactive bladder) is directly related to aging. Over time the muscles in this area weaken, and the collagen that strengthens the pelvic supporting structures breaks down.

At menopause some women may develop urge incontinence as their estrogen level wanes, and vaginal tissues begin to weaken. A vaginal ring or vaginal tablets containing estrogen can help, along with Kegel exercises, to counteract this problem. [9]

Surgery does not reduce urge incontinence, so if Kegel exercises fail, the only other options are transvaginal stimulation (described above) and/or medication.

Because so many people are suffering from incontinence, and the population as a whole is aging, pharmaceutical companies are working hard to find better treatments with fewer side effects.

For years, clinicians relied on oxybutynin (Ditropan), delivered via skin patch. It prevents urge incontinence by relaxing sphincter muscles. Now, there are two more drugs to choose from: Tolterodine (Detrol LA), approved by the FDA in 1998, is in a class of drugs called antimuscarinics; it works by stopping spasms in the bladder. Side effects can include dry mouth, dizziness, headache, and constipation.

Solifenacin is also in the antimuscarinic class. In trials, episodes of urgency were reduced by as much as 50 percent with the majority of these benefits occurring within weeks. The drug performed better than tolterodine, which produced 38 percent fewer episodes. Patients on solifenacin reported fewer side effects. [10] This drug is currently in Phase III clinical trials in the United States.

Notes

1 Parker et al., 2002.

2 Hunskaar et al., 2004.

3 Zorn et al., 1999.

4 Millard et al., 2004.

5 See the Lilly site — http://newsroom.lilly.com/news/Product/2004-02-09_duloxetine_britishjournal.html

6 Barroso et al., 2004.

7 Walsh et al., 2004.

8 Boyles et al., 2004.

9 Bachmann 1995.

10 Chapple et al., 2004.

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