Gotta Go, Gotta Go, Gotta Go Right Now
Urge incontinence and over active bladder are best summed up in this drug commercial jingle from either the late 90s or early 2000s. When you have to go, you HAVE TO GO NOW!
Often this starts as OAB or Overactive Bladder. You have to pee often. More often than all your friends. If you can’t make it through a movie at the theatre without a potty break, you may have this. If you know where every bathroom stop is between your home and your work, you may have this. If you need a depends for a car ride of an hour or less, you may have this.
Once we cross the line from Gotta Go Right Now to Went Right Now and you aren’t sitting on the toilet, then we change the diagnosis to urge incontinence. This affects about 10-20% of younger women (most of them pregnant) and increases with age to about 30% of postmenopausal women. Sometimes this is situational - like a UTI or pregnancy, but for may women, this is a daily struggle.
What characterizes the leaks of urge incontinence? Because they are caused by spasms of the detrussor (bladder) muscle, the leaks are generally large volume - often the entire bladder, often worse at night and ofter worsened by triggers like caffeine and alcohol. This is different from interstitial cystitis, though most people with IC have some element of urge incontinence. It is important to note that if this comes on suddenly or suddenly worsens, get in for a UTI check. As we age, UTI symptoms change form being more painful to causing incontinence as a primary symptom. It’s always important to rule out infection.
What can we do about this? Great news, we have more options than ever. Bad news, this is one area of medicine where prices are still too high and I hate to say that I suspect that’s because this is almost exclusively a women’s health problem.
Diet and Lifestyle modification - figure out your triggers - as stated above caffeine and alcohol are the biggest problems, but there are more specific ones - and avoid them. We also recommend limiting fluid consumption, esp when you will be in a place with limited bathroom access. Leave the Stanley Cup at home.
Timed voiding and pelvic floor PT - Training the bladder to be more patient is possible and as your strengthen your pelvic floor muscles, you will find that this is easier and easier. With the help of training devices like the the LEVA or a pelvic floor physical therapist who specializes in helping women train these muscles, you can take back control.
Vaginal estrogen - if you are peri or post menopausal and develop symptoms, often putting some vaginal estrogen back down there (which is safe for basically everyone) will help with reengerize the pelvic muscles and help calm down the bladder.
Anticholinergics - oxybutinin, vesicare, detrol, solifenacin, tolteridine - that’s a mixture of brand and generics, but it seems like brand and generic are about equal cost. One of these was initially advertised by the ditty that I used for the title, but I can’t remember which and who care anyway. These drugs work by muting a class of receptors found on the bladder. The biggest problem with them though is that the receptors they modify aren’t just in the bladder. They are in the mouth, the colon and other places. This causes their main side effects of dry mouth and constipation. These drugs can also be problematic for the elderly as they can cause a decrease in cognition. It drives me crazy that medicare requires trying 2 or 3 drugs from this class before they will pay for another class. Yet another reason I want out of the insurance rat race.
M3 receptor Agonists - Myrbetriq and Gemtessa - these newer drugss and take the word “new” with a grain of salt because myrbetriq has been on the market since I was in med school. They work on the M3 receptor, which is specific to the bladder and thus they have significantly lower side effects. Headaches are the most common complaint I’ve seen, but those are rare.
Botox - yep, you can put it there too. Using a cystoscope - a small camera that we place through the urethra and into the bladder under mild sedation - we inject the bladder wall in about 20-30 places using a total of 100 units of botox. Since we can do this in the office, it’s much less expensive that having to take a person to the operating room. The treament should last about 6-9 months and costs approximately 1300-1800 depending on how much anesthesia we need. Given that some of the above medicines are $250-500/month, it’s actually reasonably priced. The only risk is urinary retention, which is rare because we don’t inject any of the muscles of voluntary voiding.
So, if you’ve gotta go, gotta go, gotta go right now, tell your doctor. There are treatments for this problem. The biggest reason this goes untreated is because women don’t bring it up because they think either that its normal or that there are no treatments, so they don’t want to waste their doctor’s time.