The state of care for patients with overactive bladder

In this interview, Gina M. Rooker, MD, discusses the state of overactive bladder. Rooker is a urologist at Allegheny Health Network in Pennsylvania.

Gina M. Rooker, MD

Could you describe your current practice?

I am a general urologist, but probably 80% of what I do is female pelvic medicine and reconstructive surgery, which is a subspecialty, if you will, of urology. It's a board-certified subspecialty, and you can get there either from urology or from gynecology. There are gynecologists that qualify for that boarding as well, depending upon what your training and work is.

On a day-to-day basis, I do see a lot of patients who have voiding dysfunction of many varieties. Probably the most annoying one that people come to me with is overactive bladder, [or] urinary frequency, urinary urgency, voiding too much at night. It's a significant problem. It does increase as we get older. It's certainly a bigger problem with advancing age in the geriatric population, and it can be a tremendous source of cost for patients who have these issues, from pads to other modifications to make in their lifestyle. Many of these people are seeking a permanent solution. There's not always a permanent solution; there's a variety of different treatments for the problem.

[Many] elderly people who are institutionalized with some living situation have had problems with overactive bladder and [it’s] not necessarily something that's well treatable. As far as the ambulatory population, about 40% of the female population has complaints at some time or another with a urinary frequency urgency, urge incontinence, or frequent voiding at night. It certainly increases with advancing age. From menopause age on, it increases fairly significantly in incidence. As we get into the geriatric population, probably 85% of geriatric patients have complaints like this that aren't always that easy to fix.

Could you highlight some of the current treatment options that exist for OAB?

First-line therapy is behavioral modification, which is [things like] not drinking excessive amounts of fluids within the hours near bedtime for frequent nighttime voiding, limiting the irritating things in the diet. People tend to drink carbonated, caffeinated, acidic things. There are lots of things people can do, just from a behavioral modification standpoint, that can make their symptoms better. If that doesn't work, then second-line therapies are medications, there’s a variety of medications out there. Some of them have more [adverse] effects than others. A lot of the generic ones unfortunately, that are available to more people and available to the elderly population, have a lot of [adverse] effects.

Beyond that, then we talk about the third-line therapies. Among these, bladder Botox injection can be very helpful. It’s a little bit more minimally invasive than some modulation alternatives. It’s a temporary solution, not a permanent [one], but it can give people anywhere from 6 to 18 months of improvement in their symptoms. So, it’s a very popular thing in that respect. For the for the person with the right problems, that definitely can be quite helpful.

There's an ambulatory neuromodulation option that some people like called cutaneous tibial nerve stimulation. It's a procedure that's done in an office-type setting where people come in and they do a session of 30 minutes or so on a schedule basis where they're hooked up to a device that stimulates the tibial nerve, which seems like it doesn't make a whole lot of sense that would make your bladder better. [But] that's something that can be done on an ambulatory basis. It is helpful for some people. It's something where you have to do it on an ongoing basis in order to maintain the benefit from it. Some people like it, [but] it's not always a reasonable alternative for people.

Beyond that is a device called InterStim. InterStim is a sacral nerve modulation device where we put a lead wire alongside the third sacral nerve, which is what controls your bladder. That allows us to take control the bladder, if you will, with a computer device. So, InterStim can create longer-term solutions for people. It's a computer-based device, and a lot of older people are comfortable with that, some of them are not.

So, that's the gamut from behavioral modification to oral therapy, Botox, [and] neuromodulation that are treatment alternatives for overactive bladder. Another thing not to be discounted is pelvic floor physical therapy. [Patients are often] highly motivated [and it] oftentimes works pretty well.

OAB is a term that implies no identifiable neurological case such as stroke or spinal cord injury. Symptoms caused by a neurological problem would be classified under OAB. We try to leave that a little bit as a separate entity, because those things usually have a definite cause. It doesn't mean that we're necessarily more effective in controlling those problems. But overactive bladder is one of the generic terms.

What are some current unmet needs in this space?

I think the unmet needs here are first of all, I think we need better therapies. For the people who don't get better with behavioral pelvic floor therapy, we could definitely use better treatment alternatives for people. Although it sounds like there are a lot of treatment options, there are a lot of people who don't respond to any of those things. So, more treatment options for the future would be great. I think public awareness of the fact that that it is a treatable problem [would also be beneficial].