Once-unmentionable medical problems, from colorectal, prostate and breast cancer to erectile dysfunction, are today discussed openly in the mass media and even enter daily conversation. But there is one widespread, distressing and treatable (even curable) condition – overactive bladder syndrome – that remains so embarrassing even doctors are reluctant to tackle it, or even bring it up with their patients.
OBS symptoms include an urgent need to urinate, frequent urination and even leaking urine (urge incontinence) before one can get to the bathroom. This occurs when the bladder – an organ composed of detrusor muscle tissue that swells like a balloon, collects and holds urine in the body before elimination – contracts suddenly without the person having control and when the bladder is not yet full. The diagnosis is OBS when no cause – such as an enlarged prostate gland or a urinary infection – can be found for the repeated and uncontrolled bladder contractions.
Besides urge incontinence, some patients suffer from urgency, in which they get a sudden urge to go to the toilet. Frequency is the term used for passing urine more than seven times a day; in many cases it is many times more than seven. Nocturia means waking up to go to the toilet more than once at night.
The kidneys produce urine 24 hours a day, sending a trickle of urine to the bladder via the two connecting tubes, which are called ureters. The amount of urine produced by the kidneys depends on how much you eat, drink and sweat. The urethra, through which urine leaves the body, is normally kept shut thanks to pelvic- floor muscles below the bladder that wrap around the urethra.
After elimination, you don’t feel the urine, but when the bladder gradually fills, you become more and more aware. When you pass urine, the bladder muscle contracts and the pelvic floor and urethra muscles relax.
Signals are sent by the brain to the nerves in the bladder to inform you how full your bladder is and order the muscles to relax or contract at the right time. OBS develops when the message system malfunctions and the muscles contract when the bladder is not full.
An estimated 20 percent of Israelis aged 40 suffer daily from OBS, but a significant share of them don’t go to a doctor to ask for help or, if they do, do not get proper treatment. Others have occasional symptoms or don’t report a chronic problem at all. Under 40, the OBS rate is 5% to 7%. Pregnant women and new mothers often suffer temporarily from stress incontinence, not because of OBS but because their pelvic floor muscles are weak.
Although general practitioners should know what to do about OBS, many of them refer patients to gynecologists or urologists, for which there may be long waiting times, thus causing many sufferers to give up.
A NON-PROFIT website, Camoni (“Like Me”), www.
camoni.co.il, which is a Hebrew-language (only so far) forum on chronic medical conditions, added a section on OBS about a month ago. Funded by the four public health funds, the Gertner research institute at Sheba Medical Center and other donors, the health/social website is increasingly consulted by sufferers.
The “OBS community” on the website is administered by Dr. Joseph Abarbanel, a senior urologist at the Rabin Medical Center-Beilinson Campus and Clalit Health Services, while the expert who is in regular contact with OBS patients is Dr. Michael Vainrib, a urologist at Clalit’s Meir Medical Center in Kfar Saba.
The website section on OBS provides authoritative articles with advice on diet, lifestyles, medications and other treatments, as well as blogs, questions-and-answer columns, chats and the ability to consult with online experts. Abarbanel said that during the first week only, 100 patients joined the website as members.
Other medical sections on the Camoni social network, for which members register at no cost, provide objective information on Crohn’s disease and other gastroenterological conditions, osteoporosis, multiple sclerosis, attention-deficit disorder, eating disorders, strokes, chronic pain and diabetes.
Vainrib completed his urology specialty at Meir in 2009 and then received a fellowship at the University of Southern California, where he specialist in neuro-urology.
Then he returned to the Kfar Saba hospital and volunteered to be in contact with OBS patients on the Camoni site.
While a high proportion of men with benign prostatic hyperplasia (non-cancerous swelling of the prostate, causing frequent urination because the organ presses against the bladder) suffer from OBS, women also have overactive bladders, and the proportion evens out to 50-50, Vainrib said in an interview. “It’s a shame so many sufferers think it’s just part of aging or are just ashamed – and don’t seek help.”
Many OBS sufferers isolate themselves, not leaving the home because of the embarrassment. Others who do venture out without getting treatment wear black clothing so the leaks don’t show, sit on the aisle at a movie theater so they don’t suddenly have to force the audience to get up for him, avoid going to places where toilets are not available or wear adult diapers.
There are more adults who wear diapers for OBS and uncontrolled defecation than babies who wear diapers.
One adult-diaper company even pays for TV advertisements in which a shapely, middle-aged woman suddenly discards her dress, showing her adult diaper. “But,” asserts Vainrib, “patients do not need to wear diapers for this condition. It can be treated! Diapers are only a temporary solution until they get help.”
Abarbanel said that in his urology department, “we see only the tip of the iceberg. Most sufferers don’t get to us.” Besides OBS cases in which the cause of the condition is unknown, there are patients with chronic disorders such as spinal cord injury, stroke, Parkinson’s disease, dementia, multiple sclerosis and diabetic neuropathy in which abnormalities in the nervous system cause overactive bladder, he continued. “These conditions are not classed as overactive bladder syndrome as they have a known cause.”
DISCUSSING TREATMENT, Vainrib proceeds from lifestyle measures to exercises, medication and – least common by far – surgical measures. He notes that consumption of caffeine – in tea, coffee, cola, chocolate and even some painkillers – should be minimized or avoided. Caffeine is a diuretic and stimulates the bladder.
One can try doing without beverages with the stimulant for a week or so to determine whether symptoms improve.
Alcohol is another beverage that may cause uncontrolled urination. But nevertheless, don’t avoid drinking water, because it prevents dehydration, and if urine becomes more concentrated, it could irritate the detrusor muscle of the bladder. Drink six to nine glasses a day of water or other non-caffeinated liquids in the winter and even twice as much in the summer or when you exert yourself.
Other things to avoid are carbonated beverages, spicy foods, orange juice and cranberry juice. The latter is a surprise, as for some time researchers claimed that drinking cranberry juice can protect or even treat urinary infections. But Vainrib said that these claims have not been proven, while the juice may irritate and even cause OBS.
Other helpful advice on the website includes going to the bathroom only when you have to. Some people mistakenly think they should go when the bladder has accumulated only a small amount of urine. But this habit can make symptoms even worse in the long term, because the bladder may become overactive and sensitive when it’s stretched only a bit.
The American Urological Association has issued guidelines for treatment of OBS that are followed by Israeli specialists (it can be found at www.auanet.org/guidelines), Vainrib said.
Pelvic-floor (“Kegel”) exercises may be helpful; these are more well known among women who have recently given birth. But, Vainrib advised, one should learn how to do them from a physiotherapist trained in this, or from a urologist. Some believe that one learns how to do the exercises by stopping the flow of urine when the bladder is full. But this is not effective. One may be contracting the muscles of the belly or other muscles, and not just the pelvic floor.
“One should learn and practice the exercise when not urinating. Once you learn properly, you can do it at home or anywhere – even every time one stops for a red light while in the car; the red light is a good reminder, and nobody knows what you’re doing.”
You should do it often, on a regular basis, like going to the gym, said Vainrib. If you stop, the muscles can weaken again. “I can teach people when I do a rectal exam and ask the patient to contract their muscle against my finger while I put the other hand on their stomach to make sure they are not contracting the muscle that is irrelevant to the needed exercise.” This treatment can be effective in about half of OBS cases.
There are various medications that can be prescribed by one’s general practitioner or urologist instead of or in addition to bladder training. “About four or five prescription drugs are in the basket of health services provided by one’s health fund,” said Abarbanel, without naming them. “They are anticholinergic drugs that block the activity of muscle, so they reduce urge incontinence.”
But since the drugs may affect other muscles in the body, in about 10% of cases, patients develop side effects such as constipation or dry mouth. Once the drugs are drugs are no longer taken, these problems disappear.
But if the medications are effective and the side effects not very troublesome, constipation can be relieved by eating significant amounts of food fiber (whole grains, vegetables and fruits], and dry mouth can be relieved by sucking menthol candies or chewing gum.
Vainrib added that glaucoma patients must not receive anticholinergic drugs. They should be prescribed only after the patient is examined by an ophthalmologist.
He reported that a new experimental medication, from an entirely different drug family, is used in the US and Europe but not in Israel, where it has not yet been registered by the Health Ministry or included in the basket of health services. “We are doing research on this drug, which is a beta-3 agonist; it stimulates the bladder muscle to relax,” the Meir urologist said. “There are seven medical centers around the country, however, that are performing clinical trials, so the drug is free to suitable patients now that the hospitals received permission from the local Helsinki Committees [for approval of human medical experimentation] to test it. The drug is meant only for OBS.”
Patients with multiple sclerosis and spinal cord injury only are entitled to get free injection of Botox (botulin toxin) directly into their bladders. “It is not permanent, said Vainrib and Abarbanel; it has to be repeated every six months to a year (or even more). This helps control unnecessary contraction of the bladder muscle. “Perhaps it will be added to the health basket next year,” said Vainrib.
He added that another effective treatment, neuromodulation, was rejected by the basket committee at the last minute. It involves a subcutaneous (under the skin), programmable sacral stimulator. This delivers low-amplitude electrical stimulation via a lead to the sacral nerve, which is located in the upper, outer quadrant of the buttock. The stimulator can be implanted in the buttock, or alternatively in the lower abdomen. There is a small remote-control device that the patient needs to use only if he wants to change the volume of electrical stimulation; if not, it works by itself. The battery needs to be changed only once in five to seven years, said Vainrib.
An alternative to this minor surgical procedure is “posterior tidial nerve stimulation or PTNS, which may performed as maintenance in the clinic for half an hour every three months. The electric stimulation device works in 70% of OBS cases. This device is similar to the TENS (transcutaneous electrical nerve stimulation device used by women in labor or people suffering from chronic pain. But Vainrib said that urologists will not formally recommend this until research here proves is it effective, adding that “we are doing it in my hospital.”
A very small minority of patients (maybe 0.5%) who don’t get relief from the above decide to undergo surgery.
One type is called augmentation cystoplasty. In this operation, a small piece of tissue from the intestine is attached to the wall of the bladder to increase its size.
The most drastic type of operation is urinary diversion, in which the ureters are routed directly to the outside of the body to prevent urine from reaching the bladder.
This procedure is carried out only if all else fails.
“Family doctors should take the initiative and raise the subject of possible OBS in their patients over 40. I give lectures to general practitioners about this,” Abarbanel concluded. “Patients should not think there is nothing to do, or that it will pass by itself. OBS doesn’t kill; it affects the quality of life. Since overactive bladder is the number-two cause reducing the quality of life in patients – after clinical depression – patients and their families must seek help.”
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