National Average Success Rates (50-80%)
The majority of drugs used in the treatment of DO fall into a class called Anticholinergics. Acetylcholine is the main neurotransmitter (natural chemical released in your body) responsible for contraction of the bladder muscle. Anticholinergic drugs block the receptors for acetylcholine on the bladder muscle and help weaken bladder spasms. When used in the correct dose, patients will have significant improvement in their symptoms and still be able to urinate. Unfortunately acetylcholine is responsible for many other body activities including brain function, bowel function, heart function, vision, and salivation. This means that Anticholinergic drugs may have unwanted effects including dry mouth, dry eyes, constipation, blurry vision, fatigue, and memory loss.
Fortunately, different organ systems have slight differences in their acetylcholine receptors. The important receptors on the bladder muscle are called M3 receptors. Newer Anticholinergic drugs are more selective for the M3 receptor and therefore may have less unwanted side effects. The most commonly used drugs are Ditropan® (Oxybutynin), Detrol® (Tolterodine), Vesicare® (Solifenacin), Oxytrol® (Oxybutynin Patch), Sanctura XR® (Trospium), and Enablex® (Darifenacin). Ditropan is the oldest and has been in use since the 1970s. We feel that it is associated with the greatest amount of side effects.
Most of these drugs are of very similar effectiveness and side effect profiles. Two are a bit unique and worthy of separate mention. Sanctura XR® has a molecular structure which makes it difficult to cross the blood brain barrier. In theory, it should have fewer effects on cognition (brain function). Enablex® is perhaps the most selective for the M3 receptor. This means it should have less of a tendency to affect the acetylcholine receptors of other organs. There is evidence to suggest that it is associated with a lower risk of heart and brain side effects. All of these drugs are quite safe and may be prescribed with most other medications.
Nerve Stimulation Therapy:
Success Rates: National Average (50-70%)
Zipper Urogynecology (70%)
While medication may be considered a "shot gun" for the overactive bladder, nerve stimulation therapies are more like firing with a laser guided rifle. Nerve stimulation therapies are a more precise method of treating DO and are not associated with adverse effects to other organ systems. See Gallery
Sacral Nerve Stimulation Therapy
Stimulation to the sacral nerves is perhaps the most direct method of "resetting" the overactive bladder reflex. A technique called Interstim® was FDA approved in 1997 and has been extensively used since then. Over the years the procedure and technology have matured and are now quite refined.
There are two steps to the Interstim® procedure. The first step is the "test". The test involves placing a tiny wire near the appropriate nerve and attaching this wire to a small stimulator worn on your belt for up to one week. This procedure should take no longer than 10-15 minutes and is performed in our office. Based on improvement from the test, patients continue on to the second step, implant. The Interstim® implant is about the size of a book of matches and is implanted well beneath the skin of the upper buttock. When implanted, it provides up to seven years of continuous stimulation. Zipper Urogynecology performs approximately 30 successful sacral nerve stimulation procedures each month. At the time of writing this article, Dr. Zipper is the #1 Interstim Implanter in the United States.
Tibial Nerve Stimulation Therapy
This is a newer and indirect approach to stimulation of the sacral nerves. A device called Urgent PC® was approved for treatment of DO in 2007. This device provides stimulation by sending an impulse through the tibial nerve. The tibial nerve is located just beneath the skin of the ankle and travels up inside the sciatic nerve to the nerves of the sacrum. Zipper Urogynecology provides more TNS treatments then any other urogynecology center in the state of Florida. Although it is a newer technology, we have performed over 1,000 treatments with great success and without a single complication.
TNS is an office based procedure which is administered in a series of thirty minute treatments utilizing an acupuncture type needle and a small computer. The small computer sends gentle impulses up the Tibial Nerve to the sacral nerve complex. Each or our patients receives their treatment in a private room where they may watch television, view DVD movies, or surf the internet.
Electrical Stimulation Therapy (E-Stim)
Success Rates: National Average (40-70%)
Zipper Urogynecology (40-70%)
This is the oldest of the nerve stimulation therapies. It is traditionally administered by placing a thumb sized probe with electrodes into the vagina. A painless current causes stimulation of the pelvic nerves and muscles. This is typically done at home. Although most insurance companies will pay for the device, not all devices are created equal. Many devices yield inferior results.
We have found E-Stim to be one of the least effective treatments for OAB. However, as there are no significant side effects, we do sometimes use it in combination with other therapies.
Success Rates: National Average (50-70%)
Zipper Urogynecology (50-70%)
This is a form of behavioral modification that has been shown to improve DO. The patient keeps a diary in order to determine how often, on average, they go to the bathroom to urinate. Then, following very specific rules, the patient is forced to increase this time every 3-5 days by 15 minute intervals. Compliance with the rules provided by the doctor and weekly visits to the doctor office are of tantamount importance to successful bladder retraining. When performed correctly, the brains ability to control the bladder reflex can improve. Bladder retraining is not typically successful with severe DO or Neurogenic Detrusor Overactivity. The time considerations and limited effectiveness of this therapy have caused it to fall out of favor.
Pelvic Floor Physiotherapy
Success Rates: National Average (50-80%)
Zipper Urogynecology (60-80%)
Physical therapy can be used to help patients with DO or NDO strengthen and gain control over the muscles of the pelvis. Intuitively it would seem that this would only help patients with Stress Incontinence. However, a strong contraction of the pelvic muscles can stop a bladder spasm.
The mainstay of pelvic floor physiotherapy is called Biofeedback Therapy. Small pad electrodes (EKG type pads) are placed on the skin of the abdomen and anus. These pads are typically connected to a computer screen that displays easy-to-see messages which let the patient know when she contracts the correct or incorrect muscles. Hence, the patient learns to exercise and control the pelvic muscles without contracting the abdominal muscles.
Intracystic Botox® Injection
Success Rates: National Average (40-80%)
Zipper Urogynecology (90%)
Botox®, botulinum toxin, a toxin produced by the clostridium bacteria, causes temporary muscle paralysis. It has gained great popularity in the aesthetics world to treat unwanted wrinkles of the face (weakening the muscles that cause wrinkles). The drug has also gained many off-label indications including DO. Botox® has been used in the treatment of DO for over 10 years. When used correctly, it weakens the bladder muscle just enough to prevent OAB symptoms, but not enough to cause urinary retention. If it causes retention, symptoms similar to those of OAB may occur. The patient will then report no improvement. However, as the Botox begins to wear off (approx 6 weeks), strength returns and symptoms improve. Unfortunately, the Botox will continue to wear off and in 3-5 months, most patients will need another injection. Some insurance companies will not pay for Botox.
There are few centers in the world that have performed as many intracystic Botox injections as Zipper Urogynecology. Although we find Botox to be an extremely safe and effective treatment, it is quite expensive and requires repetitive treatment. Therefore, we reserve it as one of our last treatment options.
Diet and Lifestyle
Certain foods and beverages have been associated with overactive bladder symptoms. Spicy foods, tomato based foods, fruit juice, carbonated beverages, caffeinated beverages, and even decaffeinated coffee and tea can worsen overactive bladder symptoms. There is evidence to suggest that beer consumption, carbonated beverages, and obesity may be causally associated with DO symptoms. Although water is not irritating to the bladder and certainly does not cause DO, many patients drink too much water. Remember, what goes in, must come out. Many women drink eight glasses of water each day. When asked why, they typically respond, "because it is good for you". Although water is certainly one of the safest beverages, there is nothing magical about eight glasses of water. There is no data to show that people drinking 2 glasses of water each day are less healthy than those drinking 8 glasses. However, those drinking 8 glasses will certainly be hurrying to the bathroom. Under normal circumstances, your body will tell you when to drink. With the exception of people with specific medical conditions aided by water consumption (e.g. those who form frequent kidney stones), as a rule, you should drink water when you are thirsty.