Overactive Bladder: When You Have to Go, Go, Go

From the WebMD Archives

April 13, 2001 -- Kim Dunn knew there was something wrong when she had to use the bathroom every 15 minutes. "When I went, it seemed like I had to go really, really bad," she tells WebMD. "I knew that wasn't a normal pattern."

But the 45-year-old resident of Gardena, Calif. suffered with the symptoms for nearly five years before she got some help. Though she had sometimes mentioned the problem to her doctor, she rarely pressed the issue and the symptoms were never treated.

"When I went to the doctor I would mention it," she says, "but they never did anything about it -- maybe because it was never the main reason I went to the doctor."

Finally, a little over a year ago, Dunn saw an advertisement for a clinical trial of drugs to treat overactive bladder. She sought some information, and received a written test to determine if she was a candidate. "That was the first time I knew what I had," Dunn tells WebMD. "It turned out I was a lovely candidate."

Experts say that Dunn is not alone -- either in her symptoms or in the failure to get them addressed. An estimated 17 million Americans may have overactive bladder resulting in a frequent need to urinate, greater than normal urgency and -- sometimes -- incontinence. Many cases go unrecognized and untreated, often because patients are reluctant to talk about it.

"People are embarrassed about this," Daniel S. Elliott, MD, an assistant professor of urology at the Mayo Clinic in Rochester, Minn., tells WebMD. "They don't talk about it to their doctor, even though it's a very common problem, far more common than asthma. This is very definitely a quality-of-life issue. Some patients lock themselves in their house because they are too embarrassed to go out."

Yet Elliott and others say overactive bladder can be successfully treated -- with drugs or a host of nondrug strategies including exercises to train the bladder muscles, or a combination of both.

The clinical trial Dunn participated in was a 12-week study of two of the most commonly used medications -- Ditropan XL and Detrol -- to treat overactive bladder. At 37 centers around the country, 378 patients received one of the two medications and were followed for 12 weeks to compare safety and effectiveness.

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Results of the trial indicate that the Ditropan XL was as just good as Detrol in terms of side effects but significantly better in resolving symptoms, according to a report that appears in the April edition of Mayo Clinic Proceedings.

"There are now two very fine medications that can help patients who have significant problems with overactive bladder, urinary frequency and urgency, and urge incontinence -- in which patients are not able to get to the bathroom in time," says Rodney A. Appell, MD, author of the report. "Ditropan was shown to be more effective than the Detrol and had an equal ability to reduce the side effects usually associated with medication."

The study was funded by Alza Corporation, of Mountain View, Calif., which manufactures Ditropan. Appell is head of the corporation's scientific advisory board. He is also the F. Brantley Scott Professor of Urology at Baylor College of Medicine in Houston.

Ditropan XL is a new version of a drug long used for overactive bladder -- but the older version was associated with significant side effects, including dry mouth and blurred vision. As Appell explains, enzymes in the stomach and the small intestine break down the active agent in the older form of Ditropan into a metabolite, which gets into the bloodstream and causes the side effects.

But the new drug employs an ingenious system to bypass the stomach and small intestine and deliver the drug to the large intestine, which is free of the enzymes. "It's a capsule with a tiny hole in it," Appell says. "As it goes through the intestinal system it sucks in water, which pushes out the medication. That delays the delivery of the drug until it gets into the large intestine."

The drug appears to act by inhibiting release of acetylcholine, a chemical in the central nervous system that causes the bladder to contract. "In patients with an overactive bladder, the main problem is over-stimulation of the bladder muscle and the nerves going to the bladder," says Elliott, who wrote an editorial accompanying the report. "The medications are designed to blunt or lower the response of those muscles and help the bladder relax."

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Elliott says both drugs are expensive, costing about $74 per month. The high price of the treatment makes it necessary to know which is the one that gives patients "the best bang for the buck," he says.

Alan Wein, MD, professor and chair of urology at the University of Pennsylvania School of Medicine, took issue with some aspects of the trial, though. The difference in effectiveness of the two drugs, while statistically significant, was not great, he tells WebMD.

The difference in average number of incontinence episodes per week for the two drugs, for instance, was about two, Wein notes.

And he is critical of the study because it did not include a placebo to determine how much of the effects of either drug could be merely random. Finally, Wein says that a new version of Detrol, called Detrol LA -- which, like Ditropan XL, is taken once a day -- has since been developed and been shown to have even lower side effects than what was reported for Detrol.

As for all incontinence medications, Appell says most patients will need to be on medication for an indefinite period of time. But some -- perhaps 30% -- will be able to quit the medication after a short period of treatment, he tells WebMD.

Meanwhile, medication is not the only -- nor necessarily the best -- treatment for overactive bladder, says Lindsey Kerr, MD, director of the Vermont Continence Center in Burlington, Vt. She is also the spokesperson for the National Association for Continence, in Spartanburg, S.C.

"There are probably three or four [nondrug] methods," Kerr tells WebMD. "Any smart physician will not use drugs alone but will use them in combination with other methods because it works better. We don't want patients on drugs for the rest of their lives."

Kerr says typically she will ask patients to keep a diary of how much they drink and how often they use the bathroom. Sometimes, simply decreasing the amount of liquid an individual is drinking can help. Conversely, if a patient is not drinking enough water and fluids, the bladder may be irritated -- another possible cause of overactivity, Kerr says.

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By modulating the amount of liquid, she says, the bladder can often be "re-trained," she tells WebMD.

Kegel exercises, in which the patient practices contracting the pelvic floor muscles that support the bladder, can also be useful. Biofeedback -- in which patients watch a video of the muscle contracting as they exercise it -- can help patients identify the muscles so that they can practice on their own. And Kerr says there are also several devices on the market that can electrically stimulate the muscles.

Typically, Kerr says she advises patients to try a little of everything: bladder re-training, exercises, and medication. "After three to six months, we try decreasing the meds and see what happens," she tells WebMD.

Today, Kim Dunn says she no longer uses medication and no longer needs to. "I feel like a normal person now," she says.

Her advise to other men and women who experience symptoms of overactive bladder: "Be more persistent when you go to the doctor, and get them to address the issue," Dunn says. "Maybe I didn't because I got used to being like that."

WebMD Health News Reviewed by Gary D. Vogin, MD
© 2001 WebMD, Inc. All rights reserved.

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