We recently sat down with Dr. Angel Marie Johnson, the director of our Women's Health Center in Dedham, to discuss overactive bladder. Dr. Johnson is passionate about empowering women to seek help when they experience symptoms.
And that's indeed the bottom line: there is help. Don't suffer in silence. Click here to schedule an appointment with Dr. Johnson.
Q: How common is overactive bladder in women?
Dr. Johnson: Overactive bladder in women is very common and has a high prevalence in the population. As women age, their likelihood of developing overactive bladder increases. But even young women have it. I have a patient who's 21, and she has very bothersome symptoms.
Q: What are the symptoms of overactive bladder?
Dr. Johnson: There’s a variety of symptoms, but let's discuss the three most common. First is urinary frequency, meaning people find themselves going to the bathroom often. Usually greater than seven times per day. Keep in mind that it's normal to empty your bladder every three to four hours. Yet some of the women I see go to the bathroom every half an hour or so.
The second symptom is urinary urgency. The sudden urge to go to the bathroom, where you'll essentially stop what you're doing and you have to go right away—you're running to get there.
The third symptom is nocturia, which is waking up multiple times a night (one or more by definition) to go to the bathroom. It's normal to get up zero to one time per night, but if you're getting up more than one time per night, then you're dealing with nocturia, which can disrupt your sleep and affect your quality of life.
Women who have those three symptoms have what's called overactive bladder syndrome. Women can also have urgency urinary incontinence, which is when they have that sudden urge to go to the bathroom and they leak urine. Some women leak urine on the way to bathroom and some people just spontaneously have a big accident without any provocation. This is all still part of that overactive bladder picture.
Q: How do you manage overactive bladder?
Dr. Johnson: When it comes to management, we start with behavioral modification, meaning we have patients avoid common bladder irritants. Those include caffeine, specifically coffee, which, of course, makes everyone go to the bathroom. But if you already have urinary urgency and that tendency to go to the bathroom often (frequency), then coffee can really make things worse.
Another common irritant is tea. Tea can contain caffeine, but even herbal tea, which is very acidic, can also irritate your bladder and cause you to go to the bathroom often. Other bladder irritants include alcohol and carbonated beverages. The seltzer water that everybody loves—that can irritate your bladder if you have that tendency.
So I start by looking at what the patient is drinking. Then, how much fluid are they drinking? A normal amount of fluid to consume is 42 to 64 ounces per day. Yet so many women drink liters and liters of fluid a day because they think it's making them healthy. It's not. It's just causing them to have more urine in their bladder and to have to empty it. Your urinary system is not that smart. If you fill your bladder, you'll have to empty it. So I start with behavioral modifications: limiting fluid intake and the types of fluid they're drinking.
Other treatments include medication, bladder Botox, and placing a bladder pacemaker known as sacral modulation or InterStim.
Q: What happens if the behavioral modifications don't work?
Dr. Johnson: If they're still experiencing symptoms after making behavioral changes, then we have different medications that work on the bladder. The bladder is a muscle, and when it's spasming, it's giving a false sensation that you need to go to the bathroom when you really don't. So the medications help to relax the bladder muscle.
There are two different classes of medications. The first is anticholinergic. There are multiple medications within that class. They work on the bladder muscle to relax it to allow the patient to store more urine, sleep through the night, and have their bladder be less disruptive to their overall life.
A second class of medication is newer. It's called mirabegron, or the branded name is Myrbetriq. It also works on the bladder muscle, but it works slightly differently. We like to try both of them before we say that the person can't take medications.
Q: Is there anything else that people should know regarding medications?
Dr. Johnson: Yes. First, when you're trying different overactive bladder medications, you need to try it for a full four weeks because it takes a month for it to work. It's something that you have to be devoted to taking every day for a month. Commonly, patients will return to the office and say, 'Yeah, I took it for a couple of days, and it didn't work, so I stopped it.’ Unfortunately, the patient didn't give the medication a chance to do its job. Patients have to be committed to trying a medication for 4-6 weeks in order to determine efficacy.
The second thing people need to remember is that overactive bladder is a chronic condition. I'm not going to cure you. If I give you medicine and you go back to drinking your four huge coffees a day, that will overpower the medicine. Your symptoms will come back. So treatment is an ongoing process.
When I work with patients, I say the solution involves habit changes, and habit changes need to be forever. If you're committed to regaining your quality of life, we can work together. So it's essential that I have buy-in from the patient. And usually I do, especially that subgroup of people who are really, really symptomatic, because they're desperate. They want help, and I can help them. Together we can get there, but they have to do their part.
Q: What if medications don't work?
Dr. Johnson: If the medications don't work, I'll then test their bladder through what's called a urodynamic test. It's similar to the way a stress test will test the function of the heart. It's the only way for me to best estimate how the patient's bladder is functioning in their overall daily life. The test enables me to formulate an accurate diagnosis and have a treatment plan tailored to their symptoms.
Q: What can patients expect during a urodynamic test?
Dr. Johnson: It's a 45-minute office visit. I put a catheter in the vagina, and I fill their bladder with fluid. I fill the bladder at the same rate that their kidneys would naturally fill their bladder. While I'm doing that, they're connected to a machine that tells me how much their bladder can hold. So as they're filling, I can see if they leak. I'll have them cough at specific points to see if they leak. I also can see if they have that sudden urge to urinate because the test produces a graph, so I'll visually see a spike. It looks like a peak on the graph if their bladder muscle starts spasming.
I also can measure how they empty their bladder. Is their bladder functioning normally? Is it stretching like a balloon to fill, and then does it squeeze with enough force to empty? And when it empties, does it empty well? Because some of these women feel like they don't empty well, yet they're going every 10 minutes. In reality, many of the women are emptying well, but their bladder is sending faulty signals that it is full when in reality it is empty.
As for the test itself, it's not painful. We use a numbing gel before we put the catheter in, and it's a small catheter. Patients might feel a little awkward, which is normal, because it's awkward to have someone fill your bladder. I leave the room when they empty their bladder, but it's still a somewhat awkward, yet incredibly helpful test. That's why I do it.
Q: What happens after the urodynamic test?
Dr. Johnson: From there, I talk with patients about third-line treatments. First-line treatments are behavioral change. Second-line treatments are medications, and for third-line, there are three options.
The first is bladder Botox. We inject Botox into the bladder muscle to relax it. That can work well for patients who didn't have any relief with the medications.
The second is the implantation of a neurostimulator called InterStim. The InterStim doesn't work on the bladder muscle itself. Instead, it takes a step back and it works on the nerve, because your nerves in your body are the kind of controllers that tell your muscle what to do. If we work on the muscle with a medication and we don't get the level of benefit that we want, then we take a step back in the pathway and we work on the nerve. The InterStim modulates or controls the signals that the nerves are sending to the bladder. It also controls the signals that the bladder is sending to the brain. By doing that, it helps restore normal bladder function.
The third option is called Urgent PC. Like InterStim, Urgent PC activates the nerves as well, but instead of it being a stimulator that we implant, it's external. For treatment, a patient comes in weekly, we put a small acupuncture needle near the bone in their ankle, and we connect them to a programmer. Over a half hour period, the programmer activates the nerve that then works on the bladder and calms everything down.
Like any treatment, each one of those treatments has risks and benefits which are discussed in great detail prior to the start of treatment.
Q: Is there anything else you'd like readers to know about your approach to treating overactive bladder in women?
Dr. Johnson: One of the unique things that I do when I see patients with overactive bladder is I go through a care plan with them. I show them a document that has all of the different treatments that I just described. Then, we work through that flowchart together. So they know that if plan A doesn't work, we have a plan B, we have a plan C.
Historically, what happens is women will try medicine. But if the meds don't work, they give up. They feel hopeless and then they don't come back, and they just suffer in silence. So it's important for me to let patients know from the outset that we have many treatment options at our disposal, not just medications. If the meds don't work, we can try other things.
A recent study looked at people who have chronic conditions. People who have heart failure, diabetes, high blood pressure, obesity, and overactive bladder/urinary incontinence. And what the study did is it ranked it according to how much worse or better it was than death. Meaning that you would rather die than have this diagnosis. And it was interesting that people who have bothersome overactive bladder, they actually say that syndrome is worse than death.
And I want women to know that there is help. We have a variety of options that we can try. If you're committed to working with me and doing your part, we can make a plan.
Thank you, Dr. Johnson!