Overactive bladder (OAB) is a syndrome that has significant impact on psychosocial functioning. Patients with OAB experience frequent and compelling desires to urinate, and this problem can affect every aspect of life. My patients with OAB are more likely to be depressed; they are more likely to avoid social activities, to stay at home, and be isolated because of the challenges they face due to bladder control issues. And a lot of them don’t seek treatment because it’s an embarrassing issue, or they don’t think there’s anything that can be done. One study showed that it takes people an average of seven years to finally talk to their doctors about OAB. To me, this is a real shame, because there are a lot of effective treatment options for OAB. Finding the Right Treatment As a urologist, I like to start with the most conservative, least invasive treatment options and then move on to the more involved. The first line of treatment would be behavioral interventions, also known as lifestyle modifications. These include controlling fluid intake, avoiding caffeine and alcohol, retraining your bladder by scheduling when you’ll urinate, and practicing kegels, or pelvic floor exercises. Many of my patients do well with the behavioral interventions, but some need further treatment. We’ve also found that patients who treat with behavioral modifications alone don’t do as well as patients who follow behavioral modifications and also take medications. And conversely, patients who take medications without behavioral modifications do not do as well as patients who treat with both. The combination therapy is far superior to any one treatment option alone. Medication Options There is a variety of medications on the market that are approved by the U.S. Food and Drug Administration (FDA) for treating OAB. Most of them block a receptor in the bladder, causing relaxation of the bladder wall, so you can store more urine. I tell my patients to think of their bladders as a balloon. A balloon that’s too full will pop, but if you have a very pliable, large balloon, then you can hold more volume of liquid; when your bladder can hold more liquid, you won’t have as many urges to urinate. There are side effects associated with these medications, because the receptors they block are not only found in the bladder; they’re also in different parts of the body, like the eyes and salivary glands, so sometimes people experience dry eyes and dry mouth. They're also found in the intestinal wall, so some people will have constipation. There’s some data showing that one medication, oxybutynin (Ditropan), is associated with some memory loss. For that reason, I try to give older patients a different option. Generally, patients should respond to the medication within a month. Some people tend to be more sensitive to any kind of medication, so they may experience side effects or see the therapeutic effects right away. If after a month, the patient is still not happy or seeing results, we will increase the dose or try another medication. These drugs are designed to take on a daily basis. However, although it’s not recommended by the pharmaceutical companies, I’ve found it helps some of my patients to take them on an as-needed basis. Some people need the medication every day so it gets into their systems and starts working. But for young patients with less severe problems, who don’t have incontinence, they respond well to taking the medication when they really need it, like if they’re going on a long car ride. The first thing my patients usually ask me is, “do the medications work?” That’s hard for me to answer, because it’s difficult to get a good idea of their effectiveness from the studies that have been done. Every study measures success differently, and every person measures success differently. Some studies focus on how many urgency episodes a patient experiences, while others look at the number of pads a patient uses if he or she is incontinent. And what defines success for my patients is so subjective. I have patients who went from going through five diapers a day to only using three—and they’re thrilled! I also have patients who no longer have to urinate five times a night, but they still get up once a night, and that’s not good enough for them. It really is variable. Overall, I’d say that at least 50% of my patients see improvement in their OAB symptoms when I start them on medication. And if the first option doesn’t work, we’ll increase the dose or try something new. One of my patients is a young woman who said she couldn’t even go shopping because she so frequently had to find a bathroom and it was just a logistical nightmare. After treatment, she was very happy and she actually became a spokesperson for OAB awareness. It was amazing to see how her life changed once she was treating her OAB and gaining independence. One thing I make sure my patients know is that even if the medications work well, sometimes they become less effective after a year or two. We don’t know why--it may be that the OAB itself gets worse over time, or maybe blocking the receptors is not as effective anymore after a while. Unfortunately, long-term studies have shown that there is a drop-off in patient compliance because they feel like the meds aren’t working as well. I tell my patients to let me know if they feel their medications aren’t working anymore--we can always try something new. If medications don’t do the trick, there are minimally invasive options to move on to.