This is not so much a blog about how to treat an overactive bladder, as short quick blog to alert people using anticholinergic and antimuscarinic medications for OAB to discuss their continued use with your GP or specialist.
The role of the adult bladder is to store urine to around 350 to 500 mls filling passively – meaning the bladder should not spasm and contract during filling. With an overactive bladder (OAB), the smooth muscle pump of the bladder (called the detrusor) spasms as it fills and gives the person urgent urges to go before the bladder is full.
This can be due to:
- long term bad bladder habits
- stress and anxiety
- too little or too much fluid intake
- type of fluid taken in (caffeine, alcohol, diet drinks)
- excessive salt intake (>5g/day Heart Foundation recommendation)
- following gynaecological repair surgery
- neurological conditions
The symptoms of OAB are urgency, frequency with or without urge leakage, and nocturia. We also now understand that using a biopsychosocial approach to managing the urgent bladder (like we use with persistent pain management) has a much greater impact than just using a biomedical model alone, due to the anxiety caused by OAB.
Key Conservative Treatment Strategies for OAB
- Lifestyle advice and education
- Stress management including belly breathing and relaxation
- Bladder retraining and urge control strategies
- Neuromodulation using a TENS unit (called TTNS)
- Local oestrogen if post-menopausal
For many years, medications called anticholinergics and antimuscarinics (Ditropan, Oxytrol patch, Detrusitol, Enablex, Vesicare) have been prescribed by specialists and general practitioners to assist with overactive bladder symptoms (OAB – urgency, frequency, urge incontinence and nocturia).
Research is evolving and there is now convincing evidence of the link between an increased risk of dementia (all cause dementia and Alzheimer’s Dementia) following the use of these older medications.(1) Zheng et al (2021) showed a 20-26% increased risk of cognitive (memory) changes after 3 months on these medications and a 40-50% increased risk after 1-3 years.
If you are on any of these medications, you need to urgently discuss ceasing these medications with your doctor.
Betmiga (Mirabegron) is another medication for OAB and works in a different way. It doesn’t cross the blood-brain barrier so is not implicated with these findings.
Research has also shown that using local oestrogen (Ovestin, Vagifem Low) for six weeks and longer is effective in improving incontinence and QoL measures of OAB symptoms in menopausal and post-menopausal women.(2)
There is also strong emerging evidence that Transcutaneous Tibial Nerve Stimulation (TTNS) is effective at improving OAB symptoms as a stand alone treatment, but is enhanced by adding the previous strategies (lifestyle changes, education, bladder retraining, PFMT and effective bowel management). Recent studies have shown that TTNS and antimuscarinic medications (e.g. Vesicare) were equally effective but the medications had significant side-effect risk of cognitive changes as described above.
(1) Zheng Y, Shi L, Zhu X, Bao Y, Bai L, Li J, Liu J, Han Y, Shi J, Lu L. (2021) Anticholinergic drugs and the risk of dementia: A systematic review and meta-analysis. NeurosciBiobehavRev.;127:296-306.doi:10.1016/j.neubiorev.2021.04.031.Epub 2021 Apr 29. PMID: 33933505
(2) Lin XY (2021) An update on vaginal oestrogen for overactive bladder: reporting the literature. Australian&New Zealand Continence Journal 21(2)