Bladder problem can be more than just embarrassing

THE BALTIMORE SUN

Bladder problems, long considered a nuisance and source of embarrassment to millions of Americans, are now being recognized as a problem with serious medical consequences as well.

An estimated 33 million Americans - 17 percent of the population - have "overactive bladder," which includes a strong urge to urinate without actual leakage and "urge incontinence," that strong urge plus leakage.

It's now clear that people with overactive bladders have 2.5 times the risk of falling as people the same age without the problem, and 1.5 times the risk of breaking a bone, said Dr. Donald Ostergard, a professor of obstetrics and gynecology at the University of California, Irvine. Often, falls occur at night as people rush to the bathroom, sometimes slipping on spilled urine.

Urinary incontinence is also among the top three reasons for admission to a nursing home, according to the National Association for Continence (www.nafc.org). Among patients in nursing homes, roughly half are incontinent.

Meanwhile, caring for incontinent patients in nursing homes has become so expensive - someone has to change the bed and diapers several times a night - that some homes deny admission to incontinent patients, said Dr. Neeraj Kohli, director of urogynecology at Brigham and Women's Hospital in Boston.

Urinary incontinence also increases the risk of bladder and skin infections, as well as depression and social isolation. Some people "don't go out. They don't remarry. I had a patient yesterday who said she'd rather be dead than wetting herself all the time," said Dr. William Steers, chairman of urology at the University of Virginia School of Medicine.

In addition to "urge" problems caused by muscle spasms in the bladder, millions of Americans also suffer from "stress" incontinence, which means they leak urine with exertion, like coughing or jumping.

The enormity of this problem has not been lost on industry. Eager drug makers, surgical device creators and adult diaper manufacturers have turned these embarrassing bladder problems into a $24 billion-a-year industry.

With a growing array of treatments - including new drugs - becoming available, the trick now is to figure out which kind of bladder problem you have and sort out the risks and benefits of the treatments offered.

For stress incontinence, in which the muscular support of the bladder neck is weak, a study of 20 women by Austrian researchers recently showed that taking stem cells from a muscle in the arm, cultivating them in the lab, then reinjecting them into the urethral sphincter can markedly reduce the problem.

The cells, much like collagen injections, bulk up the sphincter, allowing it to close more tightly. A new trial is now starting in Canada and, if the U.S. Food and Drug Administration approves, one will begin in the United States as well, said one of the researchers, Dr. Michael Chancellor, a professor of urology at the University of Pittsburgh Medical Center.

There are no drugs on the U.S. market for stress incontinence. But duloxetine (to be marketed as Yentreve), which boosts levels of serotonin and norepinephrine in the area of the spinal cord that controls the urinary sphincter, is awaiting FDA approval, said Dr. Anurag Das, director of the center for neurourology and continence at Beth Israel Deaconess Medical Center in Boston. The drug, which can be prescribed now because it is on the market as Cymbalta for depression, can cause dry mouth and, in some patients, nausea.

There are also roughly 200 surgical procedures that use sutures, slings and "bulking agents" to shore up the sagging bladders prone to stress incontinence. Some new techniques are minimally invasive, outpatient procedures that appear highly effective, though these fixes for the anatomical problems underlying stress incontinence can lead to the muscle spasm problems of urge incontinence, noted Steers.

Lower-tech approaches can also help with stress incontinence, including exercises to strengthen muscles that support pelvic organs, biofeedback (in which electrical sensors placed on the skin or in the vagina or rectum help a person learn to control bladder muscles better) and various tamponlike devices that are held in the vagina for a few minutes a day to strengthen muscles.

For overactive bladder, the problem is not a weak sphincter, but uncontrollable spasms in bladder muscles. Caffeine and increased fluid intake can also trigger overactive bladder.

There are a number of drug options. The old standbys are Detrol (tolterodine) and Ditropan (oxybutynin), which stop spasms by blocking a chemical called acetylcholine, which makes muscles contract. But these drugs can cause dry mouth, constipation, dry eyes and headaches.

Three recently approved, more-selective drugs that work basically the same way, but with fewer side effects, are Vesicare (solifenacin), Sanctura (trospium) and Enablex (darifenacin).

Another treatment for urge incontinence is stimulation of nerves in the spinal cord that control urination, kind of like "fancy acupuncture," said Das of Beth Israel. One such procedure involves inserting a device called InterStim in the lower back near the sacral nerve to inhibit the firing of bladder nerves. Another option is to inject Botox into the bladder.

Finally, some of the behavioral techniques that reduce stress incontinence may also help with urge incontinence, including biofeedback. Adult "potty training" or "timed voiding" can also help - teaching oneself to go to the bathroom on a preset schedule so that the bladder never gets too full.

Judy Foreman's column appears every other week. Past columns are available on www.myhealthsense.com.

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