What Works Best for Women Struggling With a Leaky Bladder?

Amy Norton wrote . . . . . . . . .

For women who need relief from bladder control problems, behavioral therapies are a better bet than medication, a new research review finds.

In an analysis of 84 clinical trials, researchers found that overall, women were better off with behavioral approaches to easing urinary incontinence than relying on medication.

Study patients were over five times more likely to see their symptoms improve with behavioral therapy, compared with no treatment.

Medication also helped, but not as much. Women treated with drugs alone were twice as likely to improve, compared to doing nothing.

“I think women with urinary incontinence should be encouraged to seek treatment,” said senior researcher Dr. Peter Jeppson, a urogynecologist at the University of New Mexico in Albuquerque.

“There are a variety of treatment options, almost all of which are better than doing nothing,” Jeppson said.

The findings were published online in Annals of Internal Medicine.

Almost half of women have problems with urine leakage at some point in their lives, according to the U.S. National Institutes of Health. And while men develop urinary incontinence, too, it’s more common among women, often arising during or after pregnancy, or after menopause.

The good news is, lifestyle changes often help, said Dr. Brian Stork. He’s a urologist and assistant clinical professor at Michigan Medicine West Shore Urology in Muskegon, Mich.

Stork, who is also a spokesman for the American Urological Association, was not involved in the review.

“Most urologists will prescribe behavioral approaches first, and then medication if needed,” he said.

Diet changes to cut out bladder irritants — like caffeine and alcohol — can be highly effective, according to Stork. So can exercises to strengthen the muscles of the pelvic floor. For some patients, he said, weight loss improves incontinence by relieving pressure on the bladder.

“Bladder training,” which involves scheduled bathroom trips, may also help, according to Dr. Anne Hardart, co-director of urogynecology at Mount Sinai West Hospital in New York City.

There are two main forms of urinary incontinence: stress incontinence, which causes urine to leak when the bladder is under pressure — from coughing, laughing or lifting a heavy object, for example; and urge incontinence, which causes a sudden, uncontrollable need to urinate.

Lifestyle changes can help both kinds of incontinence, Hardart said, but exercises to strengthen the pelvic floor muscles are particularly effective for the stress form.

In her experience, Hardart said, some women are able to perform the exercises on their own, with the help of written instructions. Other women benefit from physical therapy to help them “find” those deep muscles, she said.

“In general, we’re going to start with behavioral approaches because they’re risk-free,” Hardart said. But that doesn’t mean they’re “easy,” she added, since they take some commitment.

And some patients, such as those with mild dementia or the after-effects of a stroke, may not be able to learn and consistently perform exercises, Stork said. They may need medication.

For urge incontinence, medications that can calm an overactive bladder include oxybutynin (Ditropan XL), tolterodine (Detrol) and darifenacin (Enablex).

The review found that those drugs worked better than doing nothing, but behavioral tactics were generally more effective for easing urge incontinence.

There are also potential side effects, Jeppson’s team pointed out, including dry mouth, nausea and fatigue.

In the United States, no medications are specifically approved for stress incontinence, Hardart said.

But, she added, there are non-drug options beyond exercise and lifestyle changes. Some women, for example, find relief from vaginal inserts that support the bladder.

If behavior changes and medication are not enough, Stork said, another option is neuromodulation, electrical stimulation of the nerves that control the bladder.

It can be done two ways, Hardart explained. A doctor can use a needle, inserted into the skin near the ankle, to deliver electrical impulses that reach the spinal nerves controlling the bladder. In more severe cases, a device can be implanted in the buttocks to stimulate sacral nerves that affect the bladder.

The review found that when neuromodulation was used as a third-line option, women were about four times more likely to see their symptoms improve, compared with no treatment.

The bottom line, according to Hardart, is that women don’t have to live with incontinence.

“There are a lot of options to try, and many are non-invasive,” she said

Source: HealthDay


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Overactive Bladder Drug Raises Dementia Risk of Seniors

Randy Dotinga wrote . . . . . .

A drug linked to a raised risk of dementia is taken by millions of older Americans who have an overactive bladder, researchers say.

More than one-quarter of patients with the urinary problem had been prescribed the drug oxybutynin (Ditropan), an international team of investigators found.

Yet, “oxybutynin is a particularly poor drug for overactive bladder in elderly patients,” said study lead author Dr. Daniel Pucheril, a urologist at Henry Ford Hospital in Detroit.

Prior studies have linked the drug to thinking problems and increased risk of dementia in older people, possibly because of the way it affects brain chemicals, he said.

“It’s a great and effective drug for younger patients, but is a risky drug for older patients,” Pucheril said. It boosts dementia risk even when not taken indefinitely, he said.

Alternatives exist but they’re more expensive and may not be covered by insurance, at least initially, the study authors explained.

For instance, “most Medicare Part D plans have a tiered drug formulary, which means that patients must try and ‘fail’ oxybutynin before they will be eligible for the newer generation of [so-called] antimuscarinic medications,” Pucheril said.

Also, there’s debate over the safety of alternatives.

The Urology Care Foundation estimates 33 million Americans have an overactive bladder. These people often need to urinate urgently, frequently or both. Some also suffer from incontinence.

Non-medical treatments — including changes in diet, exercises and scheduled urination — are usually the first line of treatment. Surgery is sometimes an option, as are prescription antimuscarinic medications like oxybutynin.

To determine how often oxybutynin is prescribed to seniors, researchers examined 2006-2012 statistics from the U.S. National Ambulatory Medical Care Survey. The investigators focused on about 2,600 patients aged 65 and older who received prescriptions for oxybutynin or similar medications for overactive bladder. The drug was prescribed 27 percent of the time for those patients.

Only 9 percent of those who took the drug underwent a neurological exam, even though the U.S. Food and Drug Administration recommends monitoring these patients for any signs of brain problems, the researchers pointed out.

“We cannot tell if patients are being monitored for neurologic problems in other ways,” Pucheril noted.

In addition, some doctors — but certainly not all — may be unaware of the mental side effects of oxybutynin, the researchers said.

Although alternatives exist, not everyone agrees they’re safer. A 2011 paper in Current Urology Reports described darifenacin (Enablex), tolterodine (Detrol), trospium (Sanctura) and solifenacin (Vesicare) as “having little or no risk” of oxybutynin-like effects on the brain.

However, urologist Dr. David Staskin contended that “no one has ever shown that tolterodine, darifenacin, or solifenacin is safer.” He said only trospium has been shown to not penetrate very deeply into the central nervous system.

“The problem here is whether it would eliminate the risk to switch everyone to another antimuscarinic,” said Staskin, an associate professor of urology at Tufts University School of Medicine in Boston.

According to Pucheril, other possible options include a newer class of medications called beta-3 agonists, neuromodulation (zapping nerves with electricity), and Botox delivered into the bladder.

A Canadian specialist noted that immediate-release oxybutynin is the form most linked to dementia. “Older patients on the drug should consider a review with their clinician,” said Dr. Adrian Wagg, director of geriatric medicine at the University of Alberta.

There’s no evidence that a family history of dementia adds to the drug’s risk, he said, or that people who already have dementia will face the same added risk as others.

The study was released Monday at the European Association of Urology conference in London. Research presented at meetings should be considered preliminary until published in a peer-reviewed journal.

One of the study authors reported receiving a grant from the pharmaceutical company Genentech via the American Society of Clinical Oncology.

Source: HealthDay


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