Bladder troubles can lead to more serious problems

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

People with an “overactive bladder,” a strong urge to urinate with or without actual leakage, have two and a half times the risk of falling as people the same age without the problem, and one and a half times the risk of breaking a bone, said Dr. Donald Ostergard, a professor of obstetrics and gynecology at UC 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 Assn. for Continence. Among patients already 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.

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.

An estimated 33 million Americans -- 17% of the population -- have “overactive bladders.”

In addition to the “urge” problems caused by muscle spasms in the bladder, millions of others suffer from stress incontinence, which means they leak urine during exertions such as coughing or jumping.

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

With a growing array of treatments, including new drugs now available, the trick is to sort out the risks and benefits.

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 bulk up the sphincter, allowing it to close more tightly.

A new trial is now starting in Canada and may soon start in the U.S., said Dr. Michael Chancellor, one of the researchers and a professor of urology at the University of Pittsburgh Medical Center.

So far, 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 government approval, said Dr. Anurag Das, director of the center for neurology and continence at Beth Israel Deaconess Medical Center.

The drug, which is already on the market as Cymbalta for depression, can cause dry mouth and nausea.

There are also about 200 surgical procedures that use sutures, slings and “bulking agents” for stress incontinence.

Some new techniques are minimally invasive, outpatient procedures that appear highly effective. But, notes Steers, these fixes for the anatomical problems underlying stress incontinence can lead to the muscle spasm problems of urge incontinence.

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 tampon-like devices that women hold in the vagina for a few minutes a day to strengthen muscles.

For overactive bladders, 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 that makes muscles contract. But these drugs can cause dry mouth, constipation, dry eyes and headaches.

Three recently approved and more selective drugs that work basically the same way with fewer side effects are Vesicare (solifenacin succinate), Sanctura (trospium chloride) 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, called InterStim therapy, involves inserting a device 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 same behavioral techniques that reduce stress incontinence may also help with urge incontinence, including biofeedback and teaching oneself to go to the bathroom on a preset schedule so that the bladder never gets too full.