When we think about overactive bladder (OAB) treatments, many of us inevitably focus on the many medications that we can use to treat the symptoms of urinary urgency, frequency or urgency incontinence. Or perhaps we might even think of more advanced therapies such as botulinum toxin, sacral neuromodulation or percutaneous tibial neuromodulation. However, patients and health providers should be careful not to dismiss everyday changes that can be made without ever going to the pharmacy or visiting the doctor’s office. In fact, because behavioral changes can be so important, the current American Urological Association guidelines on OAB urge providers to offer these as first-line therapies. Even better, behavioral treatments are as effective as medications with few if any side effects. For those people who may eventually require medications or more advanced therapy, multiple studies confirm that these treatments are made more effective if combined with behavioral treatments.

Behavioral treatments for OAB include fluid reduction, diet changes, weight loss, and pelvic floor exercises. Bladder training (BT) is another means of behavior therapy for OAB that can be effective in a properly motivated or dedicated person. BT begins with education about overactive bladder often accomplished with brochures, websites or videos. Completing a record for several days of how often one voids (and whether there is an urgency to void) helps to identify a time interval of typical urination. The goal becomes to gradually increase that interval, usually by 30 minutes every 1-2 weeks. There are numerous distraction techniques (pelvic contractions, relaxation techniques) that can be used to ignore any urinary urgency that comes in between the interval.

How effective is bladder training? Trials comparing BT to the most common medications used to treat OAB show that it is as effective as medications with fewer side effects. Perhaps more encouraging, other therapies including medications, are more effective if you add bladder training. So, not only can behavioral therapies be used to treat OAB on their own, but they should be continued even if you move on to other therapies.

It should be remembered that bladder training can be difficult. It requires time and attention that some people are not able to devote. The number of patients remaining adherent to bladder training tends to be low in many of these studies. We certainly could use better tools to make this therapy more successful. Yet, for the determined patient who wants a successful therapy without the cost or side effects of medication, BT can be a wonderful therapy.

Colin M. Goudelocke, M.D.

I suspect that if you ask most people (including most health providers) whether it is normal to have bacteria in the bladder, you would hear an emphatic “NO!”. The conventional wisdom has long been that the bladder is a sterile environment. But for many years there has been mounting evidence that this simply is not true. A recent review article written by Thomas-White et al provides an excellent history and summary of our developing understanding of normal and beneficial bacteria found in the bladder. These authors also detail their own research which is helping to lead to a radical new understanding of what constitutes a healthy bladder.

This enlightening paper begins by pointing out that our misunderstanding of urine as sterile dates back to the 19^th century when we were just beginning to grasp the nature of bacteria. This idea of a sterile bladder delayed one of the most important advancements in our treatment of patients with neurologic injuries of the bladder: self-catheterization. Prior to the 1960’s, patients with urinary retention were not told to self-catheterize out of fear that it would lead to infections. Unfortunately, the opposite is true and infections are actually prevented by catheterization in these patients.

Most importantly, the authors detail their ground-breaking new work that is advancing our understanding that not only are healthy bladders full of bacteria but that some of these bacteria may be very beneficial for bladder health. Their research identifying bacteria that are clearly alive and present in the bladder suggests that patients with overactive bladder (OAB) may lack an abundance of certain Lactobacillus species. These are the same types of bacteria thought to be protective of infection in the intestine and vagina. It may be that these types of bacteria are also protective against developing urinary tract infections.

For decades we have been guided by an overly simple understanding of the bladder and urine that today seems just plain wrong. This may even influence our current over-use of antibiotics, particularly as it relates to bladder bacteria.  Perhaps our abundant use of antibiotics may predispose some patients to recurrent urinary tract infections by killing beneficial and protective bacteria in the vagina and bladder. It is wonderful to see such cutting-edge scientific study that may one day revolutionize the way we approach our bladder health.

Colin M. Goudelocke, M.D.

Many people blame their frequent visits to the bathroom every night on an overactive bladder (OAB) or, for men, an enlarged prostate. While these may be frequent causes of nocturia (waking up to urinate more than one time per night), an often overlooked cause is obstructive sleep apnea. If you wonder how sleep apnea could cause you get up multiple times at night to urinate, a recent study by Miyauchi et al  confirms both the relationship between nocturia and sleep apnea as well as the improvement seen with treatment.
We begin by noting that many patients who get up frequently at night do so because they make too much urine at night. The bladder is simply filling up more quickly than it should. Normally for young people, no more than 20% of your daily urine production should come while you are asleep. In older patients, less than 33% is more normal. Patients who exceed this are said to have nocturnal polyuria, meaning they make too much urine at night. This is easily diagnosed by having patients keep a diary for several nights to measure how much urine they make during the night compared to the day.

While there are several causes of nocturnal polyuria, an often overlooked one is obstructive sleep apnea. Blockage of your airway in sleep apnea results in a lot of negative pressure in the chest as you try to breathe (try closing your throat and taking a breath).  This causes more blood to return to the heart. When this part of the heart expands from the extra blood, it releases a hormone (atrial natriuretic peptide) that makes you make more urine. It’s as if the body thinks there is too much blood volume (maybe you drank a lot of fluid) and tries to get rid of the excess fluid. So, patients with obstructive sleep apnea make too much urine at night.

The encouraging news is that treatment of the sleep apnea such as with a mask providing continuous airway pressure (CPAP) not only treats the sleep apnea but also will reduce the urine production and the nocturia. So next time you find yourself getting up that 3^rd or 4^th time at night, consider having an evaluation of whether you are making too much urine at night. If so, a test for sleep apnea may be in order.

Colin M. Goudelocke, M.D.

Voiding difficulty in women may include difficulty starting or maintaining the urine stream or the need to push or strain to empty the bladder. Often this voiding dysfunction results in incomplete emptying of the bladder. While it can result from more easily identified causes such as a previous incontinence surgery or advanced bladder prolapse, quite often the reason for the voiding dysfunction is not clearly known. Often, patients are treated for this voiding difficulty by undergoing a procedure to stretch the urethra (the urine tube that exits the bladder). This is called urethral dilation. And though this may be a commonly performed therapy, this review by Basu and Ducket accurately points out that there is little evidence to support the continued use of routine urethral dilation in the treatment of voiding dysfunction.

The authors detail the history of urethral dilation beginning in a time when very little was known about normal voiding.  Dilation of the urethra emerged as a treatment for numerous problems including urinary tract infections and bladder pain. The assumption was that these issues resulted from a urine tube that was too narrow to permit proper emptying of the bladder. However, it is now known that spontaneous narrowing of the urethra (urethral stenosis) is uncommon and probably represents only 1-2% of patients with voiding dysfunction. This is much less common than the frequency of urethral dilation would suggest. One concern is that repeated urethral dilation can even be the cause of narrowing of the urethra due to fibrotic healing.

Perhaps the popularity of urethral dilation is because it can produce a short-term effect, making voiding easier and relieving some symptoms such as incomplete bladder emptying. This is likely due to the temporary malfunction of the urethra and surrounding muscles caused by the stretching. This temporary benefit disappears in over 80% of patients by 6 months. And this may cause new urine leakage in nearly 20% of patients. Even patients with improvement are likely to be subjected to repeated urethral dilation to maintain this temporary effect.

There are treatments for voiding dysfunction that is either more effective or at least do not carry the risk of new urinary incontinence or development of urethral stricture. Patients may benefit from pelvic floor physical therapy using biofeedback, which may help to train patients to relax the muscles that constrict the urethra when voiding. Medications may help to relax these muscles as well. Finally, in patients who do not improve with biofeedback or medications, neuromodulation or botulinum toxin may be useful. These treatments rely on a better understanding of the complex interaction between the bladder and urethra that produces normal urination.

Outside of a small percentage of patients with urethral stricture (who often need a more extensive surgery rather than urethral dilation), urethral dilation provides, at best, a short-term fix that may carry significant risks. With little evidence to support its use, urethral dilation should become a rare treatment, not a common one.

Colin M. Goudelocke, M.D.

Thanks in no small part to the marketing efforts of companies that produce treatments for overactive bladder (OAB), the term “OAB” has become relatively well known among health providers and the general public alike. The fact that the term has become so common and well accepted has been a source of criticism by some who feel that it doesn’t adequately describe the symptom complex it is associated with it.

But where does the term even come from? A review of the history of the term “Overactive Bladder” by Cardona-Grau and Spettel is a fascinating exploration of how this term came to be commonly used. They point out the very interesting way in which the name OAB has been influenced by the syndrome it describes, but also how thinking about these symptoms as “overactive bladder” has influenced the way we approach and treat it.

The authors of this review note that the origin of the name overactive bladder is credited to Drs. Wein and Abrams, two giants in the field of urology, particularly bladder health. It reflects their understanding of how the symptoms of urinary urgency, frequency and sometimes incontinence are perceived by patients. It also was a term they were already using with their patients to make their condition more understandable. It took away the stigma that was attached to previous terms such as “unstable bladder” that may have made patients feel that their mental stability was being questioned.

But the term also has had an influence on the way we think about and study OAB. Prior to the introduction and later acceptance of a standard definition for OAB that is based on symptoms reported by a patient, previous definitions relied on the findings of an invasive test called urodynamics. In contrast, the definition of OAB can be applied without the need for expensive and invasive testing. It can be used by specialists and general practioners alike. I like to point out that patients are generally able to self-identify all of the symptoms we associate with OAB (even if they can’t always rule out other causes of those symptoms). The change to using the term overactive bladder largely coincided with the development of recommendations that the initial evaluation of OAB should not involve advanced testing, with a history and physical exam largely sufficing.

And while it is often noted by critics that the term OAB has been used effectively for marketing purposes by the pharmaceutical industry, the term was not invented by marketers or for marketing. Rather, it has served as a useful starting point for an understanding, by both patients and physicians, that can lead to a better and more thorough understanding of just what is this thing we call “OAB”.

Colin M. Goudelocke, M.D.

If you are a coffee drinker and you suffer from symptoms of overactive bladder (OAB) such as frequent urination or urgent urination, it is a very safe bet that someone (very often your health care provider) has told you to cut out the caffeine. Caffeine can serve as both a stimulant, an irritant, and a diuretic so it should follow that it must lead to overactive bladder, right? That has been the conventional wisdom for years, though we should always be careful to check that our wisdom is really based on facts.

A recent review article by Palma and Staak provides an overview of the most recent studies about the effects of caffeine on the bladder. When taken together, these studies demonstrate that drinking more than 2 cups of coffee per day (>200mg caffeine) is associated with worsening symptoms of overactive bladder. The effect does depend on the dose and more than 4 cups of coffee per day may result in developing symptoms of OAB even in patients with no symptoms before.

One bit of good news is that the small amount of caffeine found in decaffeinated coffee does not appear to have a negative effect on OAB symptoms.

In this case, the conventional wisdom, dispensed for years by friends, family and even your health care provider appears to be spot on. You may want to skip that extra cup of coffee tomorrow if you have a long meeting in the morning.

Colin M. Goudelocke, M.D.

In a digital world that provides endless distraction, we tend to focus on those things that directly affect us or those we care about. We are drawn to the local news, the posts of our friends, or just tomorrow’s weather forecast. Judged by this standard, for most of us, Overactive Bladder (OAB) doesn’t always seem to have that personal impact. But whether we realize it or not, almost all of us know someone well who suffers with OAB (or we suffer ourselves).  And the impact of these symptoms – financial, social, personal – is immense.

A recent review article by Reynolds et al. is an eye-opening reminder not only of how prevalent OAB is but also what an out-sized impact it has on the lives of those who live with it.  The authors note that the development of a precise and easily-used definition of OAB based on patient symptoms rather than invasive testing has allowed a better sample of how common OAB really is in the United States. Though there is some variation among the larger studies looking at the prevalence of OAB, it seems likely that around 30% of women and 16% of men report symptoms of urinary frequency or urgency at least some of the time. Up to 11% of women report urinary incontinence associated with OAB. This means that about 37 million women in the United States have overactive bladder with 14 million of them experiencing urinary leakage. To put this in perspective, more people have OAB than diabetes, asthma, or arthritis.

The individual impact of OAB on daily life can be enormous. Much of this effect can be attributed to the embarrassment and distress that urinary leakage can cause. OAB isolates, forcing people to avoid friends, family and many of the activities that they may enjoy.  For someone who has to rush to the bathroom every 30 minutes, worshiping at church, seeing a movie with friends, or going to a basketball game is virtually impossible. The authors in this review note studies finding that over 1/3 of people with OAB report their daily activities curtailed by OAB symptoms and 12% even report staying at home because of their OAB. It is not surprising that many people with OAB gain weight when they are not able to exercise regularly due to their symptoms.

Even if you don’t personally have overactive bladder or know someone who does (though you almost certainly do), as a society we pay a heavy price for OAB. Overactive bladder costs each of us the equivalent of $426 per year in lost productivity and more than three times that in pads, medications and other treatments. The review by Dr. Reynolds and collegues cites a study estimating that by 2020 OAB may cost us over $82 billion. That is more then the US government spends on education each year.

For those who personally experience OAB, there is little question of its enormous impact on everyday life. But for the rest of us, there is no denying that overactive bladder should demand our attention.

Colin M. Goudelocke, M.D.

The diagnosis of overactive bladder (OAB) depends on identifying urinary symptoms of frequency, urgency or urgency incontinence. Diagnosing OAB is not like checking for high blood pressure or diabetes. The symptoms that identify OAB are typically reported by patients rather than being directly observed by the health provider. It seems natural to question what would be the best way to identify and measure these symptoms.

Short questionnaires of a dozen or so questions about urinary symptoms are often used to classify bladder symptoms as well as to measure their severity. These are attractive because they can be completed quickly and easily and do a very good job of characterizing OAB.

The bladder diary is a written log that may include information about how frequently urination happens, how much urine is produced with each void, how much liquid is consumed, whether any urine leakage occurs, and what was happening when leakage occurred. A recent review article by Dixon and Nakib expertly summarizes the important studies that show the usefulness of voiding diaries in bladder care.

The authors begin by pointing to several studies that demonstrate that voiding diaries are completed by the vast majority of patients asked to do so. Furthermore, most patients find these diaries easy to complete and they report that completing a diary was helpful to them. We often find that patients gain significant insight about how frequently they void and the relationship of their symptoms to behaviors such as how much they may be drinking. It is not unusual to see improvement from the first to the last day of a diary as the patient begins to modify her behavior in response what she sees in the diary.

Voiding diaries can be very useful for identifying specific problems. Patients who consume too much fluid will quickly be identified and can be given very specific recommendations as to how much to reduce intake. A voiding diary showing an excess of urine produced at night can give a clue to medical problems including sleep apnea or congestive heart failure. Finally, a voiding diary can be a very useful way to distinguish between stress incontinence and urgency incontinence.

In modern medicine, we frequently focus on complex, sophisticated and often expensive tests that often do provide useful information. But, when evaluating OAB, we would do well to remember a very simple study that costs just pennies in copy costs but can provide a wealth of information.

Colin M. Goudelocke, M.D.

Urinary tract infections (UTI) affect up to 60% of women over the course of their lifetime. These infections result in bothersome symptoms including frequent, painful urination, they lead millions of people to seek medical care and they cost billions of healthcare dollars each year. Is it any wonder then that we would hope to find some way to prevent recurrence of these infections? For many, that hope has been placed in the tart little berry that makes its appearance each Thanksgiving. But how effective are cranberries at preventing infection? What about all of the cranberry extracts that we see? As with so many aspects of medicine, the answers may not always be as simple as we would like.

First, let’s talk about cranberry juice. Early on, several studies indicated that cranberry juice was effective in preventing recurrence of urinary tract infections. A class of chemicals called proanthocyanidins (PAC) found in cranberries are thought to keep E. coli (the most common cause of urinary tract infections) from binding to bladder cells. It seemed to make sense that drinking cranberry juice would prevent infections from recurring. However, PAC breaks down after 10-12 hours meaning people would need to drink cranberry juice twice daily to maximize the benefit. Furthermore, many studies show a lot of people just don’t like the tart taste of cranberry juice and stop drinking it (sorry, the sugar-sweetened 10% juice cocktail won’t cut it here). Finally, as more and more studies have been done, fewer of them have shown a benefit and, overall, the evidence for cranberry juice has been questioned. When taken as a whole, it seems more likely that cranberry juice doesn’t make much of a difference in preventing infections.
What about cranberry extracts? There are studies that show benefits from capsules containing extracted PAC, especially in certain populations that are at high risk of getting new infections. Unfortunately, these extracts suffer from a lack of standard make-up. By that, I mean that the amount of PAC from one supplement to another varies greatly. For example, one study found that the amount of PAC across 7 different cranberry extracts varied by 30 times. So, one brand of extract contained 30 times the amount of PAC compared with another. With so much variability, it is very difficult to know whether these capsules can prevent infections. So, again, when we look at all of the studies together, it seems less likely that there is much of an effect.

What to do? Well, there are studies ongoing for both cranberry juice and cranberry extract supplements that may find particular doses are effective or that certain types of people may benefit, so stay tuned. There are other compounds such as d-mannose sugar that may prove to be useful as well. Women with recurrent urinary tract infections may benefit from a medical evaluation to see if there is an underlying urologic problem that may be causing recurrent infections. I often find in my practice issues such as complications from previous surgeries that can explain recurrent infections. It may even be that our over-use of antibiotics may precipitate infections by killing of normal, beneficial vaginal bacteria. There is at least some evidence that probiotics (essential doses of healthy bacteria) may provide benefit, though these studies are ongoing.

Colin M. Goudelocke, M.D.

Historically, management of overactive bladder (OAB) can be seen to have failed to fully address the needs of patients. A majority of patients with OAB report their symptoms have a significant impact on daily living and seek medical help. Yet in at least







one study (which, is, admittedly, more than 15 years old) only about 1/4 of those patients were receiving treatment at the time evaluated. Half of those patients who did not seek treatment believed that no treatment was available. Furthermore, we know that a significant number of people will fail to see satisfactory improvement with early therapies including behavioral changes and medications.  Few of these people are treated with more advanced therapies intended for those patients patients with these refractory symptoms.

A care pathway is a set of steps designed to effectively manage a patient’s journey from disease to health. It is essentially a “roadmap” of how we believe a patient should be diagnosed and treated for a given problem.

It provides a standard set of instructions as to how we should care for patients and should be based on the most current guidelines and evidence available. It would seem logical that an optimized patient care pathway for OAB should lead to better outcomes. Furthermore, illustrating the care pathway in a way patients can see and understand (we use a “roadmap”) can help patients to see what to expect as they undergo evaluation and treatment.

In developing our OAB Care Pathway, we first sought to define what the initial steps should be in evaluating patients thought to have OAB. The initial evaluation of OAB begins with a thorough, but otherwise simple evaluation including a history of symptoms and other medical problems, as well as a physical exam designed to identify any other conditions that may mimic OAB. It is clear that for most patients with OAB, expensive and invasive tests are not needed for the evaluation.

An OAB Care Pathway should define the appropriate therapies for treating OAB. This includes behavioral changes, oral and dermal medications, percutaneous tibial nerve stimulation, sacral neuromodulation, and botulinum toxin. An optimized pathway considers not just what treatments can be used but the ideal order for those treatments. In the case of OAB, you would not want to begin with a treatment such as sacral neuromodulation before trying a more conservative therapy such as behavioral changes or medications. Again, consultation with available guidelines is helpful in defining which therapies are appropriate and when they should be used.

It is important for patients to have an idea of how long they should expect before a treatment begins to work. We use “mile markers” along the way so that patients can anticipate how long before they may see improvement.

A care pathway does little good if patients are blocked from making progress by barriers such as treatment side effects, problems with insurance coverage, or need for more advanced testing. In The OAB Clinic, an OAB Navigator assigned to each patient serves as a guide along the journey. She can help patients get back on track by answering questions, helping to facilitate medication changes, or arranging ahead of time for any needed tests. This helps to decrease the need for frequent visits, eliminating many of the “stops” along the way.

In The OAB Clinic, a part of UT Erlanger Urology in Chattanooga, Tennessee, our use of an optimized Patient Care Pathway has helped to significantly reduce those patients who leave the road to bladder health because of confusion or frustration. We have seen the number of patients “lost” plummet from about 70% to about 7%. This means that more patients are able to reach their bladder goals. With our care pathway, we hope to continue to change the history of OAB for all.

Colin M. Goudelocke M.D.  FPMRS