WHAT IS OVERACTIVE BLADDER (OAB)?
The average adult female urinates up to 8 times per day. If you are urinating more frequently than this, your bladder is considered to be overactive. The condition can manifest as urgency to urinate, urge incontinence (UUI), frequency incontinence and nocturia (needing to pee multiple times during the night). Any combination of these symptoms can be a sign of overactive bladder (OAB). Those who suffer from OAB need to know where the bathroom is at all times and even then, there is a risk they won’t make it. The bladder muscle (detrusor) contracts prematurely, without warning, causing a sudden urgent need to urinate. It can be difficult or impossible to control this urge. Unlike stress incontinence, this condition is not triggered by exertion.
Whereas the exact cause is not implicitly known, it is believed to be more neurologic in nature. Episodes of overactive bladder can be triggered by factors such as excessive coffee or alcohol consumption. Age is also a contributing factor, however overactive bladder should not be considered a normal sign of ageing. Overactive bladder is clinically defined as an overactive bladder in the absence of any of any pathology (disabilities, illnesses, infections or injuries that can cause OAB symptoms).
If you suffer from multiple sclerosis (MS) or have a spinal cord injury, you may suffer the same symptoms as OAB, however, Reflex incontinence (neurogenic bladder) is the term given in this case. Functional incontinence also produces similar symptoms to OAB but is unrelated to your bladder and urinary tract, for example, if you have Alzheimer’s, Parkinson’s or have a stroke. Function incontinence is also the term used to describe incontinence caused by conditions that produce excessive urine such as diabetes. Functional incontinence can also be a side effect of infection, medication or medical treatment. You can read more on Function and reflex incontinence on the page for those conditions.
HOW CAN I KNOW THE SEVERITY OF MY INCONTINENCE?
With overactive bladder, leakage is not always experienced. If you are urinating more than 8 times per day but not experiencing leakages, you don’t need to do the Sandvik test. If you are experiencing leakages, then you are displaying urge incontinence (UUI) as part of your overactive bladder. Leakages with UUI can vary from a few drops to complete emptying down to the floor. Studies have shown the Sandvik test to be a good indication of incontinence severity. You can use the Sandvik test to determine your level of incontinence. Your urologist may also use the Sandvik test. Minimum score 0, maximum score 12. The higher the score, the higher the degree of incontinence.
I HAVE OAB, DOES THIS MEAN I HAVE NERVE DAMAGE?
Although nerve damage can result in the symptoms of overactive bladder, it is not necessarily the cause. The autonomic nervous system is not under your conscious control. The parasympathetic (PNS) and sympathetic (SNS) nervous systems are both part of the autonomic nervous system. Even though you cannot consciously control these systems, you do have the possibility to train yourself to have some level of control over your sympathetic responses.
When you are potty trained as a child, you learn to read your body’s guarding reflex, which is controlled in part by the PNS and SNS, and in turn to control how your body responds by holding your urine until a bathroom is found. This is an example of gaining control over your sympathetic responses or in lay-mans terms, you could say you are “positively programming” your bladder function.
In the same way, you can “negatively program” your bladder. Negative programming of your bladder is caused by “just incase” peeing (JIC). If you JIC pee, you will change how your SNS interprets the volume of urine in your bladder. This will result in an increase in your frequency of urination; therefore you will pee smaller amounts more frequently. Over time, this can impact the function of your detrusor (bladder muscle) as your sensitive stretch receptions become unfamiliar with the feeling of a full bladder.
Hopefully you have read the description of the urination cycle (micturition cycle) on the urinary incontinence page. You may recall that guarding reflex signals are sent to your external urethral sphincter to increase the level of contraction in conjunction with the increasing volume of urine in the bladder. If you consistently empty your bladder when it is only partially full, this will result in less involuntary increases in contractions of external urethral sphincter. This in turn can reduce the strength of the sphincter which can lead to stress incontinence!
I AM WAKING DURING THE NIGHT TO PEE, COULD THIS MEAN I HAVE OVERACTIVE BLADDER?
As you get older, the likelihood of waking during the night to pee is increased. Waking more than once per night (nocturia) is a symptom of overactive bladder. Nocturia can also be caused by drinking too much before bedtime. If you “just incase” (JIC) pee all the time, this can also lead to nocturia as your bladder may believe it is full when only partially filled.
IS WETTING THE BED A SYMPTOM OF OVERACTIVE BLADDER?
Adult bedwetting (enuresis) can happen with overactive bladder when urge incontinence (UUI) is also present. However, enuresis is more commonly reported in cases of overflow, functional and reflexive incontinence. Enuresis is also common with alcoholism. With both nocturia and enuresis, you should speak to your doctor as interruption of sleep can lead to poor health which will negatively impact your ability to heal thus further reducing your quality of life.
CAN PELVIC FLOOR MUSCLE TRAINING (PFMT) TREAT MY OVERACTIVE BLADDER?
PFMT plays an important role in bladder retraining which is a pivotal overactive bladder treatment, even when you do not experience leakage. As explained on the Urinary incontinence page, contractions of the external urethral sphincter are an automatic response to the guarding reflex. If your bladder is sending signals to say that it is full before time, you need to tap into the guarding reflex. You do this by deliberately contracting your external urethral sphincter, which is a core component of a Kegel, the most basic pelvic floor exercise. Not only does pelvic floor muscle training help with bladder retraining, it is also used to treat incontinence and can help to improve the quality of your orgasms.
WHAT IS BLADDER TRAINING (BT)?
Bladder training is where you “positively program” your bladder taking advantage of your ability to control your sympathetic responses. Just like potty-training, this positive programming helps to return normal bladder function. An important part of bladder training is taking a baseline to establish where you are right now, and then tracking your progress over time. This is done using a bladder diary where you track your fluid intake and measure the volume of urine voided.
Each time you drink something, you need to measure the how much liquid you drink. When you urinate, you need to measure how much urine you void. You will need to have a measuring cup in the bathroom or a urine measuring pan (see the products section below) to collect and measure the volume of urine. If you are on the go, a Collapsible Measuring Cup will allow you to keep track of your urine when out and about. You can keep it in a sealable plastic bag and rinse it out after each use.
WHAT IS A BLADDER DIARY?
Your bladder diary is a record of the volume of liquid that you drink and pee each day. You can record this information with pen and paper or alternatively, you can download an app. If you would like to use the paper method or are uncomfortable with logging your information in an app, we have created a printable pdf file which you can use.
We have also created an editable version so you can still track digitally but your information is not stored anywhere but on your computer. The digital version will total your daily drink and urine volumes automatically. If you opt to use this digital version, save it to your computer and rename it each day with the date in the name so you have a daily copy.
IS THERE ANYTHING ELSE I CAN DO COMBINED WITH MY PFMT & BLADDER TRAINING?
Yes, lifestyle can have a big impact on your bladder function. If you only focus on bladder retraining and pelvic floor muscle training, you could be missing contributing factors in your lifestyle that can limit your success. Taking a whole body, whole life, whole mind approach to your treatment should improve your chances of getting control of your overactive bladder.
Your bladder function is impacted by many factors, including your activity level. Studies have shown that health is negatively effected by sedentary lifestyles. In one study, they concluded that physical activity is associated with a decreased risk of bladder cancer. Whether you are striving for optimal health or trying to treat OAB, moving more should be of benefit.
If you are experiencing leakage with your incontinence and have a BMI over 25, losing some weight can help to reduce the severity of your leakage. For every additional unit increase in your BMI, your risk of developing incontinence increases by 1%. If you are obese your risk of developing incontinence is doubled. Consider losing some weight if needed.
The food you eat and liquids you drink can have a big impact on your bladder function. Many foods and drinks act as bladder irritants, such as spicy foods, sweeteners, caffeine, carbonated drinks and alcohol. You should limit your intake of these foods while you are treating your OAB, and consider maintaining low intake of these foods once your condition has subsided.
You also need to consider the impact of constipation, which negatively impacts your pelvic floor muscle function. Try to keep bowel movements between 3 or 4 on the Bristol stool scale. A diet high in fibre can help with this. You can work with a nutritionist to create a diet that works for you.
If you are under stress, it is likely that your parasympathetic nervous system is dominant, meaning your system is running in “fight or flight” mode. You may recall that your parasympathetic nervous system is responsible for contracting your bladder, while your sympathetic nervous system keeps it relaxed. A 2015 study concluded that patients with OAB reported psychological stress levels that were significantly higher than healthy participants.
If you are consistently under stress, you should take active steps to reduce your stress levels. Try to spend time with people who make you feel positive and happy. Try to avoid stressful situations and add a daily meditation practice. You can use apps such as Calm for meditation. Gentle yoga is also good for reducing stress levels so maybe sign up to a local class.
Did you know that smoking impacts your autonomic nervous system (SNS/PNS)? A 2015 study found that Overactive Bladder (OAB) was common amongst smokers and female smokers significantly complained of nocturnal enuresis (bedwetting) and coital incontinence (peeing during sex). If you are suffering from OAB, reducing the amount you smoke or quitting completely could have a positive effect.
There are numerous products available to manage the symptoms of incontinence from pads to pessaries. There are also devices to aide pelvic floor muscle training ranging from weights to electronic stimulation devices. You should check with your urologist or pelvic health physiotherapist before using electronic stimulation. Reviews of these products will be covered in our YouTube channel. If there is a specific product that you would like to see reviewed, just contact us and we will review. The images below link to the products on in your local amazon store.*
* I am an affiliate of amazon and will receive a small commission should you purchase through one of these links.
BLADDER RETRAINING HAS NOT WORKED FOR ME, WHAT NEXT?
Bladder retraining takes time. The more severe your level of overactive bladder, the longer it will likely take. A “can do” attitude really helps. It took me a couple of months to fully retrain my bladder, but one and a half years to go from severe incontinence to very occasional stress continence following removal of my mesh sling. Consistency was key to my bladder retraining and pelvic floor rehabilitation. The lifestyle changes have a very dramatic impact and I found that making small changes slowly over time made it easier to implement big changes in my lifestyle. I provide help in the book on setting goals that make it easier to make the accumulative changes needed. Make sure you give yourself time with all conservative treatments. Your urologist and physiotherapist can advise if other treatments are necessary.
WHAT OTHER OVERACTIVE BLADDER TREATMENT OPTIONS DO I HAVE?
With OAB, the more invasive treatment options are limited to medication and nerve stimulation. We will give a description of these options below.
Transcutaneous Prosterior Tibial Nerve Stimulation (TPTNS) is stimulation of the tibial nerve with skin surface electrodes. This treatment is the least invasive of the nerve stimulation options. The treatment is preformed by placing two skin electrodes above and below the ankle where the tibial nerve is located. Whereas PTNS (Prosterior Tibial Nerve Stimulation) is performed in clinic by a doctor, TPTNS can be preformed at home using a TENS (Transcutaneous Electrical Nerve Stimulation) device. Treatment is typically for 20 minutes at a time and the duration between treatments varies from 3 days to one week.
It is not yet understood how this treatment actually works, but there have been multiple small studies in the past decade that suggest that TPTNS is effective in the management of severe OAB. More larger-scale studies are needed.
Medication is typically the next port of call when the more conservative treatments have failed. Medications to treat OAB have been used for decades but come with multiple side-effects including dry eyes and mouth. These symptoms can make you very thirsty, causing you to increase your intake of water. Drinking more than the recommended intake of fluid for one day (2.7 litres of 11.5 cups for females) can have a negative impact on the symptoms of OAB. Constipation is another common side effect, which impacts on the health of your pelvic floor.
Drugs for Overactive bladder are known as antimuscanarinic drugs. They work by inhibiting the neurotransmitters of PNS thus allowing your bladder to remain relaxed. The following drugs may be offered as treatment:
Your urologist should prescribe the drug he/she believes will work best for you.
PTNS is the more invasive version of tibial nerve stimulation. Instead of using two skin electrodes, one of the skin electrodes is replaced with a needle which is inserted into the inner ankle. You sit in a chair with your legs elevated. The needle is inserted about the width of three fingers above the malleolus (ankle bone). The skin electrode is placed under the foot in the calcaneus. It is normal for the big toe to flex during treatment. Some studies say you should feel the contraction of your pelvic floor during treatment, although this is not always felt.
If you are familiar with the use of botox to relax the muscles of the forehead, you will easily understand this treatment. Botox is injected into the bladder to reduce the contractions of the bladder muscle (detrusor). This treatment, like that of the forehead, is only a short term measure, typically lasting for several months before a repeat procedure is required. Unfortunately, the two main side effects are urine retention and urinary tract infection which happens in 10% and 20% of patients respectively. If all of the more conservative options have failed, your urologist may want to try botox as your next treatment.
The treatment is performed by inserting a cystoscope through a small tube into the urethra. The bladder is filled with sterile water. The detrusor muscle is then injected with many very small injections. It typically takes 5 to 10 minutes for this treatment to be completed.
Sacral Nerve Stimulation (SNS) is the most invasive treatment available for OAB. It involves implanting a pacemaker type device under the skin of the buttocks with an electrode that is fed into the S3 sacral nerve root. This electrode produces a mild stimulation that helps to keep the bladder relaxed. The exact mechanism that makes this an effective treatment is not understood. It is hypothesised that the treatment is effective due to its stimulation of the S3 nerve root which contains sensory fibres for the pelvic floor and parasympathetic fibres connected to the detrusor (bladder muscle). SNS is not effective for all forms of OAB and tends to be more effective when urge incontinence is present than for OAB without incontinence.
The device is 2 inches wide and quarter inch thick. Battery life is expected to last 5 years, however, the device manufacturer emphasises that the more you use it, the quicker it will run out. Surgery is required to change the battery. You can do a two week trial before having the device implanted. During this trial period, you will have probes into your sacral nerve, having a small device strapped to your waist instead of being implanted.
Short and long term efficacy is reported to be good with some studies showing the success rate higher than less invasive methods. One study found that patients below 55 tended to have higher cure rates (65%) in comparison to older patients (37%). However, the rate of complication following surgery is in the 30-40% range within the first 5 years. Complications typically require re-operation (either for repair or removal) so decision to use this type of device should not be taken lightly. Unlike pelvic mesh devices, this device is not a permanent implant.