Overactive Bladder: Real Disease or Marketing Hype?

In 2001 the National Overactive BLadder Evaluation (NOBLE) Program called 5,204 adults in the USA and asked them an embarrassing, uncomfortable question: Do you go to the bathroom too much? 

In response, 16.9 percent of women and 16.9 percent of men said yes. To the delight of the drug company that sponsored the survey, a new disease was born. It came to be known as overactive bladder.

Both Men and Women Can Have Overactive Bladder

The NOBLE survey found almost exactly equal numbers of men and women reported overactive bladder symptoms, but the severity of those symptoms differed by age. Only 0.3 percent of men under the age of 45 reported too-frequent urination, while 2.0 percent of women did. The percentage of women who complained of irritable bladder or overactive bladder increased sharply after age 44, while the percentage of men reporting these symptoms increased sharply after age 64.

Men and women also reported different rates of urge incontinence, leaking if you don't get to go. Across all age groups, urge incontinence was more common in women than in men. Of all the symptoms of overactive bladder, it was the most likely to interfere with sleep and to lower perceived quality of life.

Before the NOBLE study, overactive bladder was treated as a "women's problem." This study showed that the problem was common in both women and men, and however sexist and discriminatory the point of view was at the time, encouraged drug companies to do research to develop medications to treat it. By 2015, annual sales of medications for overactive bladder in the United States alone totaled $3 billion, despite the fact that many experts believe that the condition is best managed without drug treatment.

What Are the Symptoms of Overactive Bladder?

How do you know you have overactive bladder? The original survey would have classified you as having overactive bladder if just once in your life you had felt a sudden urge to urinate, but most doctors will look for affirmative answers to these questions:

• Do you need to urinate more than eight times a day?
• Do you have to get up to urinate more than three times a night? Do you wake up because you need to urinate, or do you wake up and then later need to urinate?
• Do you ever leak urine when you have a strong urge to go to the toilet?
• Do you use protective pads or diapers to prevent visible leaks? How many pads do you use each day?
• Does this problem keep you from doing things you like to do?

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Even if the answer to these questions is yes, the doctor will usually ask the patient to keep a three-day diary of urination, how much, when, how often there are "accidents," and how much fluid is consumed. The doctor will do an exam to see if the bladder can be felt (if it feels full, there may be an obstruction that is causing the problem with leakage). Women will be examined for signs of estrogen deficiency (lack of redness in the labia of the vagina, thinness of the membrane over the vagina), and men will be given the digital (finger) exam for enlargement of the prostate.

What Can Be Done for Overactive Bladder?

When doctors do a full examination, only about 8 percent of patients are diagnosed with overactive bladder, but that still means that the condition is a problem for tens of millions of people. It's relatively easy just to pop a pill so you won't go to the bathroom as often, but medication is just one of several options.

• The first line of treatment is behavioral therapy. Bladder training teaches patients to become aware of the relationship between their eating habits and activity patterns and episodes of incontinence. Typically patients are told to be sure to empty their bladders as soon as they wake up in the morning. They are put on a schedule of bathroom breaks and told not to go to the bathroom when they aren't on a break, and to empty their bladders even if they don't feel an urge when they are on a bathroom break. (There is no schedule at night. If you have to go, you go.) If there is a strong urge to urinate off schedule, then patients are told to use deep breathing and hold-it-in techniques for at least five minutes before they slowly go to the bathroom. Bathroom breaks are scheduled farther and farther apart so that eventually the patient only needs to go every three to four hours. Bladder training alone is enough to cure overactive bladder in about 75 percent of cases.
• Pelvic floor muscle training teaches patients how to contract pelvic floor muscles in ways that relax the detrusor muscle, the round muscle around the urinary canal that keeps the urinary sphincter closed as long as it is relaxed. While these exercises are best learned from a professional, simply stopping and restarting the urine stream at will when urinating approximates their effect. Pelvic floor muscle training exercises need to be done 30 to 80 times a day for six to twelve weeks. They are especially helpful for younger women, but they are not very useful for older men or for patients who have limited mobility.
• A vaginal cone can help women strengthen the pelvic floor muscles that keep the urinary sphincter closed. Holding the cone in place in the vagina for 15 minutes at a time twice a day for six to twelve weeks strengthens muscles enough to prevent urinary incontinence and urgent urination in about 80 percent of women who use it.
• Biofeedback-assisted pelvic floor muscle training incorporates a sensor (placed in the vagina of women or the anus of men) to tell the patient when they are doing their strength exercises correctly. About 15 percent of patients are cured of overactive bladder when they use this technique.

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• The medication oxybutynin (sold under the trade names Ditropan, Gelnique, and Oxytrol) antagonizes the nerves that tell the sphincter of the bladder to open. It can reduce the frequency of urination, but it can also cause dry mouth, constipation, blurred vision, drowsiness, and dizziness. Oxybutynin reduces the frequency of urination in about 65 percent of patients who use it, less than than bladder training or pelvic flood muscle training, but with the added benefit of stopping bladder spasms.
• Doctors often recommend avoiding chocolate, alcoholic beverages, carbonated beverages, spicy foods, and high-potassium fruits and vegetables, but there are no clear data showing that these dietary changes are helpful.

Bringing overactive bladder under complete control may require more than one method, but medication is not necessarily a must. Many people find longer lasting relief with fewer side effects from bladder training and pelvic floor exercises.