How do I know if it's OAB?

There are so many different incontinence conditions out there, it's easy to get confused about what you may be dealing with. Today's guest is Dr. Jeffrey Frankel, a renowned medical advisor known for his expertise in urology, to help make sense of what your symptoms may be telling you. 

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Rainbows Kevin MacLeod (incompetech.com)
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Transcript

The following transcript was generated electronically. Please let us know if you see any transcribing errors and we'll get them corrected immediately. 

Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America's leading advocate for people with bladder and bowel conditions, with resources, connections to doctors, and a welcoming community of patients, physicians, and caregivers. All available at nafc.org. 

Welcome back to another episode of Life Without Leaks. I'm Bruce Kassover, and joining us as always is Sarah Jenkins, the Executive Director for the National Association for Continence. Welcome, Sarah. 

Sarah Jenkins: Thanks, Bruce. It's great to be here. 

Bruce Kassover: Yeah. Today's guest is Dr. Jeffrey Frankel. He is an accomplished medical advisor, really known for expertise in urology. He's involved with the University of Washington and the Baylor College of Medicine Department of Urology. He's had participation in multiple research protocols and clinical trials as a medical director, and he really brings four decades of direct patient care, experience, and leadership. And we're really excited to have him with us today because we're going to be talking about a couple of topics, particularly related to overactive bladder. So welcome, Dr. Frankel, thank you for joining us today. 

Dr. Frankel: Thank you very much for having me and giving me the opportunity to communicate this important condition. 

Bruce Kassover: So, tell us a little bit about yourself. How did we get to be talking now and, and how did you come to enter this field? 

Dr. Frankel: As a urologist, the bladder problems are kind of a key component of our practice, and we are a surgical… and lots of medical opportunities to help patients in the office. And I've done a lot of research with some of the medications and some of the protocols that treat this condition specifically. So probably over the last 10 years, even longer, have been engaged in teaching this to both physicians, nurse practitioners, all sorts of providers, and also have some patient forums.

Bruce Kassover: Now, I would imagine that when a lot of people hear overactive bladder, what they really hear is incontinence. That there isn't a sense that there are lots of different sorts of variations of incontinence and what one person has may not be what the next person has. So maybe you could tell us a little bit about, sort of, the spectrum of things that include incontinence, and particularly what makes OAB a distinct condition.

Dr. Frankel: Sure. I think that is very important because when the patient's trying to assess themselves, they need to understand how the body normally functions, and the core component of overactive bladder is urgency. Now urgency is normal. You get the urge to void. You get up and you go to the bathroom. And I always try to emphasize to patients how complicated the bladder is.

If you've had children or do potty training, you know that children are running around talking, quite advanced in their neurological functions, but some of the last functions that they get is bladder and bowel control. But once you get that, you go on and you consider it kind of hardwired, and then probably later in life things change.

But urgency with this is a compelling desire. Need to get to the bathroom. That's kind of the core symptom. And the other symptoms are urinary frequency, which is defined as more than eight times during the day, getting up at night, which interrupts your sleep. And then urgency induced incontinence. 

Bruce Kassover: So what is the difference between a normal type of urgency and something that really rises to the level of being an actual medical problem?

Dr. Frankel: Well, that's what drives a lot of patients to talk about this because they could be standing in line at a Safeway and all of a sudden they get this strong urge to void and may have a leakage episode. It starts disrupting people's function. They get anxious about thinking about where the bathroom is because they have to get there quickly. They may be in a business meeting. They may not be able to stay for the meeting because they have to get up and void. So if it's on your mind that you might have to go to the bathroom, it really interrupts your life. Whereas everyone gets the urge to void. If we didn't, we'd have retention problems.

I did want to go back a little bit to your question about incontinence, because it is important to differentiate urge incontinence from what a lot of women have, which is stress incontinence, where they leak when they cough or sneeze or laugh, and that's a different type of incontinence than that which is associated with the need to void.

Bruce Kassover: If I have bouts of urgency and I really feel like, you know, I have that sense that I have to go, I have to go now. It is disruptive. Is that something that's often accompanied by leakage or even without leakage, is it still a urological conditions? It's still overactive bladder?

Dr. Frankel: Oh, absolutely. We have overactive bladder that's wet and dry, basically. So, a lot of people are bothered by just having the urge to go. Yoga instructors, again, students, businessmen of all ages, if you have leakage, that maybe stimulates people to come in. But just the symptom of urgency which interrupts your life compels a lot of people to come in and talk about it.

Bruce Kassover: Okay. I think that's important. That’s great. I'm glad. I'm sure that a lot of people will want to know that you don't actually have to have leakage to have a problem and to be able to seek out help for your problems. 

So, speaking of seeking out, when is it the right time to seek your doctors, is it simply when it becomes something that you feel is starting to cramp your lifestyle or is, are there particular markers or milestones or things that you should be looking out for that say, “Hey, now is the time?”

Dr. Frankel: I mean, it's a good question because with this diagnosis, people tend to put off going to the physician. They either think it's part of aging or it's normal, or it's going to come and go. If you do go in and have some other symptoms, we do want to rule out some medical conditions that can cause this, such as a bladder infection.

So if you have burning or if you have blood in the urine, you would want to get that assessed because that isn't classic overactive bladder. But a lot of these symptoms I'm talking about do show up with those, you know, conditions that require either a further workup or treatment. 

Bruce Kassover: I think that you hit on a really, one of the most important points that I'd like to talk with you about, and that's the idea of embarrassment and difficulty going to decide to see a physician. So I'm going to ask you, you are a doctor, you deal with patients, you've been doing this for decades. Are you going to laugh at me? 

Dr. Frankel: No. But I understand what the question's coming from. I mean, the average patient may be among their friends or even in their family. They'll talk about it, but it isn't something socially that people tend to want, feel comfortable necessarily bringing up.

Bruce Kassover: I would imagine that the embarrassment even starts at the very, making the appointment in the first place, just calling an office. First of all, who should I be calling? Should I be going to my general practitioner? Should I go directly straight to a specialist? Where do you recommend I turn to initially?

Dr. Frankel: Yeah, I think some of the embarrassment or delays in treatment depends on the provider. I would say a family doc or general practitioner should be open to these discussions and hopefully they take this seriously, because I've heard from patients, they bring it up and the doctor poo-poos it or says, “Oh, it's part of aging,” or “Let's move on to something else.” Or they just don't have time, because they're talking about their diabetes and hypertension, that the bladder problem, I think, should be handled generally with primary care and hopefully the provider's interested in listening to the story because the history and the description of what the patient's feeling is probably the most important thing.

Bruce Kassover: That's probably got to make you a little crazy, personally, as a physician who recognizes how important this is, to hear that other doctors discount it, they don't pay attention to it. They, you know, make patients feel like it's, it's not worth dealing with it. I mean, you actually see doctors who are not really as, as diligent as they should be? 

Dr. Frankel: It's absolutely true, but I don't look down on them. I just, I think that the patient needs to look at their provider and see if they meet their needs because they have a lot of different medical conditions to deal with, and they may have an interest in certain things. Dementia, diabetes, I mean, it's almost, it's kind of rewarding, not that I want to tell someone they have diabetes, but if they come in with overactive bladder symptoms, which can be a sign of diabetes. Urinary frequency, for instance, and you do a urine analysis and see that they're spilling sugar. Well, I'll send them back to the internist and say, “Hey, get this under control and these symptoms will resolve.” So it works both ways. I do respect what they have to go through. They see a lot of different medical conditions and manage a lot of different medications.

Bruce Kassover: I like that, that idea that it's a team approach because, yeah, it does make sense that, yeah, just because you have symptoms doesn't mean that it's only one thing or a specific thing, that there is, there is a range of things that could be involved. 

So let's say, though, that we are dealing with a patient whose primary issue is straightforward OAB. Can you give us an idea of what the sort of range of treatments might be presented to that patient and, you know, what their choices might be?

Dr. Frankel: Yes, there are quite a few things that we can do for the patient. First of all, you want to listen to the patient and see what bothers them. Why did they come in? What is their expectations as far as treatment? And then start thinking about the medical side of it, right? 

Like I think some people think they have a small bladder. All bladders really are the same size anatomically, but functionally it may appear that it's small because they're going more often. But you want to see what their drinking habits are. And I'm not talking about alcohol, I'm talking about just water. So many patients will come in to discuss overactive bladder, they'll be carrying a liter bottle of water with them that they sit down on the desk. And then you do a urine analysis, which besides looking for infection, will look at the concentration of the urine. It's called specific gravity, and you'll find that these patients’ urine is quite dilute because they're drinking so much water, the body is going to empty it out and they go to the bathroom more frequently.

I also listen to their use of caffeine, which is not only in coffee, but a lot of carbonated sodas. And also people, young people particularly take Red Bull and a lot of these caffeinated beverages also are known to stimulate the bladder. And it's amazing how people, it's like the Aha! moment. You kind of say, “Oh, I'm drinking a lot of caffeinated beverages and I'm peeing a lot. There is a correlation there.”

Bruce Kassover: And alcohol is also a, a bladder irritant also, isn’t it?

Dr. Frankel: It does cause urinate frequency; sometimes just in the fluid load if it's beer, but alcohol itself, wine does stimulate the bladder contraction, and that really is what urgency is. It's really the beginning of the bladder contraction.

You learn as a child, part of potty training to kind of suppress that contraction of the bladder muscle. That's what urgency really starts. You stop it, you go to the bathroom when it's appropriate. With patients with overactive bladder, the bladder just wants to contract and empty out, and that's what makes it more complicated and can lead to urinary leakage.

Bruce Kassover: Okay, that makes sense. So now I'm watching what I'm drinking and I'm trying to avoid some of those things that might contribute to my condition. Beyond that, if I still have a problem, what are some of the next steps on the treatment path? 

Dr. Frankel: So we do try to follow guidelines, and there's been a recent update to the guidelines and there's multiple layers of treatment. We used to go through kind of a stepwise treatment. Now kind of everything is open initially, and there's a big push for what's called ‘shared decision making’ to kind of go over various options. So some of them are behavioral. Such as the decrease in water, the changes in lifestyle. Then there's actual bladder training, which can be done through internet or through physical therapy or just exercises patients can do to help their bladder.

And then there's pharmaceutical therapies that help relax the bladder. And then there's also non-invasive therapies that help patients control their bladder to prevent leakage. So there's really multiple options that are available, and I think it's important for the provider to start laying them out for the patient so they see what's most comfortable for them.

Bruce Kassover: Well, now you mentioned in particular that you've been involved with the development or the testing of some medications. So maybe you could tell us a little bit more about what medications are available and how effective they tend to be. 

Dr. Frankel: So the history of overactive bladder medications or pharmacology goes back to what we call anticholinergic or antimuscarinic medications. Without getting into neurophysiology, but the bladder has a chemical called acetylcholine that stimulates the contraction that I'm talking about. So, historically, the medications came in to block that, and that's why they're called ‘anti-cholinergic’ because they block the receptor where this chemical hits the bladder muscle, preventing it from contracting, causing bladder relaxation.

A newer generation of medications starting in about 2010 are agonists and they cause bladder relaxation through a different mechanism of action. They stimulate bladder relaxation and they don't block anything. The receptor itself causes the detrusor or bladder muscle to relax. So not only do they work differently, they also have different sets of side effects, and some of the newer medicines are more easily tolerable.

Bruce Kassover: I was going to ask you about side effects because I mean, I know we're talking about whole classes of medications and different classes of medications, but are there some side effects in general that are relatively common 

Dr. Frankel: Historically, that has impeded some of the treatment for overactive bladder because the classic treatments 15, 20 years ago were, like Oxybutynin. Ditropan was a brand name of it. And this whole class of medications causes side effects. Dry mouth, constipation, dry eyes, and so patients had trouble tolerating the recommended dosage for the bladder because there's no perfect pill.You swallow the pill and it affects other organs of the body as well. So we're still looking for stuff that's more bladder specific. 

The agonists don't have those side effects, those anticholinergic side effects, so they don't have any of those side effects. The other thing that the new guidelines really emphasize is the anticholinergics have been associated with dementia and cognitive impairment, which a lot of patients are concerned about, so when you look at patients, particularly as we age, we want to avoid anything that influences mental capacity. 

Bruce Kassover: Yeah, I would certainly be concerned about that. Now, tell me this though, after medications, if you try medications and, for whatever reason, you're not getting the results you want, or the side effects are not really tolerable for you, what other options… I think you mentioned that there were some less invasive sorts of treatments that that could be good choices as well. 

Dr. Frankel: So I do think, you know, again, it's stepwise. We think behavioral therapy with counseling, the patient helps, medications help on their own. The combination together works well. Some people either are just opposed to medicines or they can't afford the medications or the side effect profile’s prohibitive. So we do have less invasive procedures. 

One of them is like a tibial nerve stimulation. It's almost like acupuncture. It's actually a nerve in your leg. It sounds odd, but this is stimulating this nerve. It's a series of treatments, but after about 12 treatments has been shown to improve overactive bladder symptoms, we consider that really non-invasive.

And there's also some people would say it's invasive, but Botox installation into the bladder. I know people are familiar with Botox for other indications, but it does work to relax the bladder muscle. This toxin helps relax the bladder, detrusor muscle. So those are options for patients as well. 

Bruce Kassover: And you mentioned the tibial nerve stimulation… there's also sacral nerve stimulation, if I remember correctly. 

Dr. Frankel: Yes. 

Bruce Kassover: Is that something that’s also effective for OAB, or is that only for other sorts of treatments? 

Dr. Frankel: No, that's a good point. So there's neuro, there's kind of modulation, there's newer neurotransmitters that can be placed in the patient to help with bladder and bowel function. These are electrodes that are permanently placed into the lower spine that are affixed to the bladder that can help patients with very intractable overactive bladder symptoms. I wouldn't say that's an early treatment, but it is for someone who's failed other therapies. 

Bruce Kassover: I just love how much these sorts of treatments show how much of a machine the body really is and how you can, you know, get under the hood and do things with it that would be surprising to a lay person but can have really good results. I love hearing that. 

Dr. Frankel: Yes. We take a lot for granted is the bottom line. 

Bruce Kassover: Yes. Now, if you're still having trouble at that point, are there surgeries or other sorts of treatments as well that might be worth considering? 

Dr. Frankel: Well, there are some operations… I would say they're really frowned upon. There are ways you can actually enlarge the bladder capacity. We call it ‘bladder augmentation,’ where you can actually take a piece of bowel and put it onto the bladder to increase capacity. These are very uncommon. There are patients who unfortunately have serious neurological conditions that overactive bladder is associated with, such as Parkinson's disease, multiple sclerosis, or even children are born with severe bladder problems. So a lot of these operations are for those very difficult cases. 

But some people say that the installation of Botox technically would be a surgical procedure. It's simple. It's done in the office with a little scope and does require repeat therapy, just like women have for their wrinkles. You do have to do this possibly six months, at six months intervals.

Bruce Kassover: I'm wondering: Are there different treatment paths for men versus women, or do they tend to be the same sorts of offerings? 

Dr. Frankel: You know, it's traditionally been thought of as more of a female problem, but men have this, about 15% of the men in the United States have overactive bladder. But when men come in, especially to their primary care doctor, it seems to focus on the prostate gland.

And so unfortunately, a lot of men are treated for prostate problems, which is a different treatment. But what brings them into the provider are these overactive bladder symptoms. They have less incontinence than women, but they definitely have getting up at night issues, urinary frequency issues, urinary urgency issues, and they come into the provider, but they get treated for their prostate initially. So there's some new research and new indications to really differentiate the prostate issues from the overactive bladder issues. 

Bruce Kassover: That's very interesting and I can certainly appreciate why there's so much attention on the prostate, but it's good to hear that there is…

Dr. Frankel: Yeah.

Bruce Kassover: …treatment approaches.

Dr. Frankel: It is, and I'd like to maybe elaborate on that because it can get confusing because the prostate can cause obstruction of the flow because of the way the prostate, where it sits in the urinary channel, and that can damage or influence the bladder function. But women don't have the prostate, so immediately people focus on the bladder, whereas in men, is it the bladder or is it the prostate? And if you have a weak stream or a slow flow, it could be the prostate, but a lot of men just say, “I have these symptoms that you have.” And a lot of times, it's the wives who say, “Hey, you better get treated.” Women are generally more aggressive and they'll see that their partner's getting up a lot at night and say, “Hey, maybe it's time to get this checked.”

Bruce Kassover: You're not the first person that we've heard who's mentioned that in so many cases it is the woman who is the one really prompting and sort of driving the search for answers when you have a couple. So that, that really does sort of sound very consistent with what we're hearing. 

Dr. Frankel: It’s absolutely true. I mean, being in practice for many years, very few women will come into the office and say, “My husband made the appointment for me.” But you hear that from probably half the guys. 

Bruce Kassover: So what is your advice for men who are stoic and reserved and refuse to want to get help for themselves? Any thoughts for them?

Dr. Frankel: Yeah, I think they need to understand there are treatment options. I think some men worry that maybe they have prostate cancer with some of these symptoms, which is not necessarily true. It's very usually just a bladder or prostate benign condition. And there's a lot of things we can do short of surgery.

So strongly recommend for men to kind of face the reality as we age, that the bladder is an organ that sometimes needs some help. 

Sarah Jenkins: Just a quick question, because I know, you know so many of our patients always talk about how they've waited so long to seek treatment. They just, they're so embarrassed to talk about it and they don't bring it up to their doctor.

And we talked a little bit about how they can do that, but is this something if they don't talk to their doctor or don't start to get treatment for it, it's something that can get worse over time? 

Dr. Frankel: Yes. That's a really important point because if the bladder muscle has some potential damage that is irreversible… so if you let things go on, the bladder muscle will lose its ability to relax, will lose its ability to expand and store urine. That's really the whole function of the bladder. It has receptors that are sensitive to the stretch. If the bladder doesn't have the function that it has, over time things get ignored and some things are not repairable.

So the problem gets more difficult with time, but it is such a common story. People delay the thing because they have other issues or they don't realize that there's treatment options available. 

Sarah Jenkins: Yeah, so the, the end takeaway is ‘don't wait!’

Dr. Frankel: No, don't wait. And it's not just leakage issues, it's these overactive, this constellation of symptoms that you should be aware of that really changes over time. And I think a lot of it depends on the patient's lifestyle and tolerance. Because I see patients who have a lot of leakage and they walk in and you can smell the urine, like they're wearing pads, and you ask them, do they have a problem? They say, “Oh no, I don't have a problem.” Then other patients are on the tennis court and they leak a few drops of urine and they want an operation on their bladder right away.

So it's a very personal thing. Goes back to bladder and potty training. Then, over the years, people talk to their friends and are disappointed in some of the options they've heard, or people tell them they had failures and didn't, or their doctor didn't listen to them, and they'd put off getting attention.

Bruce Kassover: So Dr. Frankel, as you know, this is Life Without Leaks, and one of the things we always like to do before we're done is leave our listeners with one little hint, tip, strategy, bit of advice to help them live a life without leaks. So, I'm wondering if you have one you might be able to share with us today.

Dr. Frankel: Well, first of all, thank you for this opportunity. I think that patients, both men and women, need to understand that there is something that can be done, especially if it interrupts their lifestyle and it may just be interrupting their classroom, it may be something that involves leaving meetings early, being unable to concentrate… We don't want you to have to miss social events because you have to have the end seat in the row, you don't feel comfortable socializing… There's lots of things that can be done which will improve not only your bladder function, but your lifestyle. 

Bruce Kassover: Now that is a good piece of advice. I appreciate it and I hope that our listeners do as well. So thank you, Dr. Frankel. We really do appreciate everything you've had to share today and, you know, look forward to hearing more from you, and hopefully the people who are out there will take action, follow your advice, and do something good for their health today. 

Dr. Frankel: I hope so. Thank you so much. 

Bruce Kassover: Life Without Leaks has been brought to you by the National Association for Continence. Our music is Rainbows by Kevin McLeod. More information about NAFC is available online at nafc.org.