Overactive Bladder in Men

Despite being incredibly common, Overactive Bladder is something that isn't talked about nearly enough, and that's especially true when it comes to men. Today's guest is Dr. Bradley Gill, chief of surgery at Cleveland Clinic Hillcrest and Mentor Hospitals and a board-certified urologist, and he's here to help us understand about the unique ways it impacts men's lives and what can be done about it. 

For more information about the National Association for Continence, click here, and be sure to follow us on Facebook, Instagram, Twitter and Pinterest.

Music:
Rainbows Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

If you look at the numbers behind incontinence in women, it’s hard to believe just how big an issue it is. Incontinence affects more women than diabetes, breast cancer and heart disease, but it doesn’t get the attention it deserves. That’s why NAFC has created the We Count campaign, to help you realize that you are not alone, and there are treatments available right now that can make a real difference in your life. Visit NAFC.org/we-count to learn more. 

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 your host, Bruce Kassover, and joining us today is friend of the podcast, Dr. Bradley Gill. He's the chief of surgery at Cleveland Clinic Hillcrest and Mentor Hospitals, and a board-certified urologist who specializes in all sorts of conditions related, in particular, to male function, and that's really what we're going to be focusing on today. We're going to be talking a lot about overactive bladder in men. So Dr. Gill, thank you for joining us today. 

Dr. Gill: Thanks for having me. It's a pleasure to be back. 

Bruce Kassover: Excellent. Now, before we even get into overactive bladder, tell us a little bit about how you came to become the specialist that you are.

Dr. Gill: Sure. So you know, going through medical school training to become a doctor, I'd like to do things with my hands and got the opportunity to hang out with some urologists and they, they tended to be really cool people, down to earth. And I saw firsthand the impact that they had for their patients.

I have a younger sister who has spina bifida and because of that has to deal with incontinence and some quality-of-life issues, and that's what made me gravitate towards my subspecialty in urology where I deal with male voiding dysfunction and a whole host of other quality of life issues.

Bruce Kassover: Now we're going to be talking about overactive bladder today in particular. I think that a lot of people, well, you watch TV and you see tons of commercials that seem to be aimed at women's bladder issues, at incontinence in women. You don't see a lot of it aimed at men. And I'm wondering, is that because men are less likely to have to deal with this, or is it just that there's some sort of a marketing thing going on? 

Dr. Gill: That's a really great question. So, you know, if you look at the statistics, there's over 30 million people in the United States over the age of 40 who have overactive bladder. So if we step that back and, and think kind of more broadly about urinary symptoms, there's a a ton of patients that are impacted by that.

And urinary symptoms become more common as patients age. So I jokingly tell my patients, "Hey, your bladder is going to become more irritable and more impatient as you age." And a lot of 'em laugh and look at me and go, "Ha, yeah, it sounds like me." But all joking aside, urinary bother from overactive bladder actually is more common in men above about the age 65 or so. Yet as you mentioned, a lot of the advertising and, and education and really awareness that we see for this is focused on women. 

Bruce Kassover: So it's more common in men. Why is that so? 

Dr. Gill: Well, historically. When a guy would have urinary issues, it would result in everybody thinking about the prostate. So the prostate, yes, it grows with age.

Yes, it gets larger. Yes, it makes it a little bit harder to empty your bladder, and it does contribute to urinary symptoms in a lot of men. But everybody focusing on the prostate seemed to forget that guys have bladders, too. And in today's world with things you know, having caffeine and sweeteners and all these things that can irritate and and aggravate the bladder, urinary symptoms from the bladder side have really shown themselves to be a major driver of complaints among men coming into urologist's office.

Bruce Kassover: That's very interesting. Now you're talking about the prostate as well, and I know that there's a lot of talk about things like BPH, benign prostatic hyperplasia, and now we're talking about OAB, overactive bladder. Are those sort of the most common types of things that men will experience as they get older? And if so, what are the differences? What are we talking about here? 

Dr. Gill: You're right, those, you know, BPH or prostate growth and overactive bladder, or OAB as we refer to them, those are the most common things that cause urinary complaints amongst patients. Your ears, your nose, and your prostate, believe it or not, grow your entire life.

And if you think about it, you probably know some guys that have bigger noses and bigger ears. Well, there's also guys that have bigger prostates. And that big prostate, what that does is it, it squeezes, it compresses the urethra. It makes it harder to empty the bladder, and, and you'll have patients come in and say, "Hey, you know, I'm peeing, my stream's always slow. I can't really generate any good flow. It takes me forever to empty my bladder." And it's like, "Oh, well, yeah, you, you know, you probably have BPH, you probably have prostate enlargement."

The counter side to that is you'll have patients that come in and say, "Hey, I'm, I'm peeing frequently. I'm going all the time. I have to rush to the bathroom." And you know, that could potentially be from BPH, from prostate enlargement, but more often than not, it's from overactive bladder. And the way that I, I, you know, present that to patients with an analogy is, your bladder's like a ketchup bottle. And if you're squeezing an empty ketchup bottle, trying to get it to, you know, to empty out on top of your fries or your burger, it's just going to sputter and splatter.

So if, if a patient's going frequently and they have a weak stream, it makes me think about overactive bladder. The one question I love to ask patients is, can you ever generate a good stream? If the answer to that is "Yeah, you know, I can, there's times where I go really well," then probably more likely to have overactive bladder than they are prostate enlargement because that prostate won't just shrink down and open up through different parts of the day. It's going to stay big and it's going to block the flow pretty consistently. 

Bruce Kassover: Okay, that's really interesting. So I'm guessing that this is the sort of thing that you really want to try and have a professional weigh in on that this is not the sort of thing that you can figure out on your own or at least confidently figure out on your own. Is that that a fair statement? 

Dr. Gill: That that's a very fair statement. You know, there can be some things that could potentially cause harm if there's severe urinary problems. You know, folks could wind up in retention, not be able to pee. They could have a backup of urine, you know, from the bladder up to the kidneys.

These are things that are, you know, really more related to BPH and prostate enlargement. So if it's really difficult to urinate, you definitely want to get a professional opinion on that. That being said, there are some simple things patients can do to help improve bladder symptoms, things that we refer to as 'bladder hygiene.'

Bruce Kassover: And what would that be? 

Dr. Gill: So some of the basic things I counsel my patients to do to help alleviate urinary symptoms, and, in particular, those from overactive bladder, are avoiding bladder irritants, and there's five of those. They're sweeteners, flavorings, colorings, caffeine, and alcohol. Those five things not only cause your body to produce more urine, so they act as a diuretic almost like a water pill in that sense.

But those molecules, when they filter through the body and they get into the urine, they hit the bladder and the bladder doesn't like them. So the bladder, even with just a small amount of urine in there, is going to say, "Hey, get this out. Get this out. I gotta go." It's going to make you rush to the bathroom and have to urinate.

That urgency to get there, even with a little bit of urine, is going to make you go frequent, small amounts. And then again, back to that empty ketchup bottle analogy, sputtering, splattering, kind of an annoying, frequent urination with a poor stream. 

Bruce Kassover: I don't know, giving up caffeine, alcohol, all the good stuff doesn't sound like it's, it's necessarily easy. I suppose the problem has to reach a point where it's significant enough for you to really want to make a change like that, isn't it? 

Dr. Gill: Well, you bring up a good point. Those things, you know, a good cup of coffee in the morning or maybe a nice cold beer at the ball game are things that people enjoy.

And it's not that we're telling patients, "Hey, you can't ever have these things again." It's more that we want you to understand how they hit your bladder. So one of the challenges I'll give patients during an appointment is to really go back to just plain old water and, and just plain milk if they can drink milk and do that for a few days.

So if they're thirsty, you know, go for a cold glass of water if they want flavor in it, add a slice of lemon or slice of lime. But really spend a couple days keeping completely away from the bladder irritants and see how good your urinary status can be. And then after that, reintroduce one of the things you like.

Have a nice cup of coffee and, and see what happens. Maybe you're going to have to go to the bathroom every 30, 40 minutes for the next couple hours as it goes through your system, but at least you'll be aware of that. 

Bruce Kassover: Fair enough. I think that makes sense. But I would imagine that what's even harder than giving up the occasional, you know, coffee or glass of wine, is actually going to the doctor in the first place.

You know, you're a man. I am, and I think that we all know that, that we are probably really bad at taking care of ourselves sometimes, and also really uncomfortable going to talk about this sort of stuff with anybody else. So what is your experience?

Dr. Gill: You really hit the nail on the head there. Us guys, our half of the species, we don't engage nearly as well with the healthcare system. And some of the research that our group has done and, and the men's health campaigns that we've been part of in the past have looked at some of these drivers, and it's really kind of fascinating.

There's the, the machismo attitude. So, you know, guys are raised to not complain unless something hurts and, you know, push through the pain. Pain is weakness, leaving the body, you know, thinking of all the things that maybe sports coaches have, have told you over the years. So that's kind of one driver where guys don't go in, so to say, for, for preventative maintenance.

Now I flip that for patients and I ask them about their cars. Right? You go in for regular oil changes and tire rotations to do maintenance, to prevent big problems. We need to shift our thinking and treat our bodies more like that.

Some of the other interesting things that have, have come out of that research, believe it or not, guys are more likely to volunteer to go shopping with their wives or do household chores versus go to see the doctor. And I always kinda laugh at that. You know, I don't think I'm that scary. But really, we have to do a better job as society of encouraging men to talk about healthcare, talk about their problems and engage with the health system to see their providers. 

Bruce Kassover: I think that that sounds like, like more than reasonable advice. I hope that people actually take you up on it. So now we have somebody who realizes that this is a problem. It's not something that they're necessarily getting great results with from some of those behavioral approaches and they come to you. What is the diagnostic process like? 

Dr. Gill: That's a great question. So the first thing you do is you always talk to the patient and you have to find out what's bothering them the most. What I like to ask is, Hey, what's, what's the worst part about urinating? You know, is it that you're, you're going often? Is it a weak stream? Is it trouble getting to the bathroom on time?

But basically, I ask that question and I just let the patient talk, and you get to know exactly what's going to help you figure out how to help the patient. Some of the other things in addition to the bladder irritants, we talk about those, we ask patients about their bowel habits, about constipation. If there's a, a large, you know, volume of stool in there, it's going to compress the bladder and the prostate. It's not going to allow the bladder to relax and hold urine as well. We also ask about neurological problems. The nerves that go down to the bladder help coordinate control and urination and storage of urine. So if there's neurological issues, those can play a role too.

The other thing we think about are medications. So there's certain treatments out there like water pills or diuretics diabetes medications that pull sugar out of the blood into the urine. Those type of treatments can also cause urinary frequency and potentially bladder irritation. So there's a lot of different things that you have to learn about from your patients in order to figure out what you can do to help them.

Bruce Kassover: All right. I like that, that that sounds like a perfectly reasonable and not that embarrassing approach. I think that, you know, the, the less somebody can be afraid about embarrassment, the more likely they will to make that call in the first place. So you go through that diagnostic process and yeah, it looks like overactive bladder really is something that, that you should, that they want to have addressed. What sort of options are available to them that you can give them as a physician? 

Dr. Gill: So in terms of treating overactive bladder, if you go back and you look at the guidelines that are out there, there's a number of different organizations that have them, and they've really evolved over the years. One of the thought processes that's recently changed was looking at things from sort of a stepwise approach.

So the first step was, Hey, do good bladder hygiene. Eliminate the irritants. Try to, you know, make sure you're going on a regular basis, don't get constipated, and those type of things. And then if that didn't work, you could consider medical therapy. If medical therapy didn't work, there are minimally invasive procedures that can be done to help. The newest iteration of guidelines puts all those things out there upfront for patients.

So it's a discussion between the provider and the patient as to what they think is going to be the best treatment for them. So thinking about that, if we want to start with medications as one of the treatment categories to first think about they generally come in two classes.

So there's a class of medications called anticholinergics. They've been around for quite a while. There's a class of medications called Beta-3 agonists, which are relatively newer type of medications. They work on the bladder by helping it relax and hold urine better. The medications each work through different receptor pathways in the bladder and each have different situations where they may be better for a patient.

So, you know, that is really one conversation that you can have with a patient as to the potential of trying a medication and seeing how it helps them. When we think about medications, we usually want to give them a two or three week period to take effect. So that's one of the other things that you have to talk to patients about is the fact that it may take a while for them to see a benefit or the effect of the medication. It's not necessarily something that's going to take hold right away. 

Bruce Kassover: And what about side effects? Anything in particular to, to note for any of these medications? 

Dr. Gill: Very good question. So every type of treatment that you're considering with a patient, you have to have a discussion about the benefits of the treatment, the risks, which would include the side effects of the treatment and what those alternatives may be.

And we could really go down a rabbit hole here talking about all the specific medications, the different side effect profiles for them. So I'll take a pass on this one and say that's probably a discussion that they should have with their healthcare provider. 

Bruce Kassover: I think that's, that's a perfectly reasonable pass to be taking. But with medications, do we have any sense, and I know this, this may be the same answer because there is such a range of choices, but do we have an idea of the sort of success rate that we might see, or just a sense of what the outcomes might be like when pe, when patients do take medications?

Dr. Gill: So, yeah, your question, you know about the success rates of medications, if we look back historically at things, what we know is that in overactive bladder, one of the challenges that historically has been there is patients continuing with medical therapy. Maybe they don't see a benefit right away. Maybe they stop their pills, they come off of treatment. Those type of things. That research is evolving, especially as newer medications are becoming available. And what we're seeing is that patients hopefully are being able to stay on therapy and see that benefit. But again, as with the discussion of side effects, the success rates of the medications, they'll vary a little bit across the various drug classes and then also, you know, the, the specific medications themselves. So again, that's a, a discussion I'll, I'll table and say, "Hey, you know, depending on what medication you're thinking about and what discussion you're having with your healthcare provider, that may be something to more specifically discuss with them."

Bruce Kassover: Okay, that makes sense as well. Now beyond medications, are there other sorts of treatments that might be on the table?

Dr. Gill: Excellent question. So, other treatments beyond medications for overactive bladder really relate to interfacing with the muscle and the nerve and the bladder. And those we break into two categories. Neuromodulation or electrical stimulation and chemo denervation. So botulinum toxin.

Botulinum toxin, it's something that's injected right into the bladder muscle and it relaxes the muscle directly and, you know, reduces contractions there. Neuromodulation is pretty cool. It's electrical stimulation, and it helps normalize the nerve signaling to the bladder and that can be done through a, a small pacemaker type device, they can be implanted near the tailbone. And they also have ones that can be implanted down near the ankle or done even temporarily with a needle, almost like acupuncture. 

Bruce Kassover: I am very glad to hear that. I know that we talk a lot about those sorts of therapies when we talk about women seeking treatment for overactive bladder, so it's nice to hear that they're available for men as well.

And that brings up, so we, we now have this sort of universe of different treatments starting with just doing some behavioral changes on your own to various medications to a number of more maybe minimally invasive, but, but you know, medical procedures. In, if I'm a patient and I have, you know, a sort of medium level OAB and I start to go through this entire process, what should I be expecting for my outcome? I mean, should I be hopeful or is this sort of a tough road to hoe? 

Dr. Gill: So from the, the patient perspective folks often ask that question, what can I expect from treatment? And one of the things that we do in our practice is we encourage communication. So we have a great messaging system from patients to be able to communicate directly with our team and let us know how they're doing.

As mentioned earlier, really, I encourage patients to have faith and hold the course. With overactive bladder medication, you may not see a benefit for a few weeks, so you really have to trust the system. And the other thing too, playing back into bladder hygiene and bladder irritants and those type of things, you have to make sure you take control of those.

If you're drinking coffee all day, even if you're on a treatment for overactive bladder, you're probably not going to see the maximal benefit from it because of all the caffeine stimulating the bladder. And with a quality-of-life issue, you have to understand where the patient is coming from and where they're trying to get to.

So, one of the other things that's important for us is goal setting. And what I talk about with patients is trying to aim for urinating every two or three hours during the day. That's really, you know, physiologic in terms of how frequent or how often the bladder's designed to empty. Maybe at a young age we get taught differently. Think back to grade school. You put your hand up, you ask to go to the bathroom, and the teacher says, "Oh, no, no, no, it's not time yet. Finish your assignment." So there's a little bit of re-education there that can be helpful. But again, with a quality of life issue, making sure that us as healthcare providers and the patients have expectations and goals that are aligned, is a way that we can really achieve success in treatment.

Bruce Kassover: I really do like that, that idea of sort of a shared partnership in wellbeing. That's, that's, that's really encouraging. So in the diagnostic process, is there any testing that's involved? 

Dr. Gill: Very good question. So with overactive bladder and urinary symptoms in general, there's some testing that we do fairly frequently, and if you look at the various guidelines, whether they be for BPH for prostate enlargement or for overactive bladder, there's certain office-based tests that you can probably expect to do. One of it, which is a urinalysis. So it's a simple test where you collect a little bit of urine in the office think about peeing in the cup, and then you do the dipstick and check to see for evidence of urinary tract infection, inflammation, sugar in the urine, which could be an indicator of diabetes or maybe diabetes medication. Again, sugar in the urine being an irritant for the bladder. Another simple test that can be done is what's called a post void residual volume. And that's where after a patient empties their bladder, a small ultrasound is placed on their belly and it's used to scan the bladder to see how much urine is left.

So for instance, if a patient who has prostate enlargement is not emptying their bladder very well, and they have a whole lot of urine left in there, they might be peeing frequently because they go in and just pee a little bit and then they fill right back up. Then they pee a little bit and then they fill right back up.

So that could be another useful piece of information for your team. Beyond that, there's other tests that can be done to further assess bladder function. And those are things called 'urodynamics'. That type of testing is traditionally done where a catheter is placed in the bladder. There may also be one that's placed in the vagina or rectum to get abdominal pressure. And then the bladder's filled up and a patient is asked to describe what they're feeling. "Does your bladder feel full? Do you feel like you need to pee right now? Would you be rushing to the bathroom at this point?" And with that, you can measure the bladder pressure, how much it holds. You can see spasticity in the bladder. You can even test for leakage with that. That testing is evolving. There's different ways you can do that now, potentially with devices placed in the bladder. And also some interesting smartphone apps that may be able to measure flow in some patients. So a lot of evolution happening there in the technological side in urology.

But the end all be all is that first visit with your team is probably going to be a discussion, and then likely urine testing maybe a little ultrasound check of the bladder. You usually don't move into invasive testing or anything like that at the first visit. 

Bruce Kassover: That urodynamics technology, though, that sounds, I mean, it's not something that I want to go and do during my lunch hour, but it does sound pretty interesting.

It’s a pretty cool technique, isn't it? 

Dr. Gill: It really is. And, and some of the new technologies there may have great potential to help us care for some of our patients with neurogenic bladder for instance, those with spinal cord injuries or congenital problems. So. Stay tuned. There's going to be a lot of really cool research that comes out of urology in the next few years.

Bruce Kassover: You know, speaking of new stuff and this is sort of a sidebar because it's it's way off, but you were talking about how diabetes and sugar in the blood could you know, be something you look out. I'm wondering, have you seen with so many people now taking GLP ones like Ozempic and Wegovy and things, which I believe have an impact on the, the, you know, the, the sugar in the body, have you seen, does that have any, any impact on, on bladder function as well? 

Dr. Gill: It's a really interesting question. So the newer diabetes medications, in particularly the SGLT-2 inhibitors, those ones work by pulling sugar from the blood into the urine, and they can actually induce overactive bladder.

All the sugar hits the bladder and the bladder says, "Hey, get this out, get this out, I gotta go." Some of the other medications, the the GLP-1s, those ones, we don't really know you know, if they have an effect, so to say on bladder function. But one thing that they can do is they can cause some constipation for patients and, and again, constipation.

If you're backed up, you have a large stool volume in there, it's going to push over on the bladder and prostate and prevent that bladder from filling and relaxing and holding. So that is something that we've seen a bit of. 

Bruce Kassover: That's very interesting. So, Dr. Gill, as you know, this is Life Without Leaks, and one of the things we always like to do before we're done is ask our guests if they have one little hint tip, strategy, bit of advice to help our listeners live a life without leaks. So maybe you could share one with us today. 

Dr. Gill: I'd be happy to. The biggest tip that I would give folks about life without leaks is being comfortable talking about it. And I see patients in my practice, maybe they have incontinence from prostate cancer treatment, maybe it's bad overactive bladder, they have trouble getting in the bathroom on time, they've had radiation treatment in the past. You take it, you know, your pick of what the cause of their urinary problems may be. Even people that haven't had any treatments that may have given them urinary symptoms as a side effect, can still have bladder problems and urinary issues. So the thing that I really encourage patients to understand is, these type of symptoms happen to everybody. They're not uncommon. We know about them in healthcare and, you know, you don't have to live with the bother and with the leakage, and with the problems. Talk to your doctors, talk to your providers. Let them know because they can reach out and they can connect you with someone like myself, a urologist, or in a similar field who can help. 

Bruce Kassover: I love that reassuring advice, and I want to thank you for joining us today. We really appreciate everything you've had to share, and we hope that our listeners take a lot of what you had to say to heart and actually go out and do something good for their wellbeing. So thank you. 

Dr. Gill: Thanks for having me. 

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.