A woman with urgency

The symptoms of overactive bladder— increasing urinary urgency and urinary frequency—should not be endured in silence. Not only can the majority of cases of OAB be successfully treated, the symptoms may indicate an underlying condition that needs to be urgently addressed.

Primary measures

An otherwise healthy 52-year-old woman, mother of three, is referred to me by her
primary care physician. For the past year she has experienced increasing urinary urgency
and frequency, up to ten times a day and two to three times at night. She also complains
of leakage of urine, or urinary incontinence. She exercises three times a week, and has
some mild urinary leakage with exercise as well, but this is secondary to her complaint
of urge incontinence, where she can’t hold it when she tries to get to the bathroom. She
reports no pain.

It has become very frustrating for her as she’s a healthy, active woman. The lack of
control over her urine has interfered severely in her social life and is affecting intimacy
with her partner as well.

The patient’s PCP has prescribed a low dose of a first-line anticholinergic medication
to block the neurotransmitter (acetylcholine) responsible for bladder muscle contraction
and allow for relaxation of the bladder. Ultrasound of her kidneys and bladder showed
no abnormality. As treatment was only minimally effective—and patient experienced dry
mouth as a side effect—she was sent to us for urologic evaluation.

Generally normal

The patient’s history uncovers little new information other than that she is a smoker. Physical
examination, including abdominal gynecologic and brief neurologic exams, is generally normal. There is, however, some mild hypermobilty of the urethra in the pelvic exam with coughing, but no leakage of urine, no evidence of uterine or vaginal wall prolapse. Urinalysis shows microscopic blood but no evidence of infection.

No suspicions raised

I inform the patient that she has the classic symptoms of overactive bladder (OAB), a small amount of microhematuria, or microscopic blood in the urine, which may or may not be anything significant, and that, as scans have shown, is successfully emptying her bladder.

The patient is prescribed a higher strength medication and asked to try pelvic floor exercises — Kegel exercises—and return in a month for follow-up.

One month later

On her new medication there were no significant side effects, but the patient also experienced no significant improvement. She gets up to urinate one time less at night, but she’s still having urgency and having trouble holding it. Upon retesting, there is persistent blood in her urine so—considering her non-response to medication—further evaluation is in order. As a smoker, the patient is at heightened risk for bladder and kidney cancer. Tests are scheduled, including a cystoscopy, to look inside the bladder, and a CAT scan. Urodynamic testing will evaluate the bladder’s response to filling.

Not completely normal

The CAT scan is completely normal, as is cystoscopy. Urodynamic testing, however, shows that at low volumes of urine, about 75ccs ( a bladder can normally hold 300 to 500 ccs or more without a problem) —she starts having mild bladder contraction and when she reaches 150 ccs her bladder just starts to contract and empty.

At this point, the patient has failed to find help through medications and has a significant overactive bladder component. While reviewing these results with the patient, I ask her whether anything else has changed for her in the past year while her bladder problem has been going on. She volunteers that in the past several months she’s noticed that her balance has been a little bit off. She’s never had anything like that before, and she has noticed that, when writing, the pen occasionally slips out of her hand.

A diagnosis

Since there are no physical findings on cystoscopy or physical exam, we need to investigate whether there is a neurologic cause for her symptoms. The patient agrees to undergo an MRI of her brain. The MRI shows mild demyelination lesions consistent with early multiple sclerosis. Her urinary symptoms, to this point, have been the only significant signs. It is now clear the patient is suffering from neurogenic bladder related to MS.

Focused treatment

Having failed with standard medications, we try the newest medication for OAB, Myrbetriq, in combination with biofeedback. Myrbetriq works through a completely different mechanism of action and achieves a response in some patients for whom the standard meds are ineffective. The biofeedback focuses on learning to control the muscle of the pelvic floor. The patient doesn’t respond well enough to this regimen and is interested in further treatment. There are two approaches that have been successful in neurogenic bladder and we help the patient make an informed decision about which she would prefer.

Informed choice

The choices are InterStim— an implanted pacemaker-type neuromodulation device —and Botox, which is botulinum toxin. After meeting with our research team, she decides to enroll in a clinical trial examining the use of Botox for neurogenic bladder in people with multiple sclerosis then underway. (Botox is now FDA approved for the treatment of neurogenic bladder). The patient continues her botox treatments every six to nine months and is under the care of a neurologist for her MS. She has an excellent quality of life, resolution of her incontinence, intimacy with her partner and is dancing again with her friends on square dance weekends.