Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, we're highlighting diagnosis and treatment of overactive bladder in women. Joining me is Dr. Jennifer Miles-Thomas. She's the Vice Chair of Regional Integration and Innovation and an Assistant Professor of Urology at Northwestern Medicine.

Dr. Miles-Thomas, it's such a pleasure to have you join us again. Can you explain a little bit about the underlying causes of overactive bladder in women, how they differ from those in men and how common is this issue? Dr. Miles-Thomas, do you feel that this is an underreported issue due to embarrassment, hesitancy to speak with a physician about it?

Dr. Jennifer Miles-Thomas: Yes. And first of all, thank you very much for having me. I believe that overactive bladder is significantly underreported and there are so many reasons why. I think culturally we're having a lot more conversations, especially about women's health, but it's still something that's personally embarrassing. To leak urine is not something that's socially acceptable. And many people have to go through many maneuvers in order to hide either the fact that they're having the urge or the fact that they have to ask many times where the restrooms are located or the fact that they have to purchase different either devices or pads to kind of prevent the close soiling and other things like that. So, it's definitely underreported.

Why does this happen? What do we think the underlying cause is? Well, to be completely transparent, we don't know. It's definitively multifactorial. There's a significant portion that could be a learned behavior. As we think back into our childhood as we were potty trained, we didn't have a baseline. We really didn't know the normal mechanisms for voiding. And sometimes throughout the process of potty training, there are some social cues that at times are forced. Like, make sure you go to the bathroom before you get in the car. Just make sure you push it out. Those types of behaviors are not normal bladder function and pelvic floor function behaviors. And sometimes later in life, they'll manifest again if the normal mechanisms weren't in place.

But I would also say there's a lot of other factors that can contribute to this, especially in women. So, one of the largest differences between men and women, we both have bladders, but we do not have a prostate. And as men age, typically, their prostates enlarge over time, which causes their bladder to have to squeeze harder to empty of urine. Well, if women don't have prostates, then our bladder is changing for other reasons. And some of those reasons could be pelvic floor dysfunction, like we talked about earlier with potty training.

But otherwise, there are quite a few foods that are known to be bladder irritants. So, you know, if you taste something that's super spicy, super sweet, you can feel that tingling, yes, on your tongue, but sometimes also on your cheek. The same thing can happen into your bladder. So if you eat a bunch of spicy foods or foods that are very acidic, or alcohol, it can irritate the lining of your bladder. And when your bladder is irritated, it does the same thing as when you have a bladder infection and it wants to twitch, it wants to squeeze, and it wants to get the irritation out. And so, those types of things will trigger and give you an overactive bladder. So, we're thinking that, yes, some of it can be structural, some of it can be mechanical with the way that you're voiding, but also some of it can be metabolic. So, we have patients that of every age and generation that have overactive bladder from very young to very old, but we also have people who've never had a problem and eat the spicy foods. So, we know for sure that this entire syndrome is multifactorial.

Melanie Cole, MS: Well, that was certainly a comprehensive answer, and it really is such an important topic that so many women, some, as you say, silently suffering with this. Dr. Miles-Thomas, what are the AUA-SUFU guidelines for the evaluation and diagnosis of overactive bladder?

Dr. Jennifer Miles-Thomas: Well, the first thing is to verify that there is nothing else going on. So when we see a patient with overactive bladder, we definitely take a definitive history. We really want to understand if there are prior storage or emptying problems, we want to understand how much of a bother this is. So if it's once in a blue moon when you're going out with drinks for a friend, or is this something that every single day you're dealing with, or are you waking up multiple times at night? We also want to know if you have any prior urologic history. Have you had recurrent infections? Have you had stones? Have you had blood in your urine? We also do a physical exam, including a pelvic exam. We want to know if you have prolapse or any other anomalies in your vaginal area or with your bladder. A urinalysis will tell us if there's an infection, if there's white cells, but we also sometimes will do what's called a PVR, which is a post-void residual. We have bladder scanners that will allow us to through ultrasound, see how much is left in your bladder. Because what we want to figure out is, do you truly have an overactive bladder that is squeezing until you're empty? Or are you not fully emptying your bladder? And it's not that it's overactive, it's just that it's not empty.

So after we've done a comprehensive physical exam and history, then we move to the next level of evaluation. And that really is to figure out if this is something that's occurring frequently, if this is something that's just nocturia, and we look at other medical history to see whether or not there are other possible interventions. Many times, patients will take medications at certain times of the day or night, including diuretics, which definitely would contribute to overactive bladder. It doesn't mean it's intrinsically an overactive bladder. It just means that they have high volumes of urine. And that's one of the main things that we really want to discriminate between. After that, we actually have additional studies that we could do if the patient previously had had, let's say, significant urologic reconstruction or surgeries or stones to truly try to isolate, is the bladder the issue or is there another comorbidity or other factor that's contributing?

One of the things that we find sometimes, especially in older generations, is we'll see lower extremity edema. That can be for multiple reasons, but we found that a lot of times, people will complain of overactivity and overactive bladder in the evening, which we term as nocturia, but that's really because of the lower extremity edema. When they finally recline, gravity is no longer pulling that fluid down, the fluid comes back into the system and then they'll have frequent urination at night trying to expel that residual fluid. So, it's a pretty comprehensive evaluation and the information that we receive from either the history, their physical exam, the meds or additional testing really help guide our true diagnosis and then give us a little bit of insight into the treatment algorithm.

Melanie Cole, MS: That's so interesting. Now, in your experience, Dr. Miles-Thomas, what are some of the most effective non-surgical treatment options for women with urinary overactive bladder? How do you determine the most appropriate treatment for each patient? Because quality of life, as we said, is an issue. There are issues with social and psychosocial, emotional issues. I mean, there are many things to consider when you're talking about the shared decision-making.

Dr. Jennifer Miles-Thomas: Yes. And it's exactly what you said, shared decision-making. The first thing we need to identify is what's the goal, right? It's not my goal. It's not the algorithm's goal. It's the patient's goal. What is most bothersome to them, and what is their goal? Do they want to be completely dry? Are they fine with just wearing one pad just in case? Do they want absolutely no pads, no panty liners? Or do they want to sleep throughout the entire night? And that kind of guides the amount of information that we provide throughout the journey.

So, you don't want to overwhelm someone with all of the available options, so we choose to give it to them in writing so that they can review it at their own leisure. We really know that a lot of times patients will hear, but they won't hear everything that we're saying. And what they really want to say is there's opportunities to make things better for you. It's going to be guided by you, what you would like to do, and it would be guided by where you set your goals, but that we're willing to work with you until we get to that point.

Melanie Cole, MS: When other providers are seeing these patients, Dr. Miles-Thomas, and they're having these discussions because this is something that is sometimes treated in primary care as well, yes?

Dr. Jennifer Miles-Thomas: Yes. Agree.

Melanie Cole, MS: So, when they're counseling them on treatment options, we also hear about pelvic floor muscle training, behavioral therapies. So, I'd like you to speak first about these non-surgical and complementary therapies that people try in managing overactive bladder and how successful they are because there's pelvic floor PT now, there's behavioral and cognitive behavioral therapy. Speak about some of those as overarching therapies.

Dr. Jennifer Miles-Thomas: I think in Medicine, a lot of times we really need to go back to basics. So, recall what we were discussing earlier and just the aspects and the way that we are potty trained, especially in this country, a lot of times we'll have pelvic floor dysfunction. And over time, after let's say vaginal deliveries or even just pregnancy, it's still pelvic trauma. And so, even though you may forget some of the experiences, your brain won't and your body won't either. And so, the dynamics and how the muscles work will change over time.

And so, conservative therapy are things like pelvic floor physical therapy, and bladder retraining, and cognitive behavioral therapies. This is really biofeedback. It's understanding how your muscles work, where your muscles are located, and understanding what it feels like. A lot of times, we'll tell people, "Oh, all you need to do is Kegel or Kegel," but do they really know what that means? And so, with pelvic floor physical therapy, I say that people typically think of pelvic floor physical therapists the same as they think of a therapist who will work on your knee or your hip or your back, and it's different. These pelvic floor physical therapists are specifically trained to work with the pelvic floor muscles, so they understand how the muscles work, they understand the normal dynamics and the abnormal dynamics. They can place sensors on your skin or sometimes inside your vagina that can actually see which muscles are contracting, and it's almost like biofeedback is very similar to just playing games where you can physically squeeze and relax and you can understand how much tension and how much relaxation you're having and watching a screen to understand and correlate what you feel with what you are seeing. And it's not just only during your PT sessions do you do this. No, you're assigned homework, homework where you go home and you practice the exercises. So, they almost become involuntary.

Once you can control your pelvic floor a little bit better, then you'll have the ability to control when you have those urges and immediately do fast and slow twitches to stop those urges from happening. So, you have more time to make it to the bathroom. But essentially, pelvic floor physical therapy, bladder retraining, and dietary changes are the first-line therapy and should be considered for everyone.

Melanie Cole, MS: Dr. Miles-Thomas, have you seen outcomes of pelvic floor muscle training and behavioral therapies? Have you seen how well these work?

Dr. Jennifer Miles-Thomas: Definitively, I have. So to be completely honest, patients a lot of times will not have complete confidence that physical therapy can work. And I have seen amazing outcomes. I have seen complete resolution of symptoms just by pelvic floor retraining. And once you see that a few times, you really feel a lot more confident in recommending this therapy to patients.

Melanie Cole, MS: Compliance is an issue. I mean, we've all heard about these exercises that we're supposed to be doing over these many years, but many providers don't know how to teach them. So when you're thinking about this field of physical therapy, pelvic floor physical therapy medicine in itself, it's a relatively new field.

Dr. Jennifer Miles-Thomas: Yes, it is. And it's about accountability. So in the past, I have tried to train patients on how to do Kegels, how to do pelvic floor relaxation. And to be honest, it didn't work as well, because it would be a few months until they saw me again, and they would still have the same issue. But I found that referral to pelvic floor physical therapists does a few things. One, the patient has to attend the appointments, and typically I will get a report so I can understand what they're doing, and how they're progressing. In addition, their appointments for followup are scheduled up usually three to four months in the future, and it's all about recall bias. So, they'll tell me at the initial presentation what their symptoms are, I can see how they progress through physical therapy, and then when I ask them very similar or the exact same questions upon their reevaluation. I can help show them the progress that they've made. The majority of my patients who attend the physical therapy appointments, practice at home, and then come back for their follow up appointments have made significant strides. If anything, they say that they're much more aware of their body, how their pelvic floor works, and that they've made improvements.

Melanie Cole, MS: That's so interesting, isn't it? And that compliance issue is really a big deal. That's why this is such a burgeoning field of that pelvic floor physical therapy. Now, on to medications. So, there's a lot of medications on the market. It can be a little bit confusing. I'd like you to speak about which patients are most likely to benefit from pharmacologic therapies. And when you're talking about that shared decision-making, the side effects of some of those. to balance it out.

Dr. Jennifer Miles-Thomas: So, patients are able to move to second line therapies, which would be medical therapy or oral medical therapy, if they have failed conservative therapies. One of the things that I make sure is that we do document what conservative therapies they've tried before arriving to your clinic. Now, I would say there's at least 12 to 13 medications on the market. And that means, whenever there's an abundance of medication, it means there's no one right answer. The bladder itself has two different types of receptors. They have muscarinic receptors, as well as beta receptors. If you stimulate the beta receptor, it causes the bladder to relax. So, that increases storage. If you stimulate or block the muscarinic receptor, you stop the contraction. So, the classes of medications are geared towards each of those receptors. Because there are so many on the market, we have not definitively figured out a way to figure out which patients should have which medical therapy first.

So, the largest class of medications are the anticholinergics or antimuscarinics. More recent data have found that long-term use of anticholinergics, especially the ones that cross into the brain, can cause dementia. And this is of concern because a lot of our population that we're seeing for overactive bladder are older or older than 65. And anything that we potentially can do or give them that increases their risk of dementia is concerning. The beta agonist therapies do not have that same potential long-term side effect. One of the two is able to potentially increase the blood pressure, one millimeter mercury per its data. But otherwise, they're tolerated fairly well.

With anticholinergics, there's also the risk of additional side effects because there are cholinergic receptors elsewhere in the body. So, I typically tell the patients that there's potential of dry mouth, dry eye, or constipation when taking those medications. A lot of times, patients, if they are having significant symptoms, they will ask to move forward into medical therapy. I always give them the option. They will either say, let's try something simple first, or they'll say, "I am really miserable at this time. I just need something to help." If I can eventually wean myself off the medication, that'd be perfectly fine. But we have the understanding that these medications don't actually fix the underlying disorder, they are just helpful for symptoms.

Melanie Cole, MS: Now, what about for patients that have overactive bladder and also comorbidities, complex medical histories, maybe obesity, any of these kinds of comorbid conditions, does that change how you go about treatment?

Dr. Jennifer Miles-Thomas: Yes. So, they have the same options, but it changes how I monitor them. So if they have obesity and immobility, then you really want to make sure that if you're giving one of these medications, that you're monitoring them to, one, make sure that they're not retaining urine. So, you're either doing PVRs and, at times, if you have no other ability, you want to do either an ultrasound or a straight cath to see how well they're emptying their bladder. Because one of the potential side effects is inability to fully empty their bladder. And you don't want to predispose them to additional things like bladder infections.

Also, we really engage with the primary care teams and the family practice teams. There always is a potential interaction. And thankfully, our EMRs are getting better and better at classifying these drugs and warning us if there's interactions. But polypharmacy is a big issue, especially for elderly patients. We also talk about the timing of some of their medications. So if they're on a diuretic and they take it before bed because they want to be out and about during the day, but then they present to me and talk about nocturia and how often they're waking up, we work with their primary teams to see if we can change the timing of the medication. As a specialist, we never make the recommendation to either stop a medication or change it, but we reach out to their primary team to do that.

We're very honest with the patient. We tell them this is not something that we recommend. There's potential interactions, especially if patients have had prior bowel work or perforations or other GI issues, that the risk of constipation is significant and that there'll be untoward sequelae if they do have one of those side effects. So, sometimes we can talk about what other options are, including third-line therapies.

Melanie Cole, MS: Well, then let's talk about some of those third-line therapies. If they haven't responded to conservative measures, maybe even medicational intervention, what surgical options are available for managing this condition? Because I know that those surgical options have really evolved over the years and we've heard a lot. There was a lot of information in the media quite a few years ago, but that's changed a lot now.

Dr. Jennifer Miles-Thomas: I think there's definitely a spotlight on women's health and overactive bladder. Definitely, there's a lot more industry, so there are medical devices as well as medications that are more recently on the market. But regarding third-line therapies, the reason we call them third-line therapies truly are because conservative is first-line medication, oral medications are second line, and anything that's an intervention is going to be third-line.

So if we start from the simplest to the most invasive, there are tibial nerve stimulators. So if we think about the spinal cord, there's a branch that goes to the bladder to control bladder function. But a small branch goes down to the ankle and posterior tibial nerve is something that we can stimulate externally or internally and, through neuromodulation, change the messages that the brain is receiving about the bladder. So, there's a couple of ways to do tibial stimulation. One there are external devices that will stimulate, like it's literally like a wrapper or boot that the patient can put on, and it will stimulate the tibial nerve causing that neuromodulation. There is something called PTNS, which is posterior tibial nerve stimulation, and it looks like an acupuncture needle, and you can place it right behind in the ankle, stimulate the posterior tibial nerve, and then that will give you also neuromodulation.

More recently, there are implantable devices because those prior therapies, it's a more frequent, right? So if you stop the stimulation, you no longer get the same response. And so now, there are implantable devices that you can place under the skin, right along the nerve that will stimulate for a longer period of time. And some of those are rechargeable.

Well, if you move along the spectrum, you become a little bit more invasive, you move up to the sacral nerve. So, there is sacral neuromodulation. It looks basically like a pacemaker, and I tell patients that it's a pacemaker for the bladder. And it's an implantable lead that you can put through the S3 foramen. You can place it right near the S3 nerve, and you can stimulate the nerve. So when you stimulate the nerve, you'll get pelvic floor contractions, and the patient may feel tapping in the vaginal area. This implantable device, if it works, it typically lasts for about five to seven years, but the more recent versions can last from seven to 15 years on a single battery.

So, let's say they have a neurologic disorder or they prefer not to have something implanted. Well, actually, we can use Botox in the bladder also. And Botox itself has so many indications. They're everything from pediatric to adult, from Plastics to migraines to spasticity and limbs, but it also works for the bladder. So, you can literally, in the office, look at the posterior wall of the bladder and we can place multiple units of Botox. Usually, any time between two days and two weeks, the saline is reabsorbed. The Botox can actually touch the muscle and stop contraction. That question always comes up of, "Oh, well, if you are stopping the contraction of the bladder, can the patient still void?" The answer is yes. We are not putting it throughout the entire bladder. Typically, we spare the trigone and we're just putting it on the posterior wall. So, all of those are viable options for patients and many of the sacral neuromodulators are now MRI compatible. So, there's still the option of getting MRIs with this implant in place.

Melanie Cole, MS: So many tools in your toolbox now, Dr. Miles-Thomas. So now, let's talk about the impact of overactive bladder on the quality of life. We've touched on it a few times. How do you address the psychological, emotional, psychosocial aspects of this condition with your patients when you're counseling them? How are you helping them to navigate when they're just starting a medication or thinking about surgical interventions, still living their life, going to work, doing the things they need to do?

Dr. Jennifer Miles-Thomas: Well, the first thing I do is listen, because it's difficult to bring up this topic, right? So frequently, I'll hear from patients, "I don't feel like I'm getting old. I hope I don't smell. I would be so embarrassed if I had an accident somewhere, so I just don't go out anymore." So, you're realizing that this is their first step. They've raised their hand. They say, "I have a problem," and they're willing to seek help. So, I sit and I listen to really understand, one, the words that they're using, how emotionally they're dealing with their diagnosis, or if it hasn't been definitively made, what they think is going on with their body.

And then, I have an honest conversation. We have a discussion regarding here are the options and we're going to move along the spectrum of non-invasive to invasive completely depending on their desires, their goals, and what they want for their quality of life. It doesn't have to be what I desire for them, but I frequently ask them, including as we're going through the algorithm, the pathways from the AUA and SUFU. How do you feel now? Is this good enough? What would you like to be different? What's bothering you the most now?

And as you progress and we have a deeper relationship with these patients, they'll be very open. "I think I'm fine now. I'm about 80% better. This is good enough. I'm not having side effects. I feel very comfortable with my decisions," or "I still don't feel I'm at my maximum yet. Let's try something different. Let's go to the next step." I really allow them to guide me because, honestly, this is quality of life. This is not quality of my life. This is quality of their lives. They're the ones who make the decision.

Melanie Cole, MS: What a compassionate physician you are. Those are such great points. And I would imagine that your patients feel the same way in this shared decision-making, that they can trust you, that they put their trust in you to work with them, especially on those quality of life issues. Are there any exciting emerging or experimental treatments for overactive bladder in women that you find really promising or exciting in the future?

Dr. Jennifer Miles-Thomas: So looking into the future, if I had a crystal ball, what I would say is there's going to be additional therapies that are likely going to be able to be instilled in the bladder and have longer term benefit for patients. It hasn't been created yet, but if we look at other fields, including Oncology, we can see that there's different types of materials that can be placed in different locations that can slowly emit drugs. So, we have drug-eluting stents, we have chemotherapy delivered in different ways.

I'm really looking forward to industry coming up with ways to place medications in the bladder for longer term use. I feel that whenever something is systemic versus local, there's always the potential and the possibility of increased risk of side effects. And if we could do local control, that would be optimal. If we really could figure out all of the underlying causes and the metabolic reasons why some people have overactive bladder and others don't, that would also be great. I think that would change the paradigm for the treatment. It would be a lot more personalized, but this is my aspiration. This is for the future, but I am excited because we're spending a lot more time, attention, and money in this disease state.

Melanie Cole, MS: Well, because it's so common. And as you said, whether a woman has overactive bladder from comorbid conditions or being pregnant or any of these reasons that they might have that, there's so much exciting work being done and it's really headed forward. As we get ready to wrap up, what advice or recommendations would you give other healthcare professionals who may encounter these women? What would you like them to know in the key takeaways about what's going on in your field, Dr. Miles-Thomas?

Dr. Jennifer Miles-Thomas: I would like other professionals who take care of these patients to know that there are options. If you feel comfortable taking care of these patients, you can look at the AUA website and they have the algorithm printed for you and you can kind of follow along the steps in order to make this definitive diagnosis. And then, if the patient needs additional therapy, feel free to refer to Urology.

But I would say the number one thing that I would recommend to other providers, physicians who are taking care of these patients is be ready to listen. The woman who came to you has been dealing with this for a long time, typically five to seven years. They finally develop the strength to speak out about it, to seek care, and all of us are busy. There's always more patients to be able to be seen. If someone brings it up, especially as you're walking out the door, if you can, sit down, just listen for a few minutes. If you're not able to help them, you are helping them by listening, and then refer.

I think the simple comment of I hear exactly what you're saying, I understand what you're going through. Let me help you by referring you to someone who can help you further. People want acknowledgement, they want understanding, and they want some guidance. There are so many different opportunities and therapies available for these patients that they just need direction and to figure out how to get to those therapies. And so if you're able to help, and you would like to go through the algorithm, it's available. If not, please refer and we would be more than happy to help your patients.

Melanie Cole, MS: Thank you so much, Dr. Miles-Thomas. You are such a great guest as always. You're an excellent educator as well. That was so informative and really important, as we said, because it really does affect quality of life in such a substantial way. So, thank you again. And to refer your patient or for more information, head on over to our website at breakthroughsforphysicians.nm.org/urology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.