Transcription:
Botox and Sacral Neuromodulation: Treating an Overactive Bladder

Alyne Ellis (Host): Do you limit the amount of water you drink because you're worried you might have an embarrassing accident? Maybe you have what's called an overactive bladder. Welcome to our Health Track Podcast. I'm Alyne Ellis and we're here today with Dr. Jaspreet Singh, a Urologist at Montefiore St. Luke's Cornwall Hospital. Welcome Dr. Singh.

Jaspreet Singh, DO (Guest): Thanks for having me this morning.

Host: So, tell me first, how common is it to have an overactive bladder and is having one, age related?

Dr. Singh: You know, before we get into that real quick, I just wanted to make sure that we're all on the same page in regards to what is an overactive bladder. An overactive bladder is a person experiencing a sudden urge to urinate, to kind of run to that bathroom, and sometimes on the way to the bathroom, kind of a loss of urine, or what do you call it like an accident. And besides that urgency feeling or that fear of leakage of urine, that desire to use the bathroom frequently. And we like to define that as the need to urinate more than every two hours throughout the day and the need to wake up more than twice a night. And this is a fairly common problem. Roughly 30 million people in the United States experience symptoms consistent with overactive bladder. And it's not only a problem that we see in our female patients. It is quite common in our male patients as well. And I would think somewhere around 10 to 12 million men face this as well as roughly 18 to 20 million women in the United States.

Host: Is it also age-related in the sense that as you age, you can expect this to be more common?

Dr. Singh: Yeah. So, typically as one ages, the likelihood or the incidence, prevalence of overactive bladder increases, I can't tell you if that it starts at age 50 or 60, but in general, the older one gets, the higher the likelihood of these overactive bladder symptoms. And I think primarily the reason to have this increase in prevalence is that the bladder is a muscle and with everything as part of the aging process, the muscle of the bladder weakens, and may not be able to store the urine as well as it should or was when one was younger. But I have seen patients in their late twenties and thirties, start to express symptoms consistent with overactive bladder. So, that I can't just say that, oh, it's a problem only in the elderly, but it does affect a lot of young people as well.

Host: There are several conditions that can cause this, that can make you feel like you have a sudden urge to urinate.

Dr. Singh: Yeah. So, one of the first things that we want to make sure that if someone is experiencing like an acute change, like all of a sudden, they're experiencing frequency, urgency, perhaps leakage, one of the first things we want to make sure is that it's not related to a urinary tract infection. That's probably the most common reason that I would see. And the difference is as opposed to overactive bladder, an infectious reason would be an acute change. Whereas overactive bladder is periodically over perhaps months to maybe even years. And so, if it's not related to another condition such as urinary tract infection, sometimes kidney stones, simple things like constipation can back up the urine or irritate the bladder.

So, we try to address things that are reversible or controllable. There are other conditions, neurologic conditions. I've had patients who present with changes in urination. And we end up diagnosing them with multiple sclerosis or perhaps Parkinson's disease. There are certain patients who have experienced strokes that may have overactive bladder symptoms. So, although most people will experience overactive bladder symptoms from just getting part, just the aging process or what we would label as idiopathic, there are other conditions that we want to make sure that are not existing before we just throw it up or chalk it up to getting older.

Host: So, if I were to come into you with symptoms like this, what would the first thing be that you would do?

Dr. Singh: So, as far as diagnosis, getting a good history is always the key. We always learn in medical school and as doctors, 80% of diagnosis is based on a good history and a physical exam. And so getting a good history, finding out how over what period of time one has been experiencing these changes. The other thing that's very important, we often forget in treating patients who have overactive bladder symptoms is what are we drinking? Because often what you're putting into the body will dictate how it comes out. For example, I have patients that will drink a pot of coffee by the time it's 11 o'clock in the morning. Now to them, they have been doing that for many years and it hasn't affected them.

But perhaps now they're in the late forties or early fifties and are finding that they're using the bathroom frequently. So, caffeine in the diet is, is clearly related to irritating the bladder. And not only that, is a diarrhetic. So, caffeine in any form, coffee, tea, ice tea, energy drinks. So, these things can irritate the bladder. Getting a history as far as is it associated with any burning or blood in the urine is also important because sometimes, and again, fortunately, it's not very common, bladder cancer may present with changes in urination.

And so, we don't want to forget the other, like as we were just talking about some of the other reasons we want to make sure the bladder is irritated. So, getting a good history and physical exam is very important. Perhaps it may include a rectal exam for our male patients to get an assessment of how large the prostate is and make sure that the prostate is healthy and also in women, a good pelvic exam. As a urologist, I'm mostly focused in on making sure that there hasn't been any prolapse of the pelvic organs, such as a prolapsed bladder or the rectum and a prolapsed bladder can influence some of these changes with urination. So, good history and physical is where we start off first.

Host: What about tests? Are there any specific tests that you can run as well?

Dr. Singh: Right. So, we want to make sure that the urine sample or the urine analysis is clear. We are checking for signs of infection or blood in the urine. Sometimes if the urinary symptoms are associated with some back pain, we're thinking about kidney stones. We may perform an ultrasound in the office to make sure that the kidneys are healthy and there is no swelling or stones in the kidney.

Sometimes if it's related to blood, we'll, we can check the urine for cells that are that may have a cancer cells. So, we want to make sure that there is no relationship to bladder cancer. And one of the things, common things we do in our urology office is to make sure that one is emptying their bladder, which involves a quick ultrasound of the bladder. Something patients who have seen me in the office may recognize as what we call a bladder scan, because one of the things that is easy to rule out is perhaps somebody who is not emptying the bladder completely, and that may cause the need to urinate frequently and urgently. It's almost as if you have a cup of water and you're emptying only half of it, it's going to fill that much quicker. So, that a quick scan gives us an evaluation to ensure that the patients are emptying the bladder. And it's not related to a poorly contracting or poorly emptying bladder.

Host: Now, when do you move on to procedures such as Botox to control this and how does that work?

Dr. Singh: Right. So, fortunately for a lot of patients, I would say roughly two out of three patients, they will be responsive to medication. So, let's take a second here to kind of review the algorithm that I tend to describe with my patients and I sit with them even in the first meeting and kind of give them a landscape of how our approach to these symptoms may be. So, that it is imperative that we identify what patients are drinking. I may offer them or request them to put together what we call a voiding diary and a voiding diary is essentially a log sheet or a diary of what the patient is drinking, well kind of fluid and what time, and also provide them a way to measure their output. For men, perhaps a urinal or for women, a hat to put on the toilet.

And so that every time they urinate, including the nighttime, that they document the amount of urine or the volume of urine. And also assess if there's any sort of incontinence or leakage associated with urination. And so, that voiding diary helps me kind of get a head start into what the behavior of the patient is, what they're drinking, how are they urinating?

And sometimes the perception of, hey, I'm going too frequently, may end up being kind of normal depending on the fluid intake. So, so it can be both reassuring and also a headstart in treatment. If there are issues, as far as the intake goes, you know, we take the time out to the first step of any treatment of overactive bladder has to be lifestyle modification and that includes addressing things like drinking too much caffeine or coffee, perhaps drinking too late in the evening. And that's causing patients to wake up at night. So, that is the first step where we identify these things. And if with these changes, patients are still experiencing urinary symptoms, we'll move on to medications.

And there are many medications that are available to us. And essentially their main function is to relax the bladder as we are defining overactive bladder as this bladder is constantly fighting the urge to contract and urinate. So, these are kind of muscle relaxers for the bladder. When medicines fail or perhaps you've tried two or three medications, the next step in the algorithm are what you're asking. You know, when do we employ Botox or surgical intervention for overactive bladder. So, so we really exhaust the first couple of steps before pursuing these interventions.

Host: And when you do get to that intervention, how does Botox work to make this better?

Dr. Singh: As I mentioned, two out of three patients will respond to medications. And one out of three, perhaps a little bit higher, if you follow patients a year after starting medications up to 50% will fail these medications. The next two steps, and we'll talk about Botox and surgical intervention a little bit. But Botox, the way it works is most people recognize Botox as a treatment for wrinkles. Botox is a potent muscle relaxant, and that's how it works on wrinkles. You inject it into contracted muscles that are causing wrinkles and it kind of smoothes them out. And that's what we're doing in our office, we're looking inside the bladder and we're injecting Botox throughout the bladder.

That is injected directly into the muscle of the bladder, which helps that bladder to relax and cut down on that, that urge or the need to urinate frequently and urgently. The downside of Botox is that it's something that requires multiple injections over a period of time because the medicine wears off. So, Botox, it's something that may help patients out for anywhere from six to nine months. But the percent of improvement that is published in literature is that up to 80% of patients who have failed medications will report an improvement of their urination.

Host: And then it sounds like you also have a surgery procedure called neuromodulation that can help.

Dr. Singh: Right. So, I'm really excited to talk about that. I suppose that there's always a bias as a surgeon that you know, if I can fix an issue, why not pursue that intervention? So, one of the discussions I do have with patients is offering them both a surgical intervention, as well as a Botox. As I mentioned, Botox is something that requires maintenance therapy and often is somewhat frustrating to patients that they will have to see me twice a year for repeated injections.

Sacral neuromodulation is a unique way of essentially controlling the sensory feedback that the bladder provides to the brain. And so, this loop that we are dealing with, the bladder senses that it's full, sends a signal to the spinal cord, the spinal cord then carries that signal to the brain. The brain interprets it interprets as wow, bladder's full, got to go. And then that feedback is got to find a bathroom, got to find it quick. Otherwise, the brain is giving the permission to the bladder, to, to, to urinate. And so this, this sensory overactivity is what sacral neuromodulation helps us kind of control. It's something and it's, it's not anything new or novel.

We've been doing sacral neuromodulation for almost three decades now. What has changed is the technology and the ability to do this as an outpatient, the ability of quick recovery and essentially a very small incision to employ everything that's needed for this intervention. And so, what it entails is kind of like a pacemaker and most patients that I talk to understand a little bit about a, pacemaker and the purpose of a pacemaker or how a pacemaker is put in, you have a lead or a wire that sits along the conduction pathway of the heart. And similarly, we're placing a lead next to the nerve that controls the bladder.

And so, that lead is placed in which gets connected to a battery or a pacemaker. And so this is constantly looping and controlling that overactivity of the sensory pathway we just talked about. So, what that allows patients is a better control of that urge so they can hold on and postpone urination and the success rate of sacral neuromodulation, again is upwards of 80 plus percent in patients who have failed medications.

Often patients fear surgical interventions. And I try to explain to patients is more as of a procedure, perhaps rather than a surgery or undertaking that most people would recognize a surgery as. The test for this, this is another unique thing about sacral neuromodulation, as opposed to Botox is that, you know, you have to give Botox and then you have to reevaluate and see, hey, is the patient improving?

So, you you're, you have to commit to getting Botox. With sacral neuromodulation, the first step is just a trial. And that trial is essentially something we do in the office, which takes about 10 to 15 minutes. It's a temporary trial, a temporary lead that is placed in the, in the sacral area. And that's where or sacral being right in the upper buttock area. That's where the nerve for the bladder arises from. And patients can go home with this temporary trial for the next five to seven days and can experience the improvement or lack of sometimes, but most patients will note an improvement in their urination as they live their regular lifestyle. And so you can try it out before committing to something like a permanent pacemaker or a permanent neuromodulator.

Host: Wow. That's really exciting. It really sounds like in many, many cases, maybe all of them, you can really help to solve this issue.

Dr. Singh: Yeah. So, you know why even come talk to someone like me as a urologist, and the real kind of bottom line reason to address not only from taking care of one's health, but obviously want to make sure that there aren't any other underlying conditions that are causing the changes in the bladder overactivity. I often find it frustrating that most patients downplay it. And say, well, you know, it's part of getting older, but you know, if you, if you have a car and the orange light is on the dashboard saying check your engine, most people would not ignore that orange light on the dashboard. And so, these urinary changes, perhaps you may downplay, but really should get it checked out and make sure there's nothing else that's causing the bladder to be irritated.

But also, you know, this is quality of life. Having control of urination builds that confidence, allows my patients to go out, complete their daily activities. Even if it's running to the grocery store, I mean the embarrassing situation of, of going shopping and then having the urge to urinate and having an accident is, mentally very exhausting. Not only that, grandkids coming over, limiting your activities, not being able to take the grandkids to the movies. So, when we look at how it impacts quality of life, there's a lot we can improve and you're right, most patients can find, out of all the treatment options we reviewed, can find a solution.

Host: Well, thank you very much. This was a very encouraging information and it's great to talk to you today.

Dr. Singh: Thanks for having me. I really enjoy talking about this topic as well. Thank you.

Host: Dr. Jaspreet Singh is a Urologist at Montefiore's St. Luke's Cornwall Hospital. I'm Alyne Ellis. Thank you for listening to this episode of our Health Track podcast. Head on over to our website@montefiore.org to get connected to one of our providers. And if you found this podcast helpful, please share it on your social channels and be sure to check back in soon for the next podcast. Thank you for listening.