Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're highlighting advances in overactive bladder management. Joining me is Dr. Alex Gomelsky. He's a clinical urologist with UF Health and a professor at the University of Florida College of Medicine. He also serves as the Mary Anne Harn Cofrin Endowed Chair, Associate Chair of Clinical Affairs, and Chief of Urogynecology and Reconstructive Pelvic Surgery in the Department of Urology.

Dr. Gomelsky, thank you so much for joining us today. I'd like to start with kind of a working definition, how overactive bladder is currently defined, and tell us a little bit about how it's different from other lower urinary tract disorders.

Dr. Alex Gomelsky: Sure. The typical diagnosis or definition of overactive bladder is urgency, which is a strong desire to urinate that is difficult to postpone, that is usually accompanied by urinary frequency, nighttime urination, and occasionally urgency leakage. The key thing there also is that it's in the absence of other obvious problems such as urinary tract infection.

And urgency and urge leakage are different than something, for example, like stress incontinence, which is leakage that a woman may experience with increases in abdominal pressure, like coughing, sneezing, laughing, running, jumping, being physically active. And this is different also from something like pelvic prolapse, which is poor muscular support of the bladder or other pelvic organs which cause them to bulge through the vaginal canal. And some women can have all of the above.

Melanie Cole, MS: Well, thank you for that. So, speak a little bit about key symptoms. I mean, you just mentioned a few, but some of the diagnostic criteria that help distinguish it, and why is it sometimes a little bit hard to diagnose?

Dr. Alex Gomelsky: I think the biggest problem we have with diagnosis sometimes is just having the woman describe her symptoms in such a way where we can really pinpoint what bothers her the most. Often in my practice, a woman will come in and say, "Well, just everything makes me leak." I say, "Okay, let's narrow that down."

And what I'm really looking for is to really get a better idea about what she is doing, if anything, when the leakage occurs. Is she changing positions from sitting to standing? Does she have a significant sense of urgency, a "got to go, got to go" sensation that she just can't postpone? Is she playing pickleball or is she physically active? Is she having other symptoms like difficulty emptying of the bladder? Is she having burning with urination? Is she having blood in the urine? Is she having any element of pain with a full bladder? So, all of those are important things to take into account when seeing a woman with leakage and can help point me down a particular road.

Melanie Cole, MS: So as we think of those strategies, really, it's about better history to improve that diagnostic accuracy, yes?

Dr. Alex Gomelsky: Absolutely. History is probably the most important part of our evaluation

Melanie Cole, MS: And are women forthcoming? Because it seems to me that one of the challenges for clinicians can also be with some of these sensitive issues like incontinence or overactive bladder management, is that patient is not as forthcoming because there's a little bit of a stigma or an embarrassment to talk about it.

Dr. Alex Gomelsky: One hundred percent. There are a lot of women that grew up in an age when these were just things that you either didn't talk about, or the assumption was that maybe with having children and pregnancies and getting older, that this was more of a normal part of the aging process and life. And so, you can live with it and tinkling a little bit when you laugh or cough. You know, Mom had it, Grandma had it. So, this is fairly normal. I think that it has become more socialized at this point, I think with social media with commercials on television, advertisements, that this is not something that is necessarily normal, and it certainly isn't something that you necessarily have to live with. So, I think that the recognition of it has increased quite a bit over the last 15, 20 years.

Melanie Cole, MS: I agree with you. And as a 62-year-old woman, I'm right there in that category. And I think that speaking to our physicians has gotten a little bit less stigmatized, a little bit easier, as long as we understand that you are the professional. And the tools in your armamentarium are more extensive now. So, what does the latest evidence tell us about the effectiveness and safety of some of the available treatment options for OAB, including both established and some of the emerging therapies?

Dr. Alex Gomelsky: Oh, sure. Well, this is a very exciting area in all of urology because we've seen such an increase in technology here and such an increase in the number of offerings that we have for these women. And I think, to kind of take a step backwards, we've seen a bit of a shift in our approach to these patients.

The American Urological Association has guidelines that will provide some structure as to how you might want to approach treatment for these women. And in 2025, they've undergone a bit of a revision, and the biggest change has been is that in the earlier version, we had very much sort of a stepwise approach to overactive bladder. We would typically start with some simple things like behavior changes, maybe some pelvic exercises. Then, we would move on to medicine, and then we would move on to what we call minimally invasive treatments.

The way I tell patients about it or other practitioners is that this was a fixed price menu at a restaurant. You have your appetizer, then you go on to the main course, and then you have dessert. The big change has been in that we can now offer these patients, after appropriate counseling, any of those things to start out with. So, the way I say now is you can have your dessert first. Depending on the patient and their lifestyle, their desires, their activity level, their other medical issues, you can offer them more advanced therapies early, and obviously after good counseling.

So, the two biggest categories of treatment we have here are things like medicines, and we have two separate classes of medicines, and seven or eight different medications that we can offer. There's two medicines in one class, and the rest of the medicines are in a separate class. The larger class of medicine are older medicines. They've been around for a long time. They are effective. Many of them can be taken just once daily and are longer acting. And the effect of the medicines is to relax the bladder and allow it to hold urine longer and hopefully give the woman a little more warning time to make it to the bathroom.

The typical side effects of those medicines are dry eyes, dry mouth, and constipation. But there is also a kind of a bit of a concern with some of those medicines because there has been some association with dementia risk in the future. And so, that's something that we need to be very mindful of if we're going to place a patient on one of those medicines.

The other class of medicine has two medicines in it. They're relatively new, although at least one of them is now generic, and they don't have those same side effects. And their side effect profiles are more favorable, and one of them can even be crushed and given to older adults with swallowing difficulties. There are some advantages in them, but the insurance coverage may tend to be a little bit spotty on those. But I think that's bound to improve in the future

After the medicines, we do have what we call the minimally invasive treatments. And those go into two big categories. There are Botox injections into the bladder, and then there's different nerve modulation procedures. As many people know, Botox is a toxin. In its pure form, it's one of the strongest paralyzing agents known to man. But in tiny, tiny doses, it can be used in different parts of the body, such as the face for cosmetic purposes. For muscle spasms in the underarms, it can be used to control symptoms in those areas. And it's been FDA-approved for use in the bladder for a long time. It's injected into the bladder in tiny doses using a scope. So, we look through the urethra, the urine channel, and inject it in tiny doses. And typically, a few days later, the bladder begins to relax. And the results may last for six to nine months with one injection with really no moving parts.

The downside to the Botox injection is that urinary retention, at least temporarily, may be possible if it works too well. And there are some women that may occasionally need to catheterize themselves short-term to get the bladder drained. But for women that are looking for something that doesn't involve any moving parts, it's a nice option. It can often be done in the clinic setting or under a little sedation in the outpatient center.

The other category is really kind of where a lot of the excitement is, and that's the neuromodulation, the different nerve stimulation procedures. Sacral nerve stimulation has been FDA-approved for over 25 years. We target nerves that control the bladder that run underneath the tailbone, and we can essentially control those nerves with something like a bladder pacemaker. And that's a device that's implanted inside. In fact, it looks very much like a pacemaker, and it will have a battery and a remote control. And it's a 15-year MRI compatible device, and the battery may need to be replaced at that point. This is a little bit like one of those old-time transistor radios where you can tweak the settings on it for better results.

And we now also have tibial nerve stimulation. So, this is actually based on some acupuncture techniques, but there's a nerve running behind the ankle that can be stimulated with a little battery, which can be placed under local anesthesia, so no general anesthesia required. And this nerve communicates with the bladder nerves. And so, another way that we can do some nerve stimulation, which is not very invasive, but potentially improve the overactive bladder. That's the exciting stuff going on.

Melanie Cole, MS: Wow. Well, it certainly is an exciting time in your field, and that was an excellent overview of the treatment options. And so, Doctor, when we're thinking about patient selection and shared decision-making with all of these options, and as you said, the menu can be rearranged and you can jump to what used to be one of the latter treatment modalities earlier if that's what is required.

So, you're speaking to other clinicians now. How do you want them to develop these individualized treatment plans that account for that shared decision-making, patient preferences, symptom burden, comorbidities? Because obviously, things like obesity and age and hormonal factors can come into play here, and even adherence considerations. How do you work with your patients? Tell other clinicians what you'd like them to know about that.

Dr. Alex Gomelsky: I think that's an excellent point. Patient selection is the key in this. I think talking to them and find out what they're looking for and what their expectations are. I'm fairly honest with my patients in where I say, you know, we're looking for improvement. If we get significant improvement, that's fantastic.

If we get a complete resolution, that's amazing. But what we're looking for is an improvement in the symptoms and an improvement in the quality of life. For some, that may be using fewer pads. For some patients, it may be being completely dry. So we need to establish what their expectations are.

And then, as you mentioned, we want to take that woman into account. Is she heavy? Does she have mobility issues? That's easy to tell when they walk in your office or if they come in in a wheelchair. If they have difficulty transferring from their chair to the bathroom or the bathroom is too far away, those are issues that may need to be addressed in order to help any treatment work better.

I also will offer all the treatments to everybody, and I tell them, "Here are the pros and here are the cons." The Botox is sort of one-stop shopping. There are no moving parts, and some patients prefer that. They'd rather have something injected in the bladder. They don't have to worry about monitoring their response with a little remote control, and they enjoy that. Others are a little bit more hands-on, and they like the idea of something that maybe won't require repeat procedures every six to nine months. Maybe they have a battery in for 15 years.

So, you kind of have to feel them out. You have to talk to them about it. I guess I'm still a little bit of a traditionalist, where I will definitely try the simple stuff first, the behavior modification. I offer physical therapy to all my patients, and definitely will try at least one medication before moving on to the more advanced treatments. I also very much believe that the treatments are additive, that it's not use one treatment, get rid of it, and then try another one if not effective. We look at attacking the bladder at different points. And so, a combined treatment therapy may be a very good option for many of these patients.

Melanie Cole, MS: Well, I think that's the crux here, Dr. Gomelsky, is that the combined therapies and whatever works for the women. So as we wrap up, and you kind of already touched on this when you were talking about behavioral interventions and really trying some of the more conservative measures first to see how do they compare when you think of talking to other clinicians about this, when we're looking at those pharmacologic treatments, when we're looking at those procedurals, when we are looking at behavioral interventions and pelvic floor physical therapy and any of these other modalities, when should clinicians consider escalation of care? How do you want them to think of this menu?

Dr. Alex Gomelsky: I think that trying behavioral therapy and at least one medicine, I think, is very reasonable. And again, I mentioned that the medicines should definitely be considered for their side effect profiles, especially in our older adults. I think that's a great way to start. I think most women have very few contraindications to trying that first.

I would imagine in my practice that maybe 50% to 60% of women will see improvement just with those two treatments alone. And so, at that point, we can certainly consider moving on to other treatments, maybe a combination of medicines if we want to give that a try. So, I think that's a very reasonable start for pretty much anybody before looking to do something a little bit more invasive.

Melanie Cole, MS: Well, that is great advice and great information. Doctor, thank you so much for joining us today and really sharing your incredible expertise for other clinicians. Thank you again. And for more information, you can visit ufhealth.org/urogynecology. And to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org.

That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole.