Ever Since I Had My Baby

by Roger Goldberg

  If you’ve developed an overactive bladder, it means your bladder has regressed to an untrained state and unshackled itself from your command. It no longer tolerates any sense of fullness at all and instead produces a strong urge from only small amounts of urine. Not only that, but like a distractible child at a carnival, it might begin to react whimsically to both physical and mental triggers. For instance, a mildly overactive bladder may associate the sound or feel of running water with the idea that a toilet is nearby, and hastily decide, “Hey … why not empty?” So it contracts, and you’re forced to control the sudden urge wherever you happen to be. If an overactive bladder worsens, it begins to respond to even more far-fetched associations. You may notice that touching a doorknob triggers an overwhelming urge to urinate, as if your bladder were recalling times when you’d barely reached the bathroom following a long walk or car ride. The bladder’s muscular walls contract, and again you find yourself fighting off waves of urge as you run to the toilet. For some women, an overwhelming urge to urinate is the extent of the problem; for others, it’s actual leakage before reaching the toilet. Over time, the overactive bladder finds more and more excuses to contract on its own, and before you know it, your bladder is controlling you.

  The good news? You can regain control. Let’s take a look at the tools you can use to tame your overactive bladder and reduce urge incontinence, from simple tips to high-tech gadgetry.

  IMPROVING URGE INCONTINENCE THROUGH LIFESTYLE AND HABITS

  RETRAINING YOUR OVERACTIVE BLADDER FOR BETTER BEHAVIOR: “BORN AGAIN BATHROOM HABITS”

  It’s common for women with incontinence and other pelvic symptoms to adopt poor voiding habits. The strong urges of an overactive bladder, for instance, may lead to a habit of more and more frequent urination. Others begin to change their bathroom habits due to a sense of never feeling empty. Still others alter their toileting patterns out of fear over accidents: for example, staying as empty as possible to avoid potential embarrassment.

  Some of these habits, as they become ingrained, can slowly but surely exacerbate certain postreproductive symptoms. Your bladder is a creature of habit—it craves routine, and it’s largely up to you to decide whether these routines will be functional or dysfunctional, controlled or chaotic. The way you choose to empty can have a profound impact.

  UNDERSTANDING THE WAYS YOU EMPTY

  THE NURSE’S AND TEACHER’S BLADDER

  Nurses and teachers display endless devotion to their patients and students, but they’re notoriously unkind to their bladders and bowels. Shift by shift, class by class, their workdays seem to go by without a pause, and postponing bodily urges becomes a part of daily life. Unfortunately, too much postponement is not a good habit. Allowing your bladder to overfill can make it weaker and less able to fully empty, as the muscle is constantly stretched out.

  EMPTYING JUST IN CASE

  Some women make a habit of emptying more often than necessary. Do you urinate several times before leaving the house, just in case? Does the slightest urge send you for the bathroom even if you know there’s not much inside? At night, after waking for reasons unrelated to your bladder, perhaps you empty because you happen to be awake. Women who work from home or are retired are often prone to these patterns. Emptying too often can have a very powerful effect on the way your bladder behaves, as it begins to expect a trip to the bathroom even at very low volumes.

  VALSALVA

  Although the name valsalva may at first conjure the romantic image of a wild-eyed fifteenth-century Italian sea explorer, its actual meaning is decidedly less glamorous. Valsalva refers to emptying your bladder by bearing down, in the same way you’d strain to push out a bowel movement or have a baby. Some women void in this way because they’re simply not patient enough to let their bladder or bowels empty on their own; for others, it’s the only way they can fully empty. Valsalva voiding is common among women, but over time, repetitive straining may erode the pelvic-floor support, and encourage prolapse or incontinence. Valsalva voiding is not the world’s worst bathroom habit, but it’s a good one to avoid.

  DOUBLE VOIDING

  Double voiding is a common habit among women who have a cystocele, an overactive bladder, or a weak bladder muscle. A short time after emptying what seem to be all the bladder’s contents, the double voider senses a second urge and empties once again. For some women, this second urge will occur right away; for others, it doesn’t occur until a minute or two later. In the vast majority of cases, double voiding is a harmless habit, but it’s worth mentioning during your evaluation, in case you have a condition that may need further treatment.

  CREDE

  After you’ve urinated as much as possible, pressing on the lower abdomen and pelvis with a hand or closed fist can generate enough pressure against the bladder to force out any retained urine. This is the Crede maneuver, most often used when the bladder muscle has lost all its strength—for instance, by individuals with overflow incontinence caused by an injury or neurological disorder. If you rely upon Crede to empty your bladder, know that it is not a typical postreproductive habit. See a specialist for a full evaluation.

  NO CAMELS

  Camels are desert-dwelling beasts who very seldom urinate. Some humans—most notably teachers, nurses, and truck drivers who work long shifts without a trip to the toilet—challenge themselves over the years to become camels. Don’t become a camel! Constantly stretching the bladder makes it weaker and less sensitive over the years. The way you choose to empty can impact your function and freedom in the years ahead.

  ADOPTING NEW STRATEGIES

  By now you should have identified the ways you most commonly void. Did you discover you have some bad habits? Not to worry. Just as bad bathroom habits were learned, they can be gradually unlearned. A few simple methods might help you to start regaining control.

  THE BLADDER DRILL: TAMING AN OVERACTIVE BLADDER

  My life has come to a screeching halt—I don’t even bother with restaurants anymore.

  —Forty-one-year-old with an overactive bladder

  Bladder drills are the oldest trick in the book for improving your voiding pattern and controlling an overactive bladder. If you’ve developed frequent voiding, waking at night, urge incontinence, or silent leakage of urine, bladder drills may be the easiest first step toward fixing the problem on your own, and you can do them right at home.

  Bladder drills are like enlisting for toilet training all over again. The overall aim is to gradually teach your bladder to tolerate more and more fullness, and to resist contracting until normal bladder fullness has been reached. In slightly more scientific terms, it’s all about suppressing premature activation of the micturition reflex. Remember that bundle of autonomic nerves that can become unruly and lead to an overactive bladder or urge incontinence? You’re about to send a clear message to that pesky bundle that you’re the boss.

  As with any behavioral approach, bladder drills will require you to be self-motivated and diligent, but they often work! One study showed improvement among 83 to 90 percent of women, versus only 23 percent in a placebo group. Especially if your major problem is an overactive bladder or urge incontinence, bladder drills can be a powerful tool when used on their own or alongside any other therapy you’ve chosen, with no added side effects. You might find they’re more effective than even the latest medication or slickest device.

  Voiding by the Clock

  To begin bladder drills, you first need to decide on an initial voiding interval. From your voiding diary (see Appendix B), estimate how often you’ve been urinating during the daytime. Then choose a comfortable interval that you feel you’ll be able to maintain throughout the day. Voiding every fifteen or thirty minutes is okay if that’s been your recent pattern. The idea is to start comfortably and to avoid taking on too abrupt a challenge.

  During your waking hours, you’re now allowed to empty your bladder only at your scheduled times. For example, if you’ve started your bladder drills at a two-hour interva
l and wake at eight o’clock each morning with a trip to the toilet, then you should follow up with voids at ten A.M., noon, two P.M., and so on until bedtime. Your bladder drills apply only to the daytime; don’t bother thinking about them after you’ve gone to bed. You should, however, always empty your bladder right before bedtime. With time, you might even find that the benefits of your daytime bladder drills eventually “spill over” into the night.

  The Moment of Truth: Learning to Resist the Urge

  When you feel an urge beginning to build before your scheduled time has arrived, don’t run to the bathroom! Instead, hold your breath and run through the following simple steps.

  Step #1: Avoid panic. Women with weak pelvic muscles usually respond to a sudden bladder urge by running to the bathroom, even when they know their bladder isn’t very full. Unfortunately, this reflex of anticipating the toilet often fuels an even stronger bladder contraction that may be even harder to control. Although the trigger is largely psychological, the resulting bladder spasm is very physical and very real. Resisting the bolt to the bathroom and adopting a new reaction to the unexpected urge represent the essence of bladder drills. Remember the basic idea: you’re controlling your bladder now. Breathe deeply and proceed to Step #2.

  Step #2: Squeeze your strongest Kegel squeeze. Squeeze a Kegel (see Appendix A) like you really mean business, and hold it strongly. This immediate tightening of your pelvic-floor muscles will help to shut off the bladder’s urge before it becomes stronger. The better shape your pelvic-floor muscles are in, the easier and more effective this squeeze will be.

  Step #3: Distract yourself. Shifting focus away from the bladder is the next step. First distract your mind. Forgetting about your bladder may seem a laughable idea at first, but with time and improved pelvic-floor strength, you’ll see it’s possible. Try thinking about your child’s next report card, or an upcoming business meeting—maddening or obsessive thoughts provide great distraction. Or try a mental puzzle, such as naming the planets of the solar system forward and then backward.

  Next, distract your body. Try a change in position. If you’re standing still, start walking, or try raising yourself up on your toes. If you’re sitting, try pointing your toes down to the floor like a ballerina. By triggering nerve pathways that lead to your lower spine (the same area where nerves to the bladder cluster), these maneuvers can help to inhibit the bladder muscle and calm its urge.

  Step #4: Cross your legs. All right, so it’s not a very sophisticated tip, but clamping your thighs tightly together can be a last-ditch safeguard against leakage when you suddenly cough, sneeze, or feel an unexpected urge. Though it might be a bit conspicuous out in public, it’s harmless and quite effective. Developing strong thigh (adductor) muscles with lower-body conditioning will allow you to reliably use this technique when you need it most.

  DON’T BE A SOFTIE

  Playing hardball with your bladder is the only way to achieve great results. That means not running to the bathroom out of fear; no exceptions, even when you’re standing in the shower and that strong urge comes on. Once you’ve made the commitment to bladder drills, wear pads or other protection if you’d like, and don’t fret over occasional leakage if you’re truly playing by the rules.

  Pushing Your Limits

  Once you’re feeling comfortable with your voiding interval, the next goal is to lengthen it, slowly but surely. Every ten to fourteen days, try increasing your interval by around thirty minutes. For example, if you’ve been comfortably voiding every sixty minutes for a few weeks, try increasing to seventy-five, and stay there for the next several weeks. Your ultimate goal should be a three-to-four-hour interval (no more than six to seven voids over twenty-four hours), assuming an average fluid intake. Just remember to approach that goal slowly, never extending your voiding interval by over thirty minutes every two weeks. Above all, remember to have patience while making progress. Working in small steps, you should take anywhere from three to twelve months to achieve your ultimate goal. If your symptoms remain a bother at that point, it’s time to seek another strategy.

  START YOUR MORNING WITH A SQUEEZE

  As you improve with bladder drills, one part of the day often remains a big challenge: first thing in the morning. Many women notice that their overactive bladder is most difficult to control from the moment their feet hit the floor at the bedside, all the way to the toilet. That occurs not only because the bladder may be fairly full after a long night’s sleep but also because the urine tends to become more chemically concentrated overnight, and irritates the bladder lining as a result.

  Before getting out of bed, even if you don’t feel an urge, make it your routine to stop for a moment. Now start with a strong Kegel squeeze, then another. Do a set of ten, and as with a bladder drill, try to distract yourself mentally. Think about the tasks waiting for you at work or at home. Then calmly, slowly, and confidently walk to the bathroom. No mad dash, no panic, and before long, perhaps to your surprise, a better start to your day.

  MEDICATIONS FOR URGE INCONTINENCE AND OVERACTIVE BLADDER

  Do you have an overactive bladder?

  Is your life an accident waiting to happen?

  If you’ve flipped through any of the most popular women’s magazines, you might have come across one of these questions posed by the leading pharmaceutical companies, and caught wind of a whole new trend in women’s health. Medications for the overactive bladder have emerged as a billion-dollar industry, and you’re right at the epicenter of a modern marketing blitz. Colorful advertisements don’t hesitate to remind you how disruptive constant bladder urges, urinary frequency, and incontinence can be for active women. Beyond the hype, do these medications work?

  Actually, yes. Of all incontinence types, urge incontinence and the overactive bladder are the most likely to be fully relieved with medication. But finding the right medication for your symptoms, and arriving at the right dose, may require trial and error and a good deal of patience.

  ANTICHOLINERGICS AND ANTISPASMODICS

  Remember the autonomic nerve supply to the bladder and how those nerves can act up to cause an overactive bladder and urge incontinence? Most available drugs are designed to diminish this nerve activity, relax the bladder, and prevent bladder spasms. Anti-cholinergic medications are the most common among them.

  These pills don’t truly cure the problem, and they’re not magic bullets targeting the bladder. By entering the bloodstream, they eventually reach the salivary glands, decreasing their activity and causing dry mouth. They slow the activity of your esophagus and bowel, sometimes causing heartburn or constipation. Beyond those common side effects, a wide range of other, less common ones may also occur.

  The generic medications include:

  Oxybutynin (Ditropan). This was the gold-standard overactive-bladder medication for several decades, and it remains an alternative today. It’s been shown to reduce leakage episodes by 19 to 58 percent over placebo. Oxybutynin counteracts and even prevents bladder spasms by relaxing the smooth muscle of the bladder wall and calming the bundle of nerves surrounding it. It’s available in generic form, so it costs less. Unfortunately, it needs to be taken three to four times daily, and side effects are very common. A newly developed skin patch was recently tested and found to be effective for urge incontinence; it remains to be proven whether certain women will experience fewer side effects with this approach, as compared with oral therapy. But by far, the most widely used novel nongeneric form of oxybutynin, already on the market, is Ditropan XL (see below). Side effects may include: dry mouth, dry eyes (especially if you wear contacts), constipation, drowsiness, blurred vision, and a host of other, less likely side effects.

  Several other anticholinergic medications are available, with a chance of success comparable to oxybutynin and a similar probability of side effects. They can occasionally provide effective and inexpensive relief.

  Hyoscyamine (Levbid, Levsin, Cystospaz, Urised). Tablets are usually taken twice daily. Levbid is also
available in sublingual form (placed beneath the tongue rather than swallowed).

  Propantheline (Pro-Banthine), flavoxate (Urispas), dicyclomine (Bentyl). Tablets are taken several times daily, with side effects similar to oxybutynin’s.

  The name-brand medications include:

  Ditropan XL. Ditropan XL looks like a pill but actually is a capsule-size delivery system with a microscopic hole drilled into its center and filled with regular oxybutynin. Over a twenty-four-hour period, it releases medication through the tiny opening at a slow and regular rate. It avoids the sharp peaks and valleys in medication levels, so side effects are considerably fewer. Only around 7 percent of women need to discontinue due to side effects, and many are able to reach dose levels they would never have been able to tolerate with the generic pills. Ditropan XL also offers the convenience of taking only one pill daily.

  Side effects are the same as generic oxybutynin’s but less common.

  Tolterodine (Detrol in the U.S., Detrusitol in Europe). Detrol entered the market in 1998 and has become widely popular across the United States and Europe. According to animal studies, it may target the bladder wall more selectively than standard anticholinergic medications, avoiding the salivary glands and thus raising hope that dry mouth might occur less frequently. Indeed, huge numbers of women have found relief with this medication, with very manageable side effects. It is taken twice daily. Detrol LA is becoming a popular first-line option and offers once-daily dosing.