Side effects are the same as oxybutynin’s but less common.
TRICYCLIC ANTIDEPRESSANTS
If your doctor prescribed an antidepressant for your bladder or pelvic symptoms, don’t be too surprised. It’s not a thinly veiled message that this bladder problem is all in your head. Certain antidepressants have been used for decades to treat overactive bladder symptoms.
Imipramine (Tofranil). This drug boasts the unique ability to not only alleviate urge incontinence but also to occasionally improve mild forms of stress incontinence. Because of this dual action, and because it’s available in relatively inexpensive generic form, imipramine has remained a popular choice even in our “designer-drug” era. Because of its tendency to cause sedation, it’s best taken after dinner, so you’ll sleep off the peak medication levels during the night. Small doses can also be taken during the day.
Side effects may include: sleepiness, dry mouth, constipation, confusion, altered blood pressure, and a long list of less likely symptoms.
Doxepin (Sinequan), amitriptyline (Elavil). Similar to imipramine and often chosen for patients with conditions causing a very sensitive or painful bladder.
Desmopressin (DDAVP). This is a different type of medication altogether, not specifically targeting the bladder but useful for treating nighttime urinary frequency (nocturia) or leakage resulting from an abnormally high nighttime production of urine. It’s an antidiuretic that signals the kidneys to slow their output—causing you to temporarily retain fluids in the rest of your body. When starting DDAVP, you need to work closely with your doctor to avoid risks relating to fluid overload and altered body salts. If you can avoid these side effects, DDAVP is effective for some types of nighttime urgency and incontinence. A recent multinational trial of DDAVP indicated that it may also be useful for treating daytime urinary incontinence.
COPING WITH SIDE EFFECTS
The latest generation of anticholinergic medications, such as Detrol and Ditropan XL, maintains the beneficial effects of older overactive-bladder medications with fewer side effects. Still, side effects occur. Some doctors will begin with a mild dose, slowly increasing it as necessary over a period of weeks. If you’ve noticed no relief of your bladder symptoms once you’ve reached your maximum tolerable dose, or the side effects become too much to bear, you may need to switch to another medication. But if you’re generally happy with your medication and are facing side effects that you’d like to minimize, here are a few ways to cope.
Dry mouth. This common anticholinergic side effect can be quite a nuisance, and can even pose a risk to dental health over time. Carry a water bottle and stay well hydrated, swishing sips of water to keep your mouth moist throughout the day. To stimulate the production of saliva, try chewing gum or sucking on hard candies, especially those with bitter flavor, such as lemon drops or peppermints. Artificial-saliva products are available in sprays, gels, or lozenges, but they offer little advantage over less expensive options.
Dry eyes. Artificial tears, available over the counter, are especially useful if you wear contact lenses. Contact your doctor for any blurred vision or eye discomfort.
Constipation. Counteract the bowel-slowing effects of these medications with plenty of dietary fiber, adequate fluids, regular exercise, and a daily stool softener.
Retention of urine. Your stream may feel slower and less forceful; this is a normal side effect. Double voiding (see chapter 8)—waiting an extra minute or two after you’ve urinated for the arrival of a second bladder contraction—is a harmless way to be sure you’re emptying completely. Avoid the temptation to strain, since this can damage your pelvic-floor supports and their nerve supply. If you feel you’re not emptying as fully as before, mention this to your doctor.
Less common. Confusion, drowsiness, headache, and rapid heart rate. Report these side effects to your doctor.
“WILL I NEED TO TAKE THIS STUFF FOREVER?”
Overactive-bladder medications can be used indefinitely, for years and years, but that’s often not necessary. For many women, medication provides just a first step toward regaining confidence and control—a sort of temporary crutch allowing them to begin a more long-term process of behavioral retraining (see “The Bladder Drill,”). Over time, as these improved voiding habits influence bladder control, you’ll depend less and less on the medication.
SURGERY FOR URGE INCONTINENCE
NEUROMODULATION: THE PELVIC PACEMAKER
Now for one of the most fascinating advances in overactive-bladder treatment: the Interstim device, or the pacemaker for the pelvis. The procedure involves placement of a tiny permanent electrode beside the key sacral nerves that exit the spine and head toward the pelvic floor. The device has received FDA approval for urge incontinence and overactive-bladder symptoms, and it is being investigated for a handful of other problems, including fecal incontinence (see chapter 10).
The Interstim “pacemaker”
The first step involves an office procedure called the test stimulation. The doctor inserts a small, thin wire beneath the skin of the back, using just a bit of local anesthesia. When the tip of this wire is positioned correctly, it’s securely taped to your back. Over the next three to five days, a small battery-powered device stimulates the pelvic nerves and muscles, producing a mild pulling or tightening sensation in the pelvic and vaginal area. If the test stimulation is a success—meaning that your symptoms improve with the temporary wire in place—you can proceed with the second phase: implantation. This involves surgical placement of the actual pacemaker—around the size of a large stopwatch—beneath the skin, during a relatively short operation requiring general anesthesia. It provides constant stimulation to the pelvic nerves.
Assessing the long-term results for this treatment will require several more years of follow-up. But to date, the response of many different pelvic and urinary symptoms has been remarkable. Urge incontinence and the overactive bladder, urinary retention, bladder pain, and even constipation can improve dramatically. One large report on the Interstim device reported 61 percent excellent response, and 22 percent good response for the overactive bladder. According to another series testing seventeen women, 94 percent considered it a success and would do it again. Impressively, success can be achieved for some of the most challenging patients, those who failed to improve with all other treatments.
As with any operation, complications can occur, including infection, low-back pain, or shifting of the pacemaker from its proper position, which sometimes requires another operation. According to initial reports, around a third of recipients needed additional surgery to either alleviate pain or replace the device; however, this appears to be less common as techniques improve. In the near future, modifications of this amazing technology are anticipated to make the implantation procedure even less invasive. In the meantime, its early success has already raised enormous excitement.
“A TREATMENT IN MY BACK SIDE FOR A PROBLEM IN MY FRONT?”
Neuromodulation, the pelvic pacemaker, may change the way we view many common female symptoms. A number of disorders once thought to arise in the bladder and pelvis may really begin higher up in the nervous system, closer to the spine.
OTHER OPERATIONS FOR URGE INCONTINENCE
Major surgical procedures aren’t generally considered for urge incontinence except in very unusual cases, which usually involve severe underlying neurological problems. In these circumstances, bladder augmentation (which surgically enlarges the bladder) may be considered.
TYPE #3: OVERFLOW INCONTINENCE
This type of leakage occurs when the bladder is unable to empty fully and remains in a constantly overfilled state. Unlike the overactive bladder, with overflow incontinence, the bladder muscle is usually underactive. From time to time, the bladder reaches its absolute capacity and excess urine simply spills, overflowing like an overfilled pail of water, often without urge or warning. The bladder never fully empties with overflow incontinence; it just remains a bit less full for a while. Overflow incontinence
is uncommon. Nevertheless, you should understand it, because it can indicate an elevated risk of an underlying neurological condition, spinal injury, diabetes, or a blockage problem such as narrowing of the urethra. Also, if left untreated, it can increase your risk for kidney infections and damage to the kidneys resulting from slowing of their drainage.
How would you know if you have overflow incontinence? Most commonly, you would notice small, frequent leaks of urine with a weak stream, and you probably wouldn’t feel truly empty even after urinating. One tricky aspect of overflow incontinence is that it might also cause leakage with coughing or straining, mimicking the more commonplace stress incontinence. The critical difference is that with overflow incontinence, the bladder never fully empties; the problem is caused by bladder weakness rather than urethral weakness.
During your first office visit, the doctor will test you on postvoid residual (see chapter 13): after you urinate, the amount of urine left inside your bladder is measured with either a small catheter or an ultrasound machine. If this test shows you’re retaining urine, your doctor may recommend more complex office testing to better understand whether you have overflow incontinence, and to rule out an underlying neurological or medical cause.
TYPE #4: MIXED INCONTINENCE
Mixed incontinence signifies two or more of these incontinence problems (stress, urge, overflow) occurring together. By far, the most common pairing is stress incontinence alongside urge incontinence. The symptoms caused by this dynamic duo can be truly incapacitating. Between all of the uncontrollable urges—and the anxiety that begins to accompany coughing, exercising, or even changing positions—mixed incontinence can leave you with very little worry-free time to enjoy your life.
While there’s no need to make yourself an overnight expert in each of the several varieties, you should understand a few take-home points. First of all, mixed incontinence makes guesswork more difficult from your doctor’s point of view. While somebody with simple overactive-bladder symptoms may be offered a trial of medication before any testing is done, the presence of mixed symptoms makes early testing more important. These tests will help your doctor to decipher exactly what is happening beneath a frequently nebulous mix of bladder symptoms, and to decide what needs treatment most (see “Urodynamics,” chapter 13). The second key aspect of mixed incontinence relates to how quickly and easily you can expect to achieve total relief. You may start a trial of medication for urge incontinence but still leak; and that’s probably because your stress incontinence has yet to be addressed. Likewise, surgery for stress incontinence may be performed perfectly but fail to leave you completely happy and dry. In most cases, this is because the urge incontinence has persisted even after the stress incontinence has resolved. If you’re diagnosed with mixed incontinence, you may ultimately need a mix of at least two different treatments in order to fix your leakage. Finding the right combinations of therapy will often require trial and error and a good deal of patience on your part.
Since mixed incontinence usually includes overactive-bladder symptoms, all of the previously discussed tips for better bladder behavior still apply. Kegel exercises, cones, and biofeedback (discussed in Appendix A) are also useful tools.
MEDICATIONS FOR MIXED INCONTINENCE
The same basic medications for urge incontinence and stress incontinence are also used to treat mixed incontinence.
ELECTRICAL AND MAGNETIC STIMULATION THERAPY: A NONINVASIVE OPTION FOR STRESS, URGE, AND MIXED INCONTINENCE
PELVIC-FLOOR ELECTRICAL STIMULATION
Electrical shock therapy for your pelvis? Sounds like a bad scene from a B horror film—but actually, it’s a real-life medical alternative used to treat certain types of urinary incontinence, fecal incontinence, even sexual dysfunction and pelvic pain. Have you known someone suffering from back pain or muscle spasms who uses electrical stimulation? Pelvic-floor stimulation (PFS) is similar, using a mild electrical current to recondition the muscles and nerves of the pelvic floor.
Electrical stimulation devices consist of a probe around the size of a tampon, inserted vaginally or rectally, attached to a small portable device that delivers a mild electrical current to the pelvic-floor muscles and nerves. If you can insert a tampon, you should be able to insert a probe. Daily treatments are self-administered, beginning frequently—sessions of fifteen to thirty minutes, twice daily, in most cases. Ideally, different current strengths and frequencies are used, depending on the condition. As you gain awareness of the muscles and supports being stimulated, you can join in with your own Kegel squeeze. After symptoms have begun to improve, often over a period of several weeks to months, the number of sessions can be tapered off.
For urge incontinence. Overactive-bladder symptoms, such as urge incontinence, urinary frequency, and bladder irritation or pain, can respond favorably to pelvic-floor stimulation. The odds of success appear to be greater (50 to 70 percent) for treating these symptoms than for treating stress incontinence.
For stress incontinence. Pelvic-floor stimulation has been reported to help up to 48 percent of women, though surprisingly, roughly 13 to 28 percent of women treated with a placebo in published series have also reported improvement.
THE MAGNETIC STIMULATION CHAIR
Electromagnetic fields exist all over our world—in outdoor power lines, cellular phones, airplanes, computers, and televisions. The same basic type of energy is used in medicine to treat a number of common pelvic and urinary symptoms, ranging from an overactive bladder to an underactive one. Magnetic stimulation chairs deliver twenty-minute treatment sessions, involving no discomfort, while you remain fully clothed. The rather magical scientific feature is that magnetic stimulation can be targeted to areas deep in the body, passing through skin and other tissues without irritating them at all.
Although the device has not been tested in a placebo-controlled study (the only true way to prove its effectiveness), improvement has been reported for up to 69 percent of women with urinary incontinence in one clinical trial of biweekly treatments for six consecutive weeks. Improvements have also been seen in overactive-bladder patients for reducing the frequency of urination, nighttime voiding, daytime leaking, and overall quality-of-life survey scores. Trials are under way to test the magnetic chair right after childbirth for preventing urinary incontinence, and also for treating fecal incontinence. In its present form, magnetic stimulation can be performed only in the doctor’s office, requiring multiple visits. Regardless, it remains yet another nonsurgical treatment option worth considering if low-tech alternatives have failed and you’re intent on avoiding more invasive therapy.
WHAT TO EXPECT FROM SURGERY IF YOU HAVE MIXED INCONTINENCE
If you’re heading into surgery, mixed incontinence means mixed news. The bad news is that surgery for stress incontinence may have an unpredictable effect on overactive-bladder symptoms: they can get worse, stay the same, or improve. So even if your operation keeps you from leaking with coughing, sneezing, or lifting, don’t be shocked if you’re still bothered by urinary frequency, nighttime voiding, and/or urge incontinence. The good news is that both components of your problem can still be effectively treated. A combination of medications, behavioral tips, gadgets, and procedures can eliminate both culprits causing your mixed incontinence. Just don’t expect an operation for stress incontinence to cure your overactive bladder—after all, that’s not what it was designed to do!
General Treatments and Tips for All Incontinence Types
DIET AND SELF-HELP REMEDIES
Everything you eat and drink affects the way your body feels. Cajun spice can burn your stomach; grapefruit juice can make your whole chest feel sour. Too much caffeine can leave a throbbing headache in its path, and a bag of salty chips may leave your mouth feeling parched and dry. But how often are you aware of the connection between what you eat or drink and how your body feels down below? When substances in your diet reach their final destination in your bladder and bowels, they can profoundly affect postreproductive symptoms.
If you’re looking for quick and easy relief at home, take a careful look at your diet.
Take Stephanie, an avid diet-cola drinker who came to the office complaining of urinary frequency, urge incontinence, and waking several times each night with a strong need to void. At work, it had been her routine to drink three cans of pop, one before lunch and two afterward. At night, she kept a caffeine-free standby on her nightstand for after-hours thirst quenching. Though her bladder irritation and incontinence had been an increasing bother for several years, she had never associated her pesky symptoms with her love for soda. At our first visit, I shared with her a list of foods and drinks to consider avoiding, and she was surprised to see diet cola near the top. Not a medical miracle performed on my part, but Stephanie accepted my simple advice and kicked the habit, and her problem gradually improved.
Even if you’re not a card-carrying member of the Pepsi generation, read on—you might not be off the hook. Less obvious foods and drinks may be contributing to your bladder symptoms. An innocent cup of decaffeinated tea, perhaps a weakness for pasta with red sauce and a glass of wine on the side, or a cappuccino after dinner. Your postreproductive body might feel a great deal better with the help of a few culinary tips.
Ever Since I Had My Baby Page 17