Bladder Retraining for an OVERACTIVE BLADDER
Information for patients undergoing
Bladder Retraining for an OVERACTIVE BLADDER
Dr Greg Cario
Director of the Sydney Women’s Endosurgery Centre( SWEC), Australia’s leading Centre for the development and training in Advanced Laparoscopic and Pelvic Floor Surgery for Women
Director of the St George Urodynamic Centre for Pelvic Floor Disorders
You have recently been diagnosed as having an overactive bladder. This is also referred to as detrusor instability or an unstable or irritable bladder. Usually you would have had a Urodynamic test which will have shown a problem during the filling phase of the study. Normally the bladder should fill like a wet paper bag with no increase in pressure up to a volume of 500 ml. During your filling study there were signs of an increase in bladder pressure and on occasion major contractions of the bladder before full bladder capacity.
The normal reflex for bladder contraction starts with a bladder sensation which is relayed to the spinal cord. This message should be relayed up the spinal cord to the brain to decide whether it is appropriate for a bladder contraction to occur. If it is not convenient timing, a message should go down to the sacral segment of the spinal cord and should stop the reflex contraction allowing the bladder to fill further. In your case these messages up and down the spinal cord have been lost and need to be re-established to gain proper bladder control.
You will be starting on a 2 hourly rigid bladder retraining programme where you will be asked to empty your bladder by the time of day and not by bladder sensation. This means that if you wake at 7.00 am you will void completely at that time and not void again until 9.00 am, 11.00 am etc. It is essential that you resist any urgency to void during this interval. This may require you to wear a pad just in case an accident occurs. It also means that you must go to the toilet at a two hourly interval whether you want to or not. Voiding should be a relaxed affair and you should make sure that you empty your bladder completely over a relaxed period of time. This may mean that you void in the normal fashion while sitting on the seat and if you feel there is more urine present then you should lift your bottom off the toilet seat which relaxes your pelvic floor and may allow you to pass more urine.
You would usually be advised by Dr Cario to also take an anticholinergic drug to help sedate your bladder while you are getting into a normal pattern. These drugs are very effective and should give you a “honeymoon period” where your bladder appears to have improved significantly. These drugs are usually only taken for two months. They are prescribed at a high dosage which makes them very effective but can also give you troublesome side effects which include a dry mouth due to decreased saliva production, constipation due to relaxation of the bowel smooth muscle and sometimes some agitation and palpitations. The traditional drug Ditropan is taken from half a tablet to a full tablet three times a day within the half hour before each meal. Usually you begin on half a tablet which is 2.5 mg to see whether there are any side effects before continuing to the full dosage. More recently a new generation anticholinergic drug called Vesicare is commonly taken once a day only and is reported to have no significant side effects in up to 90% of cases.
New drugs called adrenergic drugs like Mirabegron or Betmiga act by a different pathway and are also very effective if the anticholinergic drugs don’t help or have too many side effects in particular dry mouth These drugs are not covered by the PBS and are more expensive but appears to be at least as effective without the side effects. Dr Cario will discuss this with you if this is a financial issue.
You would usually return to see Dr Cario after the first month still on a two hourly pattern. Following this he will increase the time interval of the voiding by 30 min increments to stretch your bladder to accommodate 500 ml more comfortably without an increase in bladder pressure. This will usually have you voiding in a 3-4 hourly pattern which is perfectly normal from a functional point of view. Once you reach a three hourly pattern your leakage episodes should almost completely disappear. After this time Dr Cario will advise you how to wean yourself off these drugs for the long term. This may take a further 1-2 months.
It is essential that you understand the nature of this bladder retraining and drug therapy as the results are directly related to the motivation of the patient. Clinical trials have shown that this is effective in up to 70% of patients where there is no other pathology present and my experience with treating this condition over the last 20 years is that if the patients understand the treatment and abide exactly by the protocol that the success rates can be even higher.
This may seem like a very simple way of treating a very distressing problem but it works. Good luck!