Solving Women's Bladder Problems
Urinary incontinence affects millions of women. But new drugs in development promise hope for bladder control.
By Jeanie Lerche Davis
Reviewed By Brunilda Nazario
We've seen the TV commercials. When you gotta go, you gotta go, go, go. But make no mistake, it's no laughing matter. Urinary incontinence plagues some 20 million Americans - and up to 25% of women are affected by it.
"It's an enormously prevalent problem," Rony Adam, MD, a urogynecologist at Emory University School of Medicine, tells WebMD.
Norman Zinner, MD, professor of urology at UCLA, has helped test one of several promising new drugs to treat this vexing disorder. "Overactive bladder is an exceptionally common problem, very troublesome. It causes a lot of lost workdays, embarrassment, and shame. Many women don't seek therapy even though therapy is available," Zinner tells WebMD. "They just think it's part of getting old, but it isn't."
For some women, the cure may be simplistic -- drink less water, says Adam. "People are drinking lots of water these days, maybe 10 liters of water a day. I have a lot of patients who think they have stress incontinence, but we find out they're flooding themselves with water. That can overwhelm the most normal bladder."
Also, what you drink can stimulate the bladder and make it more sensitive, he says. Caffeine is a diuretic that stimulates the bladder muscle. Coffee, tea, soda drinks, chocolate -- especially dark chocolate -- have caffeine. Cut the caffeine, cut the problem.
Even urinary tract infections can feel like incontinence, and the problem resolves itself once they are treated, Adam says.
But chronic leakage is not so straightforward. Doctors distinguish between "urge incontinence" and "stress incontinence" -- and each has its own causes and range of treatments. There's much research going on, with new drug treatments emerging. There's even a Chinese herbal mix that seems to show promise.
Stress incontinence, typically activity-related, is loss of urine when you sneeze, laugh, or exercise, which puts pressure on the bladder. It is the most common type of urinary incontinence in women, doctors say. "It's an architectural problem," says Adam. The support system for the bladder has been damaged -- through pregnancy and childbirth, or possibly the effects of aging, he explains.
Urge incontinence, also known as "overactive bladder," is an urge to urinate that is so strong you cannot reach the toilet in time -- even when your bladder contains only a small amount of urine. "The bladder does not stay calm; it contracts and squeezes whenever it feels like it," says Adam. "When it feels full, it contracts. It's like bladder action before potty training."
As women get older, bladder control can deteriorate. Declining estrogen causes vaginal and bladder tissues to atrophy, leading to incontinence problems, he explains. Also, gaining too much body weight puts pressure on the urinary system, which can cause urinary problems.
Even constipation can lead to urinary incontinence -- the proximity of the bowel and bladder mechanisms can lead to problems with both, says Adam. "It may be a coordination of nerve impulses, since the nerve supply to the pelvis and the rectum is the same."
A study last summer pointed to HRT as a cause of incontinence. Among women who took HRT for five years, there was a five-fold increase in risk of stress incontinence while women taking it for a year had double the risk.
While it's not understood why estrogen would have this effect, it may be that, because estrogen makes tissue suppler, it may also make it more relaxed, which decreases bladder control.
Fixing the Leak
Adam says treatment can improve urinary continence. "There are a lot of things we can offer our patients."
With mild to moderate incontinence problems, exercise therapy or medications work. He first helps resolve any constipation problems. Then, he teaches women to do Kegel exercises (which strengthen muscles supporting the pelvis) and biofeedback (to retrain bladder muscles). "Basically, women are learning to deal with it a little better -- to squeeze before you cough, which helps keep the bladder in position," Adam tells WebMD.
Estrogen creams can make the vagina more pliable, which helps women regain control. Also, an E-string (a small, flexible plastic ring placed in the vagina) can deliver just enough estrogen to solve the problem. "You don't feel the ring; you can have intercourse with it. It stays in place for three months at a time, and it works for both kinds of incontinence," says Adam.
The common decongestant pseudophedrine even helps a mild incontinence problem, Adam tells WebMD. The drug stimulates receptors in the bladder, giving you a better chance at controlling urine, he says. "It seems to squeeze the urethra a little bit, especially if [incontinence] is linked with a special activity -- playing tennis, walking the dog -- a defined circumstance. Take two tablets 30 minutes before the activity may be all you need." Also, studies have shown that estrogen cream plus Sudafed makes the Sudafed work better, Adam points out.
With urge incontinence, there aren't so many options. "Bladder training" -- learning new muscle control techniques -- can help.
Also, a treatment called "pelvic sacral neuromodulation," which involves an implanted electrode near the tailbone, modulates sensory nerves to the bladder by sending a constant pulse of electricity. "It regulates the bladder, seems to reprogram it," says Adam. "It really works. It's been around two, maybe three years."
In the Pipeline
The drug oxybutynin -- which relieves bladder spasms and a host of urinary problems -- is very effective in controlling incontinence, but has numerous side effects. However, oxybutynin will soon be available in transdermal patch form. "That should eliminate dry mouth, constipation, and other side effects," says Adam.
Duloxetine, a new antidepressant that has demonstrated some effectiveness for stress incontinence, "seems fairly promising," Adam tells WebMD. Data from four 12-week studies suggested that the drug reduced frequency of incontinence episodes by 52%, time between voids increased by 18 minutes. Of the 958 women taking duloxetine, 80% reported their symptoms as better for up to one year after the studies ended. Duloxetine works with the neurotransmitters serotonin and norepinephrine (SNRI), stimulating increased activity in bladder nerves -- increasing contractions, thereby reducing accidental leakage.
Solifenacin succinate, a new drug for urge incontinence, suppresses bladder contractions by blocking receptors on the bladder. This action makes the bladder less irritated and helps it to relax, which in turn increases the bladder's capacity to hold urine. Three studies at 150 medical centers throughout the U.S. and Europe, involving 2,100 patients with urge incontinence, showed that 53% of patients became continent by the study's end; 82% of the patients taking the drug reported a 50% or more reduction in incontinence -- without side effects like dry mouth or constipation.
Trospium, also for urge incontinence, has completed Phase III clinical trials and been submitted to the FDA for approval. Trospium also works to relax muscle tissue in the bladder, thus decreasing bladder contractions. The 12-week trial involved 523 patients, 71% of whom were women, all had 10 or more voids a day, and one or more accidents a day. At the study's end, those taking trospium had fewer toilet voids per day, fewer accidents, and less urgency.
In fact, research into these neuroconnections shows a shared pathway between receptors in the brain and the bladder, says Adam.
For people who have "mixed incontinence" -- symptoms of both stress and urge problems -- he prescribes the antidepressant imiprimine. "We give doses much lower than people would take for depression, but to utilize its side effects. It has alpha-agonist action and anti-cholinergic so it works perfectly for those with mixed incontinence."
Peipei Wishnow, PhD, helped develop BetterWOMAN, a 20-herb mix based on a formula used in traditional Chinese medicine. The mix can be taken for stress and urge incontinence and for frequent urination, she tells WebMD. Wishnow heads the company that produces BetterWOMAN.
The herbal mix "naturally moderates hormones, so it strengthens bladder muscles naturally, to help women regain control," she tells WebMD. "It also improves blood circulation in the bladder area and modulates neuromuscular function."
In her two-month study of 45 women, there were 75%-80% improvements in urinary function. Those women who continued taking the herbs after the study's end also had some "sexual benefits" -- increased vaginal lubrication, increased libido, and more orgasms, she reports.
"Very, very good results," says Wishnow. "Women don't have to suffer."