Dr. Rickey outlines treatment options for overactive bladder


"I think people don't understand how exhausting it is for people to manage these symptoms day in and day out," says Leslie Rickey, MD, MPH.

In this video, Leslie Rickey, MD, MPH, discusses treatment options for overactive bladder. Rickey is an associate professor of urology and of obstetrics, gynecology & reproductive sciences at Yale School of Medicine, New Haven, Connecticut.


Please provide an overview of treatment options for overactive bladder.

Overactive bladder is a really common condition that disproportionately affects women. One of the things that's particularly distressing about overactive bladder is the unpredictability of it. This urgency comes on out of nowhere, or they feel like they have no control over their bladder, and so if leakage is the main issue, they have to find a bathroom. They could have a little bit of leakage, or they could have a lot of leakage. This prevents women from participating in activities, from traveling. I think people don't understand how exhausting it is for people to manage these symptoms day in and day out. It creates like a background stress, a sense of panic, and people really stop doing the things they like to do. So I think that's one of the first things I like to say about overactive bladder, because as urologists and urogynecologists, we see a lot of these women. So I think really drilling down into the symptoms that are bothering them and how we can best help them meet their treatment goals is really important. I think there's also a broad heterogeneity of these patients. Some of them are more bothered just by frequency, some are more bothered by getting up at night, and some are more bothered by the leakage component. There's another treatment network called the LURN Treatment Network through the NIH and NIDDK, and they're trying to more precisely phenotype these different patients so that we can better target treatment. That being said, we have some pretty well-described pathways, and before you even get to some of those third lines, you want to make sure you've really educated your patients and understand when they're leaking, why they're leaking, what their fluid intake is, when they're drinking it, what they're drinking, because doing some really basic educational and what we call behavioral treatments can be really impactful. I also want to highlight the use of pelvic floor physical therapists and pelvic floor muscle training. Sometimes, strengthening these muscles can go a long way to helping them control their leakage. Other patients have more of a sensory condition, where they have pain in those pelvic floor muscles, and they need somebody to help do more trigger point release or muscle release. It's not always just strengthening. A good pelvic floor physical therapist can help distinguish between those 2, and they do a lot of evaluating the patients and educating them in addition to doing the pelvic floor physical therapy. Of course, medications have been a mainstay for a long time. They can work really well for a lot of people. But there are other people who either have some side effects to some of the medications, or they don't get the treatment outcome; it doesn't work well enough. And so I think in that population, I think what happens is that those medications get prescribed, and then maybe there's not a clear follow-up plan, or they think if the medications don't work, they're done. So I think having a clear plan with your patients [where you say], "Look, we're going to try these over the next few months. If it doesn't work well enough for you or you have a side effect, let's work together." Offices can work on reaching out to the patients, but I think also empowering them to let you know what's not working so that you can move them on to some of these third-line, more invasive treatments. So I do let them know about them upfront so that they know there are other things if the medications don't work, because sometimes by the time they've seen me, although I think you sometimes need to back up to those earlier interventions they haven't tried yet that are less invasive, I think trying to move patients quickly into the next step when it's right for them is also important. We have great treatments for women that have what I'm going to call refractory leakage that's really affecting their quality of life and their mental and physical health. Botox is a treatment that can be done right in your office. I'd say 97% of the patients that I have on Botox are done in the office, and we just get them on a regular schedule. They know they're going to come in, if they're responders to it, usually every 6 to 9 months. That's a great minimally invasive treatment. Then there's also sacral neuromodulation, which is done with an implantable device. As most urologists will know, that can also help decrease leakage episodes. Both of those treatments have been shown to have a really positive impact on quality of life. Finally, there is a less invasive treatment option: posterior tibial nerve stimulation or peripheral nerve stimulation. Right now, that is most often done as an office treatment where someone has to come in repeated times and get that nerve stimulated. There is now an implantable device that can be implanted near the nerve, near the ankle so that the patient can utilize that treatment more easily at home. I think it's an effective treatment. I think ideally, it is something that works probably better for most people to be able to access it themselves at home, because coming into the office for repeated treatments is just not a reality for some people, but it can be effective in the right patient population.

This transcription was edited for clarity.

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