R. Mark Ellerkmann, MD, Director of Urogynecology at the Weinberg Center for Women’s Health and Medicine, Mercy Medical Center, Baltimore, talks about a an FDA approved outpatient procedure using Botox that helps patients with urinary incontinence and overactive bladder.
Interview conducted by Ivanhoe Broadcast News in January 2018.
I want to ask some basic questions about urinary incontinence, overactive bladder. For starters what is it and what’s happening?
Dr. Ellerkmann: Overactive bladder is a very common problem that affects men and women as we get older. It’s more common in women. It’s a clinical diagnosis based on a constellation of symptoms. First and foremost: urinary urgency. This symptom may be accompanied by urinary frequency and/or getting up one or more times per night to void (nocturia) and/or urge-related urinary incontinence. A classic presentation is someone coming home, putting the key in the front door and needing to make a mad dash to the bathroom, perhaps not getting there in time and having an episode of incontinence.
You said advancing age is one cause. Are there some other causes or risk factors?
Dr. Ellerkmann: One risk factor unfortunately is being a female; overactive bladder is more prevalent in women. Other risk factors include being older and being post-menopausal. Modifiable risk factors include obesity and specific beverages and foods that can irritate the bladder. Anything that can irritate the bladder can cause symptoms of overactive bladder. That could be something as simple as too much caffeine in the diet to an infection to something perhaps more serious like bladder cancer or a kidney stone irritating the bladder just like a grain of sand can irritate an oyster.
The results unfortunately are a little bit different.
Dr. Ellerkmann: A little different, absolutely.
What are some of the treatments?
Dr. Ellerkmann: We like to initially initiate treatment for overactive bladder with conservative and behavioral strategies. Pelvic floor physical therapy can be helpful. Scheduled voiding practice- -that is, getting to the bathroom in a timely fashion on a schedule can be very helpful. Modest weight loss can be helpful and also avoiding things in the diet that can irritate the bladder. Caffeinated and carbonated beverages, tea, citrus juices, artificial sweeteners, chocolate and spicy foods are all known irritants that, if avoided, can impact improvement in this clinical diagnosis.
What about in terms of schedule, is there a time? For example I have friends that won’t drink water after six pm. Is that a common thing to look toward?
Dr. Ellerkmann: A very helpful evaluation is a urinary diary over twenty four hours or a three day period to really evaluate how much fluid someone is consuming, the frequency of urination and the number of incontinent episodes during a specific time period. Looking at what they’re drinking, and when they are drinking can be very helpful. If someone is experiencing significant urinary frequency, typically more than eight voids over a twenty four hour period, we look at the timing between those voids. Then we try and decrease that time interval to a point where they don’t need to rush to the bathroom. It’s very patient specific.
I want to ask you again about a voiding diary, how long would a person need to keep track of what their intake is?
Dr. Ellerkmann: A twenty-four hour voiding diary can be very helpful. Better yet is a three day voiding diary. It can give us a little more specific information about what is being consumed especially with respect to bladder irritants. How much is being consumed, how often one is voiding, and if those episodes of voiding or going to the bathroom are associated with urge-related leakage.
What are the top things to avoid if you’re having this problem?
Dr. Ellerkmann: The top things to avoid in the diet are caffeinated beverages, carbonated beverages, citrus juices, spicy foods, chocolate and artificial sweeteners. Of these, patients may note specific ones that are more bothersome than others.
How about alcohol?
Dr. Ellerkmann: Alcohol is not only an irritant to the bladder but also a diuretic, meaning that it impacts the kidneys to make more urine.
When you try changing the diet with some of these other first steps toward improving and you’re not getting any relief, what are your next options?
Dr. Ellerkmann: We move on to the world of pharmacology. There are seven medications that are currently FDA approved for overactive bladder and urge-related incontinence. Failing a positive clinical response to conservative, behavorial and dietary strategies, it is reasonable to trial one of these medications, assuming no contraindications or treatable cause of overactive bladder like an infection. None of these medications are superior to the other. They all work very similarly to help the bladder not contract as much. When we speak about pharmacological management, it is important to note that they all have potential side effects and they are not always effective. The majority of these medicines have common side effects like dry mouth and constipation that will often lead patients to discontinuing them. So we are somewhat limited in the realm of medication for treatment for this problem as well.
The next step would be surgical options?
Dr. Ellerkmann: If a patient’s symptoms remain refractory, meaning they’re not responsive to conservative, behavioral and dietary strategies and medication is either ineffective or not tolerated, then we move on to what I call adjuvant or additional treatment options which are really limited to the use of onabotulinumtoxinA (what is commonly known as Botox) or neuromodulation. Neuromodulation is the electrical stimulation of nerves that ultimately supply or innervate the bladder. Neuromodulation can also be helpful in minimizing overactive bladder symptoms.
Talk to me about Botox. Is this a fairly new treatment for this condition?
Dr. Ellerkmann: It’s not really a new treatment, it was FDA approved in 2013 to treat the most common type of overactive bladder, which most women and men suffer from. Botox is a neurotoxin and it’s been used in various applications. Most people are familiar with Botox with regard to cosmetic surgery. Some people opt to receive Botox injections to help with crow’s feet or skin furrows in the brow, but it’s been used for a lot of other indications as well. When we talk about overactive bladder we talk about the cause, which is a bladder muscle that is overactive—literally contracting when we don’t want it to. We refer to the bladder muscle as the detrusor muscle and there are two classifications of detrusor overactivity, neurogenic and non-neurogenic. The majority of individuals with overactive bladder symptoms have non-neurogenic (also known as idiopathic) detrusor overactivity
Do you have any estimate of how many people undergo the treatment option using Botox every year?
Dr. Ellerkmann: Over 66,000 people with overactive bladder have been treated in the United States since its FDA approval in 2013. Botox has become increasingly popular as an adjuvant treatment option for this condition.
It was approved in two thousand thirteen but you didn’t hear that much about it. Is this becoming a more popular option?
Dr. Ellerkmann: Absolutely. Botox has been shown to significantly reduce the number of daily leakage episodes as well as symptoms of urgency. When it is effective for patients, the benefits can last 6-12 months. Furthermore, there are few risks and side effects associated with Botox injections for overactive bladder. The most common side effects following administration include urinary tract infection, difficulty with urination and temporary urinary retention. We like to try conservative strategies first, we even like to try medication, but in patients who are intolerant to medication or who do not respond to medication it offers a very viable option.
Let’s talk about how it works. What is it about Botox?
Dr. Ellerkmann: Botox is a potent neurotoxin and it’s produced by a bacteria called clostridium. In small amounts it can be helpful at essentially paralyzing muscle. It works by blocking the release of a neurotransmitter called acetylcholine. It does not allow acetylcholine to be released and stimulate muscle.
Obviously people have heard of Botox to get rid of wrinkles and we know that the injection is going right in to the site. Can you explain how this would work for an overactive bladder?
Dr. Ellerkmann: Botox is injected in multiple areas of the bladder muscle through a small lighted instrument called a cystoscope. The bladder is filled with water or saline, the bladder is numbed with lidocaine and then we take a very tiny little needle and inject the Botox. Just like plastic surgeons inject Botox in the skin, we inject the Botox into the muscle of the bladder. We obviously limit how much Botox is injected. Typically the treatments consist of 100-200 units of Botox which are diluted prior to injection. We try to inject somewhere between fifteen and twenty sites throughout the bladder to provide for a nice distribution of the Botox in the detrusor muscle.
Is this an outpatient procedure? How long does it take? Is it painful?
Dr. Ellerkmann: Good question. It is an outpatient procedure; it can be done in the office setting. Some patients prefer to have it performed under a little IV sedation, like a colonoscopy. The procedure itself takes about 15-20 minutes. In the office setting, we instill a little numbing medicine into the bladder ahead of time prior to injecting the Botox in the office. Alternatively, the procedure can be performed under IV sedation. It is important to make sure that the patient can void adequately after the procedure. Typically, patients begin to experience the benefit of their Botox injection somewhere between twenty four and seventy four hours after its administration. It’s not always effective, but I’ve had patients come back very pleased with their clinical responses. Other patients don’t respond as well, so it’s somewhat patient dependent.
How long will a Botox injection last and can you have repeat treatments?
Dr. Ellerkmann: Botox may control symptoms of overactive bladder for as long as 6-12 months, but the effect does wear off over time. The FDA requires at least three months to elapse between injections, so the soonest that one can receive another injection is three months.
Is there a limit to how many times you can have an injection?
Dr. Ellerkmann: That has not been specified, so the answer to that is no.
Who is a good candidate?
Dr. Ellerkmann: Good candidates for Botox are those patients who have either failed conservative and medical management of this problem or for patients who cannot tolerate overactive bladder medications or for patients for whom such medications are contraindicated.
Can you tell me a little bit about Karan’s case?
Dr. Ellerkmann: Karan came to me with what we refer to as refractory overactive bladder symptoms. She had tried conservative strategies; she had tried to eliminate things in her diet that could be irritating her bladder. She tried to get to the bathroom on a schedule. We then trialed several different medications for her overactive bladder; unfortunately, none of these seemed to improve her symptoms. They also resulted in some side effects like dry mouth and constipation. So she was given the choice between neuromodulation and a trial of Botox and she opted to try Botox. I think she has been quite happy with her clinical response.
Is this covered by insurance?
Dr. Ellerkmann: Yes, it is covered by most commercial insurance as well as for those patients with Medicare.
Is there anything I didn’t ask you that you would want people to know about this procedure?
Dr. Ellerkmann: It is important for patients to realize that symptoms of overactive bladder are very common and are typically not due to a serious underlying problem. Symptoms of overactive bladder and urge incontinence can adversely affect one’s quality of life and sense of well being. And yet, there are very good treatment options available—ranging from conservative, behavioral and dietary strategies, to certain medications and other treatment options like Botox and neuromodulation. For many patients, Botox may offer a very effective treatment option for reducing daily episodes of urge-related urinary incontinence, reducing symptoms of urgency and frequency and improving one’s quality of life with a low risk of complications.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Mark Ellerkmann, MD
443-275-5050
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