Posts Tagged ‘urgency incontinence’

Percutaneous Tibial Nerve Stimulation (PTNS) For Overactive Bladder (OAB)

July 29, 2017

Andrew Siegel MD   7/29/17

ptns-v2@2x

PTNS therapy is a non-drug, non-surgical option to treat OAB symptoms including urinary urgency, frequency and urgency incontinence. PTNS consists of 12 weekly sessions in the office, followed by a maintenance regimen. During each 30-minute session, a thin needle electrode is placed into the ankle region and is connected to an external electrical stimulator. Up to 80% of patients improve with minimal, if any, side-effects.

OAB

Overactive bladder is a common and annoying condition present in both females and males marked by episodes of urinary urgency, frequency and, at times, incontinence. A variety of methods can be used to improve symptoms and quality of life, including the following: behavioral modifications, bladder retraining, pelvic floor muscle training, bladder relaxant medications and Botox injections.  Although medications are commonly used for OAB, the problem is that side effects and expense often limit their continued usage.

Neuromodulation

An effective alternative is neuromodulation, the least invasive technique of which is known as PTNS.  PTNS uses a thin, acupuncture-style needle placed in the ankle that is attached to a hand-held device that generates electrical stimulation.  This is a significantly less invasive means of neuromodulation than is Interstim, which requires implantable wire electrodes to be placed in the spine and continuous electrical stimulation with an implantable battery-powered pulse generator. In both instances, the sacral plexus—responsible for regulating bladder and pelvic floor function—is “modulated” by the electrical stimulation, causing a beneficial effect with improvement of OAB symptoms. With PTNS, the electrical stimulation travels up the tibial nerve to the sacral plexus, whereas with Interstim, the sacral plexus is directly stimulated by electrodes.

Nuts and Bolts of PTNS

PTNS involves once weekly visits to the office for 12 weeks, 30 minutes per session.  It can be performed on both female and male patients.

At each session, the patient is seated comfortably with the treatment leg elevated and supported.  A fine caliber needle electrode—similar to an acupuncture needle—is inserted into the inner ankle in the vicinity of the tibial nerve.  A grounding surface electrode is placed as well.  An adjustable electrical pulse is applied to the needle electrode via an external pulse generator. Activation of the tibial nerve is confirmed with a sensory (mild sensation in ankle or sole) and/or a motor (toe flex/fan or foot extension) response. Thereafter, the power of electrical stimulation is adjusted to an appropriate level and the 30-minute session begins. The patient can read, listen to music, nap, meditate, etc.

Clinical Response

Improvement in OAB symptoms often occurs by session 6, sometimes sooner. Patients who respond well to the 12-week protocol may require occasional maintenance treatments.  70-80% of patients will achieve long-term improvement in OAB symptoms. PTNS incurs minimal risks with the most common side effects being mild pain and skin irritation where the needle electrode is placed.

Insurance

PTNS is covered by most insurances, including Medicare.  PTNS cannot be used in patients with pacemakers or implantable defibrillators, those prone to excessive bleeding, those with nerve damage or women who are pregnant or planning to get pregnant during the treatment period.

YouTube on PTNS

“My PTNS” educational program

My nurse practitioner and I will be giving a seminar (free of charge) on PTNS on 7PM on Thursday, September 14, 2017 at the Marriott Hotel, 138 New Pehle Avenue, Saddle Brook, NJ.  Light refreshments will be served.  Space is limited, so if interested, please call 201-487-8866 to reserve a spot.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

Amazon page for Dr. Siegel’s books

 

 

Advertisements

12 STEPS TO OVERCOMING “OVER-ACTIVE” BLADDER (OAB)

May 6, 2017

Andrew Siegel MD  5/6/17 (my daughter’s 18th birthday!)

For most people, the urinary bladder is a cooperative and obedient organ, behaving and adhering to its master’s will, squeezing only when appropriate. However, some people have bladders that are unruly and disobedient, acting rashly and irrationally, squeezing at inappropriate times without their master’s permission. This condition is referred to as “overactive bladder” or OAB for short. This problem can occur in both women and men, although it is more common in females.

Picture1

“Gotta go,” the urinary urgency that is the hallmark of OAB

8. UUI

Image above (artist Ashley Halsey from “The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health”) illustrates a bladder contracting involuntarily, leading to urinary leakage

OAB (http://www.njurology.com/overactive-bladder/) is a common condition often due to one’s bladder contracting (squeezing) at any time without warning.  This involuntary bladder contraction can give rise to the symptoms of urgency, frequency (daytime and nighttime) and urgency incontinence. The key symptom of OAB is urinary urgency (a.k.a. “gotta go”), the sudden and compelling desire to urinate that is difficult to postpone.

Although OAB symptoms can occur without specific provocation, they may be triggered by exposure to running water, cold or rainy weather, hand-washing, entering the shower, positional changes such as arising from sitting, and getting nearer and nearer to a bathroom, particularly at the time of placing the key in the door to one’s home.

An evaluation includes a urinalysis (dipstick exam of the urine), a urine culture (test for urinary infection) if indicated, and determination of the post-void residual volume (amount of urine left in bladder immediately after emptying). A 24-hour voiding diary (record of urination documenting time and volume) is an extremely helpful tool.  Urodynamics (test of storage and emptying bladder functions), cystoscopy (visual inspection of inside of bladder), and renal and bladder ultrasound (imaging tests using sound waves) may also prove helpful.

The management of OAB is challenging, yet rewarding, and necessitates a partnership between patient and physician. Successful treatment requires a willing, informed and engaged patient with a positive attitude. Management options for OAB range from non-invasive strategies to pills to surgery. It is sensible to start with the simplest and least invasive means of treatment and progress accordingly to more aggressive and invasive treatments if there is not a satisfactory response to conservative measures.  Behavioral treatments are first-line: fluid management, bladder training, bladder control strategies, pelvic floor muscle training and lifestyle measures.  Behavioral therapies may be combined with medication(s), which are considered second-line treatment. Third-line treatments include neuromodulation (stimulating specific nerves to improve OAB symptoms) and Botox injections into the urinary bladder.

References that will help the process include the following:

Book: THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health www.TheKegelFix.com

Book: MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health www.MalePelvicFitness.com

DVD: Easy-to-use, follow-along, FDA-registered pelvic training program that includes a detailed instruction guide, an interactive DVD and digital access to the guided training routines: www.PelvicRx.com

12 Steps To Overcoming OAB

The goal of the 12 steps that follow is to re-establish control of the urinary bladder.  Providing that the recommendations are diligently adhered to, there can be significant improvement, if not resolution, of OAB symptoms.

  1. FLUID AND CAFFEINE MODERATION/MEDICATION ASSESSMENT  Symptoms of OAB will often not occur until a “critical” urinary volume is reached, and by limiting fluid intake, it will take a longer time to achieve this volume. Try to sensibly restrict your fluid intake in order to decrease the volume of urinary output. Caffeine (present in tea, coffee, colas, some energy drinks and chocolate) and alcohol increase urinary output and are urinary irritants, so it is best to limit intake of these beverages/foods.  Additionally, many foods—particularly fruits and vegetables—have hidden water content, so moderation applies here as well.  It is important to try to consume most of your fluid intake before 7:00 PM to improve nocturnal frequency. Diuretic medications (water pills) can contribute to OAB symptoms. It is worthwhile to check with your medical doctor to see if it is possible to change to an alternative, non-diuretic medication. This will not always be feasible, but if so, may substantially improve your symptoms.
  2. URGENCY INHIBITION Reacting to the first sense of urgency by running to the bathroom needs to be substituted with urgency inhibition techniques. Stop in your tracks, sit, relax and breathe deeply. Pulse your pelvic floor muscles rhythmically (see below) to deploy your own natural reflex to resist and suppress urgency.
  3. TIMED VOIDING (for incontinence) Urinating by the “clock” and not by your own sense of urgency will keep your bladder as empty as possible. By emptying the bladder before the critical volume is reached (at which urgency incontinence occurs), the incontinence can be controlled.  Voiding on a two-hour basis is usually effective, although the specific timetable has to be tailored to the individual in accordance with the voiding diary.  Such “preemptive” or “defensive” voiding is a very useful technique since purposeful urinary frequency is more desirable than incontinence.
  4. BLADDER RETRAINING (for urgency/frequency) This is imposing a gradually increasing interval between voids to establish a more normal pattern of urination. Relying on your own sense of urgency often does not give you accurate information about the status of your bladder fullness.  Urinating by the “clock” and not by your own sense of urgency will keep your voided volumes more appropriate. Voiding on a two-hour basis is usually effective as a starting point, although the specific timetable has to be tailored to the individual, based upon the voiding diary.  A gradual and progressive increase in the interval between voiding can be achieved by consciously delaying urinating.  A goal of an increase in the voiding interval by 15-30 minutes per week is desirable.  Eventually, a return to more acceptable voiding intervals is possible.  The urgency inhibiting techniques mentioned above are helpful with this process.
  5. BOWEL REGULARITY Avoidance of constipation is an important means of helping control OAB symptoms. Because of the proximity of the rectum and bladder, a full rectum can put pressure on the bladder, resulting in worsening of urgency, frequency and incontinence.
  6. PELVIC FLOOR MUSCLE TRAINING (PFMT)  *All patients need to understand the vital role of the pelvic floor muscles (PFM) in inhibiting urgency and frequency and preventing urge leakage.  PFMT voluntarily employs the PFM to help stimulate inhibitory reflexes between the pelvic floor muscles and the bladder.  Rhythmic pulsing of the PFM can inhibit an involuntary contraction once it starts and prevent an involuntary contraction before it even begins. Initially, one must develop an awareness of the presence, location, and nature of the PFM and then train these muscles to increase their strength and tone.  These are not the muscles of the abdominal wall, thighs or buttocks.  A simple means of recognizing the PFM for a female is to insert a finger inside her vagina and squeeze the PFM until the vagina tightens around her finger.  A simple means of identifying the PFM for either gender is to start urinating and when about half completed, to abruptly stop the stream. It is the PFM that allows one to do so. It is important to recognize the specific triggers that induce urgency, frequency or incontinence and prior to exposure to a trigger or at the time of the perceived urgency, rhythmic pulsing of the PFM–“snapping” the PFM several times–can either preempt the abnormal bladder contraction before it occurs or diminish or abort the bladder contraction after it begins.  Thus, by actively squeezing the PFM just before and during these trigger activities, the urgency can be diminished and the urgency incontinence can often be avoided.

oab

Schematic diagram above illustrates the relationship of the contractile state of the bladder muscle to the contractile state of the PFM. Note that a voluntary PFM contraction can turn off an involuntary bladder contraction (+ symbol denotes contraction; – symbol denotes relaxation)

7. LIFESTYLE MEASURES: HEALTHY WEIGHT, EXERCISE, TOBACCO CESSATION   The burden of excess pounds can worsen OAB issues by putting pressure on the urinary bladder. Even a modest weight loss may improve OAB symptoms.  Pursuing physical activities can help maintain general fitness and improve urinary control. Lower impact exercises–yoga, Pilates, cycling, swimming, etc.–can best help alleviate pressure on the urinary bladder by boosting core muscle strength and tone and improving posture and alignment. The chemical constituents of tobacco constrict blood vessels, impair blood flow, decrease tissue oxygenation and promote inflammation, compromising the bladder, urethra and PFM.  By eliminating tobacco, symptoms of OAB can be improved. 

8.  BLADDER RELAXANT MEDICATIONS A variety of medications are useful to suppress OAB symptoms. It may take several trials of different medications or combinations of medications to achieve optimal results. The medications include the following: Tolterodine (Detrol LA), Oxybutynin (Ditropan XL), Transdermal Oxybutynin (Oxytrol patch), Oxybutynin gel (Gelnique), Trospium (Sanctura), Solifenacin (Vesicare), Darifenacin (Enablex) and Fesoterodine (Toviaz).  The most common side effects are dry mouth and constipation.  These medications cannot be used in the presence of urinary or gastric retention or uncontrolled narrow-angle glaucoma.  The newest medication, Mirabegron (Myrbetriq), has a different mechanism of action and fewer side effects.

9.  BIOFEEDBACK This is an adjunct to PFMT in which electronic instrumentation is used to relay feedback information about your PFM contractions.  This can enhance awareness and strength of the PFM.

10.  BOTOX TREATMENT This is a simple office procedure in which Botox is injected directly into the bladder muscle, helping reduce OAB symptoms by relaxing those areas of the bladder into which it is injected. Botox injections generally will last for six to nine months and are covered by Medicare and most insurance companies.

11.  PERCUTANEOUS TIBIAL NERVE STIMULATION (PTNS) This is a minimally invasive form of neuromodulation in which a tiny acupuncture-style needle is inserted near the tibial nerve in the ankle and a hand-held stimulator generates electrical stimulation with the intent of improving OAB symptoms. This is done once weekly for 12 weeks.

12.  INTERSTIM This is a more invasive form of neuromodulation in which electrical impulses are used to stimulate and modulate sacral nerves in an effort to relieve the OAB symptoms. A battery-powered neuro-stimulator (bladder “pacemaker”) provides the mild electrical impulses that are carried by a small lead wire to stimulate the selected sacral nerves that affect bladder function.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Uterine Fibroids And The Bladder

January 9, 2016

Andrew Siegel MD   1/9/16

shutterstock_femalebluepelvic

 

Fibroids are muscular growths that develop within the womb that can put direct pressure on the next door neighbor of the uterus–the urinary bladder.  This compression can give rise to a host of annoying urinary symptoms including urinary urgency, frequency, urinary leakage and difficulty urinating.  

Although fibroids usually grow within the uterine wall, at times they do so internally into the uterine cavity or, alternatively, externally on the outside of the uterus. They are virtually always benign and much of the time they do not cause symptoms. When symptomatic they may cause the following: heavy uterine bleeding; pelvic pressure; a swollen and distended lower abdomen; urinary and bowel issues; pelvic and lower back pain; pain with sexual intercourse; as well as fertility problems, reproductive issues and complications of pregnancy (breech births, failure of labor to progress, the need for C-section, preterm delivery, and bleeding following delivery).

The most common presenting symptom of uterine fibroids is uterine bleeding, which often begins as prolonged menstruation and can be severe enough to cause a low blood count.  Fibroids are problems of the reproductive years, prevalent in women in their 30s, 40s and 50s. They can be solitary or multiple, range in size from tiny to huge and vary in location within the uterus. The largest fibroids can outgrow their blood supply and undergo degenerative changes. When extremely large, they can distort the lower abdomen, simulating pregnancy. Fibroids are “tumors”–-although benign–- that microscopically consist of interlacing bundles of smooth muscle surrounded by condensed uterine tissue. There is a genetic basis for fibroids with an increased prevalence in women with a family history. Obesity increases one’s risk for fibroids.

The growth of uterine fibroids is largely controlled by estrogen, the key female sex hormone. Fibroids tend to grow rapidly during pregnancy and regress after menopause when estrogen production ceases.

The presence of fibroids may significantly impair one’s quality of life. Because of the pressure they apply against the typically balloon-thin female urinary bladder, they often cause urinary symptoms, much as in pregnancy when an enlarged uterus compresses the bladder. Urinary symptoms most often occur when the fibroids are located closest to the bladder and/or urethra. Typical symptoms include urinary urgency, frequency and stress urinary incontinence (leakage of urine with sneezing, coughing, and exertion). Symptoms are proportionate to the size of the fibroid, with larger fibroids causing more significant symptoms. On occasion, a fibroid can cause an obstruction of the urinary tract, impairing one’s ability to empty their bladder, sometimes requiring the placement of a urinary catheter to alleviate the obstruction.

On pelvic examination, fibroids can often be recognized as pelvic masses. Thye can be further evaluated with imaging studies, including ultrasound, computerized tomography and magnetic resonance imaging. They characteristically cause a “popcorn” appearing calcification on abdominal radiographs.

Those fibroids that do not cause symptoms or bleeding do not require treatment. There are numerous pharmacological options for symptomatic fibroids including medications that lower estrogen levels that cause suppression and shrinkage of the fibroids. Surgery may be required when there is an inadequate response to conservative measures. Surgical options include removing or destroying the uterine lining to control heavy bleeding, deliberately blocking the blood supply to the fibroid, surgical removal of one or more of the fibroids and, at times, removing the entire uterus (hysterectomy).

Bottom Line: As a urologist, I not uncommonly see women with urinary urgency, frequency, incontinence or urinary obstruction caused by one or more uterine fibroids pushing and compressing the bladder or urethra. It is usually very obvious on pelvic ultrasound or cystoscopy (visual inspection of the bladder), where the fibroid can be seen to cause extrinsic compression. The good news is that such fibroids are eminently manageable, which most often resolves the urinary issues.    

Wishing you the best of health and a very happy New Year,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

Use Your Pelvic Floor To Overcome Over-Active Bladder

May 16, 2015

Andrew Siegel MD  5/16/15

shutterstock_orange gu tract closeupshutterstock_femalebluepelvic

Over-Active Bladder (OAB) is urinary urgency (the sudden and urgent desire to urinate) and frequency (urinating too often, which can be during both awake and sleep hours), with or without urgency incontinence (urinary leakage associated with the urgent desire to urinate). It is often due to involuntary contractions of the bladder in which the bladder squeezes—inappropriately so—without its “owner’s” permission. Although it can occur without provocation, it is commonly triggered by positional changes such as going from sitting to standing, exposure to running water, approaching a bathroom, and when placing the key in the door to one’s home.

The American Urological Association guidelines for OAB recommend pelvic floor muscle (PFM) training as first-line therapy for OAB because voluntary PFM contractions can effectively inhibit involuntary bladder contractions and squelch the urgency and urgency incontinence.

Bladder Physiology 101

In order to effectively tap into the powers of the pelvic floor, a basic understanding of bladder function is necessary. During urine storage, the bladder muscle is in a relaxed (non-contracting state) and the urinary sphincters (contributed to by the PFM muscles), responsible for urinary control, are engaged (contracted). During urine emptying, the bladder muscle contracts and the sphincter muscles relax synchronously. This “antagonistic” relationship between the bladder muscle and the PFMs can be used to the advantage of those suffering with OAB. Since people with OAB often have bladders that contract involuntarily causing the symptoms of urgency and frequency, a means of getting the bladder to relax is to intentionally engage the PFMs to benefit from the reflex relaxation of the bladder that occurs with voluntary contraction of the PFMs.

The PFM-Bladder Reflex

This is a very useful and practical reflex that you can easily access. This reflex is unique because it can be engaged voluntarily and because it results in the relaxation of a muscle as opposed to its contraction. Anyone who has ever experienced an urgent desire to urinate or move one’s bowels will find this reflex of great practical use. When the reflex is deployed, it will result in relaxation of both the urinary bladder and rectum and a quieting down of the urgency.

How To Use The Reflex To Your Advantage

When you feel the sudden and urgent desire to urinate, pulse the PFMs five times, briefly but intensely. When the PFM are so deployed, the bladder muscle reflexively relaxes and the feeling of intense urgency should disappear. Likewise, when the PFM are so deployed, the rectum relaxes and the feeling of intense bowel urgency should diminish. This reflex is a keeper when you are stuck in traffic and have no access to a toilet!

PFM training helps stimulate the inhibitory reflex between the PFMs and the bladder muscle. A PFM training program will stimulate your awareness of the PFM and enable you to isolate them and increase their strength, tone, and endurance. The inhibitory reflex will become more robust and you will develop an enhanced ability to counteract urgency, frequency and urgency incontinence. Urgency can often be diminished and the urgency incontinence can often be abolished.

Getting beyond inhibiting urgency after it occurs is preventing it from occurring in the first place. In order to do so, it is important to recognize the specific triggers that induce the urgency, frequency or incontinence: hand washing, key in the door, rising from sitting, running water, entering the shower, cold or rainy weather, etc. Prior to exposure to a trigger, rapid flexes of the PFM can preempt the involuntary bladder contraction before it has a chance to occur.

Bottom Line: There are many treatments available for OAB, including decreasing your fluid and caffeine intake, bladder re-training, oral medications, Botox injections into the bladder and neuro-stimulation. As a first-line approach, tap into the powers of your PFM and harness the natural reflex in which involuntary bladder contractions can be inhibited or prevented by engaging your PFM.

Wishing you the best of health,

2014-04-23 20:16:29

AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in your email in box go to the following link and click on “email subscription”: 

www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback:          

http://www.MalePelvicFitness.com

Co-creator of Private Gym pelvic floor muscle training program for men:

http://www.PrivateGym.com 

The Private Gym is a comprehensive, interactive, follow-along exercise program that provides the resources to strengthen the pelvic floor muscles that are vital to sexual and urinary health. The program builds upon the foundational work of Dr. Arnold Kegel, who popularized exercises for women to increase pelvic muscle strength and tone. This FDA registered program is effective, safe and easy-to-use. The “Basic Training” program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises and the “Complete Program” provides maximal opportunity for gains through its patented resistance equipment.