Monday, October 15, 2007


Neuromodulation of lower urinary tract problems has to do with the "gated theory" of bladder signals.
Simply put, the gentle electrical current that is delivered to the S3 root modulates or gates the signal in/out of the bladder that we try to treat. In OAB patients, the overactive signal is modulated, that is, lowered. The sense of urgency, frequency and incontinence that goes along with OAB is dimished often by 50-75%.

Conversely, Interstim is also indicated for urinary retention that is not due to obstruction (such as prostate enlargement in men). The electric signal stimulates the bladder to contract where it otherwise doesn't (or, blocks an inhibitory signal to the bladder that then allows the bladder to contract.)

Either way, its a fascinating technology that can vastly improve patients lives.

It is most often placed in a 2 stage procedure.

The first stage consists of placing the temporary lead through the skin in the back under x-ray guidance in the operating room. The patient is awake but sedated. The patient helps identify proper placement of the lead by what they sense: where they sense the "tingle".

Once the lead is placed, the patient goes home to see how well it works. The lead is hooked up to a small battery-operated pulse generator and can dial up or down the amplitude of the signal.

About 2/3 of patients respond. They go on to have the permanent lead and generator placed.

About 1/2 of non-responders to Stage I can be salvaged by redoing it.

Even once placed, the amplitude and width of the electrical signal can be adjusted depending on sensation and need.

Tuesday, October 9, 2007

Interstim- Sacral Neuromodulation

What happens when medications for OAB don't work or are not tolerated?

There are several methods to treat OAB with nerve stimuation, akin a to "bladder pacemaker" that stimulates the S3 nerve root (without touching it) and alters that abnormal overactive signal by intercepting it before sending it to the spinal cord and brain.

It is a very interesting and novel method of treating OAB, a technology that has been now FDA approved for about a decade.

More to come. . . .

Wednesday, September 12, 2007

Overactive Bladder Part 3

There are multiple treatments for OAB. They include medical therapies (medication), behavioral modification, and neuromodulation (electrical stimulation).

Medical treatment:
There are a wide variety of medications approved by the FDA for urgency, frequency and urge incontinence. These include:
Ditropan (oxybutynin)
Detrol (tolterodine)
Oxytrol patch (oxybutynin)
Enablex (darifenacin)
Vesicare (solifenacin)
Santura (trospium)

All are effective, and all cause dry mouth and constipation to varying degrees. Some individuals may respond better to one versus another.
They cannot be taken with certain types of glaucoma, and gastric outlet obstruction. They may or may not be appropriate depending on patient situation.

Medication works best with behavior modification. Behavior modification itself works best with medical therapy. Common bladder retraining exercises include: Kegel muscle contraction and delaying voiding.

Next installment: Neuromodulation

Monday, September 10, 2007

Overactive Bladder Part II

Overactive Bladder Stats: 21 million adults in US (10% of adult pop.) will have OAB-Dry, while 12 million adults in the US (6% of adult pop.) will have OAB-Wet.

OAB with or without incontinence can present coincidentally with Stress Incontinence- this is known as Mixed Incontinence.

OAB can be the result of:
Normal aging
Neurological causes
learned habit
overconsumption of fluids
pelvic trauma

Conditions that can be confused with OAB:

polyuria: large urine volume production
"irritable bladder syndrome"- food/caffiene/spice intolerance
interstitial cystitis
radiation cystitis
bladder tumor
bladder infection

An inventory of urinary symptoms and lifestyle as well as physical exam should be performed.
A "voiding diary" should be kept:

This is a log of how much fluid is consumed over 24-48 hours, in addition to the time and frequency of when an urge or leakage is experienced, as well as the volume of urine voided.

A urine analysis or blood and infection is performed usually.

residual urine can be checked as well.

Tuesday, September 4, 2007

Overactive Bladder

Overactive Bladder (OAB) is quite a prevalent problem in both the female and male population. It can exist both with and without urinary incontinence. OAB is defined as having frequency and urgency of urination that is abnormal. Frequency of urination is abnormal if it occurs more than 8 times a day during waking hours, while urgency is abnormal if it is uncontrollable or painful. It can occur with and without incontinence, known as urge incontinence.

OAB with incontinence is also known as OAB-Wet, while simple OAB without incontinence is known as OAB-Dry. About 1/3 of women with OAB have OAB-wet. 85% of women with OAB will present with frequency, while 50% will have urgency.

Approx. 21 million adults in the US (10%) will have OAB-Dry, while 6.1 million (12% of the adult pop.) will have OAB-Wet.

Because of embarrassment only about 1/2 of all patients bring it up with their physician.


Wednesday, August 15, 2007

Burning with Urination: "Dysuria"

There are a host of reasons of why women may experience buring with urination.

Acidic urine- food consumption that is acidic, and/or low water intake

Food sensitivity- caffeine, alcohol, spices, etc

Urinary tract infection(UTI)/Bladder infection- these are common, andoften occur with lower abdominal pressure, low grade temperature or back pain

Irritation after sex- ensure good lubrication and hygiene before and after

Sexually transmitted diseases- get tested if you suspect something

Persistent pain after a UTI has been treated with antibiotics- give it time

Pelvic floor dysfunction- straining to urinate can lead to bad habits of not relaxing the sphincter to urinate and lead to pain during urination

Urethral Stricture- rare in women, usually post-surgical, or can occur in women who have had numerous dilations of the urethra

Urethral Diverticulum- even rarer, and usually occurs with painful intercourse and urinary dribbling

Interstitial Cystitis- does NOT cause burning with urination

Urethral syndrome- pain itself of the the urethra- may be multifactorial

Radiation injury- from radiation for any type of pelvic cancer

"Spirit of Women" Series- change of plans

Unfortunately due to a scheduling conflict I will not be giving the talk on Male Menopause on September 22, 2007 at Banner Desert Medical Center. It will be given by Dr. Pinnamaneni, an endocrinologist, in my place.

I am in the process of arranging several talks on women's urinary health issues in the next 5 months in the East Valley.

Thursday, July 26, 2007

Stress and Incontinence

Urinary incontinence is a surprisingly common condition that affects roughly 35% of women over fifty. It's also known as "stress urinary incontinence," genuine stress incontinence, and urethral hypermobility. This condition is characterized by an involuntary loss of bladder control caused by physical exertion or intra-abdominal pressure. Coughing, sneezing, physical exercise, laughing, lifting and standing could all cause urine loss when coupled with this condition. Approximately 60% of women with incontinence have stress incontinence.

Stress incontinence is a bladder storage problem in which the strength of the urethral sphincter is weakened, and the sphincter is not able to prevent urine flow when there is increased pressure in the abdominal area. The inability to control urine flow, even in small amounts, can be terribly distressing and embarrassing.

In many instances, stress urinary incontinence may begin gradually, but become more frequent and severe over time. The wetness, odor, discomfort, and skin irritation, that this condition causes can be particularly damaging to the self-esteem of those afflicted. It can also affect the sufferer's social life and relationships.

Women with stress urinary incontinence report that the condition has affected their sexual relationships because of the fear of urine leakage during sexual activity. The condition can also cause depression and social withdrawal. People suffering from stress urinary incontinence may become so anxious about the location of nearby toilets that they'll plan their routes ahead of time. This type of behavior is called "toilet mapping."

What Causes Stress Incontinence?

There are a number of factors that increase a person's risk of developing stress urinary incontinence.

Age: Stress urinary incontinence is usually associated with women who are forty-five to sixty-five years old. The frequency and severity of attacks often increases with age.

Race: Caucasians are more likely to develop stress urinary incontinence than men or women of other races, although scientists are not entirely clear on why this is. One theory suggests that Caucasian women have a shorter urethra, weaker pelvic floor muscles, and a lower bladder neck than women of other races, thus making them more likely to have incontinence. There is no data on the relationship between stress urinary incontinence and race in men.

Pregnancy and Childbirth: Pregnancy and vaginal childbirth greatly increase the risk of stress urinary incontinence in women. Vaginal delivery involves significant loosening and lengthening of the pelvic floor muscle to permit the passage of an infant. Factors that occur during delivery such as the use of forceps, episiotomy, and pudendal anesthesia may further increase a woman's risk of developing the condition.

Menopause and Hormonal Changes: After menopause, the pelvic muscles begin to relax dramatically in response to the general aging process. The hormonal changes associated with menopause, namely, the depletion of estrogen, is also associated with reduced urethral mucosa vascularity and thickness. This weakens the urethra's ability to maintain a tight seal, especially when intra-abdominal pressure increases.

Pelvic surgery: Women who have had a hysterectomy or other types of pelvic surgery often experience a 40% increase in their risk of developing stress urinary incontinence. This may be caused by scarring, or the loss of structural support to the bladder.

Smoking: There is significant intra-abdominal pressure exerted on the bladder and urethra during coughing. The chronic and frequent coughing often associated with smoking may lead to damage of the structural supports of the vagina and bladder.

Obesity: Being overweight or obese increases the risk of developing stress urinary incontinence due to the increased pressure on the bladder from excess weight.

Physical Activity: Stress urinary incontinence can affect both men and women who are fit, slim, and in shape. Intense physical exercise can cause the condition to develop. Up to one third of women experience urine loss during physical activities. Muscle fatigue, and over exertion of the abdominal muscles may provoke the condition. Physical activities most likely to be associated with stress urinary incontinence include any sports that require jumping and jarring of the abdominal muscles such as gymnastics, basketball and volleyball.

Medications: Several medications can cause over-activity of the bladder and loss of pelvic muscle control. Diuretics, anticholinergic medications, sedatives, depressants, and muscle relaxants can all affect bladder control, urinary retention, fecal impaction, and sedation.

Chronic diseases: Diseases such as multiple sclerosis, spinal cord injury, diabetes, Parkinson's disease, and stroke can increase a person's risk for developing stress urinary incontinence as they affect the nervous system and the neuropathy of the bladder.

Caffeine: Caffeinated foods and beverages irritate the bladder and can cause spasmodic bladder and urethral contractivity.

"Spirit of Women" Series

There will be another installment of the "Spirit of Women" health series at Banner Desert Medical Center, in Mesa, AZ on September 22, 2007 at 9:30am.

I will be giving a talk entitled "Do Men in our Lives Need Hormone Replacement Therapy?- For the Women Who Love Them".

It will be the third such talk I will have given. Prior talks I have given for this seminar series were:

"Female Sexual Dysfunction- When Does Less-Than-Perfect-Sex Become a Problem?"

"The Most Active Thing About My Life is My Bladder- Urinary Incontinence"

Any interested parties who wish me to speak on female health topics such as these can post a reply, and I will respond to them.

Tuesday, July 24, 2007

Local Estrogen replacement therapy

Topical or local application of estrogen to the vagina is useful to treat many conditions. The goal of such treatment is to reverse or diminish age-related changes to the vagina. There is limited systemic absorption of estrogens applied locally, yet locally it increases blood flow, reduces vaginal pH, and increases secretions. Topical replacement estrogen can be appropriate for peri-menopausal or post-menopausal women who have the following problems:

Vaginal dryness
Pain with intercourse
Recurrent bladder infections
Urinary urgency, or urge incontinence

Vaginal atrophy is an inevitable change with age as a result of estrogen loss that can be progressive. Women are often embarressed and don't often seek treatment. Restrictions on taking oral estrogen replacement due to potential cardiovascular risks makes vaginal atrophy more likely to occur, and can be addressed easily. Topical creams or even small suppository pills can be used. Women who have a history of breast or endometrial cancer, or undiagnosed bleeding should not use topical vaginal estrogen.