Incontinence is one of the more common problems I see in my clinic. And, in many cases, it’s due to a condition called overactive bladder syndrome, which leaves patients constantly needing the loo.
It’s caused by muscle spasms in the bladder, and sufferers often say they feel trapped at home, for fear of being caught short while out and about.
Millions of people with overactive bladder syndrome are prescribed daily anticholinergics, tablets which can lower the frequency of the spasms.
But research has linked anticholinergics to an increased risk of dementia. This must make worrying reading for sufferers.
However, not only are alternative medicines available, but simple steps can also be taken to reduce the distressing symptoms of an overactive bladder.
I am taking these tablets for my overactive bladder – now I’m worried about the dementia risk. Should I come off them?
There isn’t a simple answer to this – it really depends on the patient and the circumstances.
A study published in the British Medical Journal concluded that taking anticholinergics raises the risk of dementia by 18 per cent. This can’t be dismissed – and I wouldn’t say ‘don’t worry’ – but it’s also not a forgone conclusion.
As with all pills, it’s about weighing the pros and cons, writes Dr Philippa Kaye
If someone already suffers cognitive impairment, they probably shouldn’t be on anticholinergics. And we’re cautious about it in over-65s in general. They are likely to be more at risk. But that doesn’t mean they have to come off the drugs.
As with all pills, it’s about weighing the pros and cons.
Quite aside from the dementia worries, if a patient has been on the tablets for years and their incontinence is well-controlled, it might be time to reduce the dose or take a break. In some cases, the symptoms won’t return, which means the medication is no longer necessary. However, they might be taking anticholinergics, and doing other things to help control an overactive bladder, such as pelvic floor exercises and avoiding caffeine and alcohol – but still have issues.
So we might suggest regular reviews. And if there is a real concern about dementia – say, due to a family history – we might discuss alternative medicines and treatment options.
So, what are the alternative medicines I could take?
Firstly, we think only certain anticholinergics increase the risk of a dementia diagnosis.
Patients prescribed oxybutynin hydrochloride, tolterodine tartrate or solifenacin succinate are about a third more likely to develop dementia.
But those on darifenacin, fesoterodine fumarate, flavoxate hydrochloride, propiverine hydrochloride, and trospium chloride, do not have an increased risk. Darifenacin is one of the first medicines NHS guidance recommends GPs prescribe.
Unhappily, oxybutynin hydrochloride, tolterodine tartrate and solifenacin succinate – the three linked to dementia – are considered the most effective drugs for treating overactive bladder.
If patients are worried about taking these tablets they could ask their GP to switch them to a different anticholinergic.
But it’s possible that they might already have tried it, to no avail, or see their symptoms worsen after switching to the new pill.
Crucially, anticholinergics are not meant to be taken long term without review and many patients will be advised to take a break from them.
If I want to stop taking tablets, are there drug-free ways to control an overactive bladder?
The short answer is, yes. Caffeine and alcohol should be avoided, as these can irritate the bladder and worsen symptoms.
Patients also mention green tea – which many people don’t realise is caffeinated – spicy food, citrus fruit, tomatoes and fizzy drinks as triggers. Obesity raises the risk of overactive bladder syndrome and patients who lose weight often see symptoms subside.
This can’t be done overnight, but other research suggest regular exercise also eases symptoms.
For many women, an overactive bladder is a sign of an underlying condition linked to the menopause called genitourinary syndrome. This is due to low oestrogen, leading to vaginal and vulval dryness, itching, pain during sex and overactive bladder symptoms.
This can be treated with an oestrogen cream which is applied to the vagina. So it’s important that any woman with an overactive bladder, is examined by a GP for signs of genitourinary syndrome of the menopause. A common mistake made by patients is to avoid drinking water in the hope it will mean they need to pee less.
However, not only does this not work, it can also mean the urine is more concentrated, which irritates the bladder further.
I’ve heard you can retrain the bladder to end the urge to pee – is this true?
Yes, GPs should be able to refer overactive bladder patients for bladder drill, also known as bladder retraining, on the NHS. A physiotherapist or a women’s health specialist will prescribe exercises that train the bladder to hold larger volumes.
Patients may be advised at first to pass urine every hour. Gradually, this will be increased by five or 15 minutes until they can last for up to four hours.
This typically involves learning coping techniques such as squeezing the pelvic floor when the urge to go strikes then counting to a certain number, crossing the legs or sitting on a rolled up towel.
It can take several months before patients notice an improvement, but many people’s lives have been changed for the better by bladder retraining.
I’ve tried everything but nothing seems to help – could surgery be the answer?
Yes, but there are other less invasive options patients should try first.
One is regular Botox injections into the bladder, which help relax the organ and relieve symptoms. However, some patients find they struggle to fully empty their bladder as a result of the jabs.
Another is nerve stimulation, in which an electric shock is used to stimulate nerves in the ankle or lower back, which can improve bladder function for some.
In extreme cases, patients may be offered a cystoplasty, a procedure where the bladder is enlarged in order to relieve the symptoms.
However, surgery is offered only to a limited number of NHS patients, who often have to wait years. For most sufferers, lifestyle changes and bladder retraining – not surgery or medicines – are key to fixing the problem.
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