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Once-unmentionable bladder control finally getting attention

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Knight Ridder Newspapers


PHILADELPHIA - Karen Wilkins recently summoned her courage and went to the mall.

To her relief, she didn't have to go. Not once.

She was able to shop for a few hours without racing to the bathroom or leaking urine, thanks to a device that electrically stimulated nerves in her lower spine.

"I'm like a whole new person," Wilkins, 49, of Malvern, Pa., said last month after the small, battery-powered stimulator was implanted and connected by a wire to her sacral nerves.

Wilkins is among an estimated 33 million Americans - 16 percent of adults - coping with overactive bladder, that gotta-go-again-and-again feeling, according to the National Overactive Bladder Evaluation Program. For about a third of them, urinary urgency and frequency come with the even more embarrassing, disruptive symptom of leaks, or incontinence.

Once unmentionable, the problem of bladder control has finally come out of the water closet, and is getting much-needed attention from health-care and pharmaceutical companies, experts say.

Even so, many people suffer in silence. They may mistakenly believe that incontinence is an inevitable part of aging, or their doctors may be unaware of the ever-growing array of therapies.

Wilkins, for example, saw four urologists and tried a series of conservative treatments - dietary changes, pelvic muscle exercises, medications - before she found University of Pennsylvania urogynecologist Lily Arya, who suggested sacral nerve stimulation.

"The key message for patients," said Nancy Muller, executive director of the National Association for Continence, a nonprofit educational organization, "is to revisit your doctor and be persistent, because technology is evolving."

The National Overactive Bladder Evaluation Program found that, contrary to conventional wisdom, overactive bladder afflicts men and women at about the same rate. The survey of 5,200 noninstitutionalized U.S. adults was published in 2003 by Johns Hopkins University researchers.

Overactive bladder is a catch-all term for what happens when small, secondary nerves in the urinary tract become abnormally active, said Kristene Whitmore, a urologist at Drexel University College of Medicine and co-author of Overcoming Bladder Disorders.

These misfiring nerves signal the spinal cord and brain to tell bladder muscles to contract too much, too often. This relentless squeezing of the bladder triggers the urge to urinate.

Overactive bladder symptoms may be linked to bladder infections, spinal cord injury, multiple sclerosis, bladder tumors - or an unknown cause.

The good news is that there are new treatments for this common, frustrating problem.

In just the past six months, Muller noted, the market has added three drugs that inhibit the troublemaking nerve impulses - Sanctura, VESIcare and Enablex - plus the skin patch Oxytrol, developed to reduce unpleasant side effects from the oral form of the drug oxybutynin.

The sacral nerve stimulator, called InterStim, regulates bladder function much the way a pacemaker regulates heart function, by gently activating selected nerves. (InterStim is made by Medtronic, a Minnesota-based maker of pacemakers.)

InterStim, which is covered by Medicare and health plans, was approved by the Food and Drug Administration in 1997 for patients who had failed - or could not tolerate - more conservative treatments.

Other "neuromodulation" therapies may be on the way. Advanced Bionics Corp. of Valencia, Calif., is developing Bion, an implantable matchstick-size device that calms overactive bladder by stimulating the pudendal nerve. This nerve carries sensations from the sacral nerves to external genitals and the lower rectum.

InterStim remains relatively unknown, largely because it is marketed to urologists, not patients or primary-care physicians, Arya said.

"Sometimes, my patient says, 'I don't know. This sounds too freaky to me.' So they ask their primary-care doctor about it, then he calls and asks me for information,'" Arya said. "I feel very comfortable recommending this, because it's very safe."

At least, it is now. Initially, Arya did not offer it because implanting the stimulator and the wire was "a big deal," requiring general anesthesia and a long skin incision. In 2002, the FDA approved a new, minimally invasive procedure that involves a small skin puncture and local anesthesia.

The therapy is effective for about 70 percent of patients. To see if it will work, each patient tries a temporary, external stimulator for about a week. If symptoms improve, the permanent stimulator - a stopwatch-size device powered by a battery that lasts a decade -is placed under the skin through a small incision.

The stimulator, programmed in the doctor's office, can be adjusted or deactivated by the patient at any time.

"I was hesitant, but I spoke to my family physician and we determined it was worth a try," recalls Tanya Scanzello, 58, an occupational health nurse in Collegeville, Pa., who has had a sacral nerve stimulator since December.

Scanzello's overactive bladder symptoms were compounded by a different type of urinary control problem called stress incontinence - when a mere cough or sneeze can bring on a leak.

Stress incontinence may be due to a weak sphincter muscle at the base of the bladder, or to weak pelvic muscles, which run like a sling under the bladder. In men, this type of leakage is often a side effect of prostate problems, while in women, the culprit may be the rigors of childbirth or the hormonal changes of menopause.

Scanzello had tried many treatments, including sling surgery to give added support to the neck of the bladder. Nothing worked.

Although InterStim does not treat stress incontinence, the therapy made Scanzello feel dramatically better by soothing her urgency-frequency symptoms. For many patients with multiple bladder problems, these symptoms are the most bothersome.

"It's not a cure, but I had improvement almost immediately," she said. "I was on a plane to Colorado two days later."



BEHAVIORAL THERAPIES: These include timed urination, fluid restriction, and pelvic muscle exercises (Kegels). Biofeedback equipment may help with Kegels.

MEDICATIONS: Overactive bladder drugs include Enablex (Novartis Pharmaceuticals), Ditropan XL (Ortho-McNeil), Oxytrol (Watson Pharmaceuticals), VESIcare (Astellas/GlaxoSmithKline), Detrol (Pfizer), Sanctura, (Madaus) Pro-Banthine (Roberts), and Urispas (Pharmascience). Stress incontinence drugs include Tofranil, Sudafed and estrogen products.

SUPPORTIVE DEVICES: These include drainage tubes periodically inserted into the bladder and rings inserted into the vagina to support the bladder.

NEUROMODULATION: Sacral nerve stimulation. This therapy also relieves pain or urinary retention caused when muscles that control urination go into spasm.

SURGERY: Urethral sling surgeries involve placing a sling of muscle, ligament or synthetic material to support the neck of the bladder. Surgery to enlarge the bladder, called augmentation cystoplasty, is a major, last-resort treatment for a bladder that is abnormally small.

-Source: National Association for Continence, American Urological Association.


(c) 2005, The Philadelphia Inquirer. Distributed by Knight Ridder/Tribune News Service.

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