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Incontinence relief is now coming from a surprising source – Botox

Incontinence relief is now coming from a surprising source – Botox

Connie Ziegler didn’t let sudden paralysis stop her active lifestyle, but the resilient Derry Township woman was almost derailed by something that many women suffer silently: Overactive bladder.

“I couldn’t tell when I had to go and I leaked because of bladder spasms. I don’t let anything stop me, but I would stay home because I was embarrassed and ashamed,” said Ziegler, 57, who five years ago developed transverse myeletis, a neurological disorder caused by inflammation of the spinal cord that can develop after a viral infection. It can have permanent effects such as paralysis and bowel

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Derry Township resident Connie Ziegler and her service dog Dutch are out and about again, thanks to Botox injections that addressed incontinence from overactive bladder.

Ziegler – and the one in 12 Americans like her who struggle with incontinence issues – has a new ally in a muscle relaxant used to smooth wrinkles: Botox.

A study released at the American Urological Association’s annual meeting in May showed that Botox injected directly into the bladder delivered a 50 percent or greater drop in daily urinary incontinence incidents. Between 44 percent and 52 percent of patients saw an end to their incontinence altogether. Botox has been approved by the U.S. Food and Drug Administration to treat overactive bladder since January 2013.

“If you are visiting the bathroom more than eight times a day or in less than two-hour intervals, that’s overactive bladder,” said Dr. Jose Manjon “Since I’ve had the injections, I’ve had no leakage. I’m back to my old self,” said Ziegler, who relies on a power wheelchair and her trusty service dog, Dutch, to get around. “I’d recommend it to anyone.”

The injections, which can be given in the office with numbing medication to the bladder or under sedation in the operating room, normally last about six to 12 months and are then repeated.

“With urge incontinence, the bladder is overworking; it’s gets a mind of its own and squeezes or spasms frequently. Botox is a neurotoxin that relaxes the bladder muscle,” said Dr. Vanessa Elliott, of Urology Associates of Central PA in Camp Hill. “It works very well.”

Mixed signals

Overactive bladder – also called urge incontinence – is caused by urinary muscle spasms. This is different than stress incontinence, which causes urine to leak when laughing or coughing, and often can be effectively addressed by doing Kegel exercises that strengthen pelvic floor muscles.

“If you are visiting the bathroom more than eight times a day or in less than two-hour intervals, that’s overactive bladder,” said Dr. Jose Manjon, a urogynecologist at the UPMC Pinnacle Health System Continence Center in Lower Paxton Township

Normally the nerves inside the bladder are inactive as it fills and when it’s full, the brain sends a signal down to contract the muscle and relax the urethra for urination. With overactive bladder, the nerve fibers are firing incorrect messages to the brain and the bladder start to spasm, Majon said.

Sometimes there are medical reasons, like spinal cord injuries, Parkinson’s disease, multiple sclerosis or stroke, but in the majority of cases, the cause is unknown, he said. It’s important to rule out other medical conditions that can cause continence issues, such as urinary tract infection or vaginal atrophy, before treating, he said.

The condition affects mostly women and it worsens with age, with statistics that estimate it affects nearly 60 percent of women over age 40 and 75 percent of women older than age 75. Some who feel the urge can get to the bathroom in time, but many others can’t and end up leaking a little urine or enough to soak a pad, doctors said.

“I have patients who are in their 20s and in their 80s. Some are wearing Depends or using multiple pads a day and others are changing their clothes frequently for drops,” Elliott said.

Shame fuels problem

While the severity of incontinence varies greatly, one thing is constant: Many people with incontinence have been suffering silently for years because they are too embarrassed to seek help.

“Most patients live eight years with it because they are embarrassed to talk about it or they think it’s a normal part of aging. It’s not and if we talk about it and treat it, the majority of people can be helped,” Manjon said. “Left untreated, it can really impact quality of life because people are afraid to go out to social and family activities. It can affect work, sleep, self-esteem and sexual relations because sex may trigger leakage.”

It’s something women don’t feel comfortable discussing with friends either, Elliott said.

“I’ve had patients who got help and don’t leak anymore and they tell me, ‘I was shocked because all my friends have leakage too, but we never talk about it,'” she said.

While Botox works extremely well, it’s also very expensive and most insurance companies require that patients fail on other oral medications before they will pay for Botox injections, doctors said.

Sources of help

The first line of treatment is behavioral modification. Patients may be asked to cut out known triggers, such as caffeine or alcohol or restrict fluid intake after 7 p.m. They may also be sent to physical therapy that can include pelvic floor strengthening exercises and biofeedback.

Oral medications aimed at blocking neurotransmitters are another line of treatment, however many people can’t tolerate the side effects of dry mouth and constipation and stop taking them, doctors said.

A surgical option involves implanting a bladder pacemaker, called InterStim, which addresses the communication problem between the brain and nerves. The device sends mild electrical pulses to the sacral nerves, located near the tailbone, which control the bladder and muscles related to urination.

“This is a great option. People come back to me with a huge smile and a hug and say, ‘I can’t believe you gave me my life back,” Manjon said.

In her practice, Elliott said the bladder pacemaker and Botox are equally popular and both have an 80 to 90 percent success rate. “There are nuances to each that determine who is the best candidate. For InterStim, you can’t get any MRIs other than to the brain so if you have a condition that requires MRIs, you wouldn’t want InterStim,” she said.

In about 10 percent of patients, Botox works so well that it can temporarily cause problems urinating, which mean a patient must be catheterized. The problem wears off as the Botox wears off, but the idea of it is enough to keep some patients from trying Botox, Elliott said.

“The majority of people are so sick of being wet that they say ‘I’ll try anything,’ and it usually is well tolerated,” she said. “It’s such a small procedure for such great relief.”

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