Interesting Study of the Week–“Overactive Bladder”

Mici, fabulous jail nurse, Bonneville Co. Jail, Idaho Falls, Idaho.

Shamliyan T, Wyman JF, Ramakrishnan R, Sainfort F, Kane RL. Benefits and harms of pharmacologic treatment for urinary incontinence in women. A systematic review. Ann Intern Med 2012;156:861-874.

We have all seen the commercials touting medications for the conditon the advertisements call “overactive bladder.”  This ,of course, refers to a sudden and unexpected urge to urinate, even when the bladder is not full.  These patients tend to have frequent nocturia.  And some patients who do not step lively enough will sometimes pee their pants a little bit, and this is termed “urge incontinence.”  If the incontinence occurs when the patient has a sudden increase of intra-abdominal pressure (like laughing or coughing), this is called “stress incontinence.”  Patients who have both have “mixed incontinence” and may not like good jokes.

This syndrome tends to occur in women more than men and in the elderly more than the young.  The term “overactive bladder,” as far as I can determine, was coined by the pharmaceutical industry as a way of labeling the condition in a friendlier way.  “Do you have ‘Overactive Bladder'” sounds better than”Do you have to run to the bathroom a lot and sometimes pee your pants?”  The medications advertised to help this condition are anti-cholinergics with muscarinic activity such as Ditropan (oxybutynin), Enablex (darifenacin) and Detrol (tolerodine).  In the advertisements, of course, the women who take these drugs are suddenly able to attend important events that they used to miss because of their embarrassing “overactive bladder.”

This great study asks the question:  just how effective are these medications for urge incontinence?  The study was done by a wonderful little government entity called the Agency for Healthcare Research and Quality.  They consistently do great work.  The researchers reviewed 72 different studies of anti-cholinergic drugs used in the treatment of urge incontinence.  The results:

1.  Approximately 10% (range 8.5% -13%) of patients become fully continent when taking these drugs.  That, of course, means that 9 out of 10 continue to have incontinence despite being on the medications.

2.  The researchers defined “clinically significant decrease” in incontinence as a reduction in episodes of at least 50%.  How many patients reached this threshold?  The answer is approximately half.  However, that barely outperformed placebo.

3.  There was not difference in response rates between those with urge incontinence, stress incontinence or “mixed” incontinence.

To my eye, these results are underwhelming.

Another consideration important in corrections is that since these medications are anti-cholinergics, they can be used by inmates to get high.  I wrote about this phenomenon previously in Is This Inmate Gaming Me?  Since I wrote that blog post, I have heard from medical personnel in several other correctional facilities who have also either suspected or discovered inmate abuse of these drugs, particularly oxybutynin.

So keep this in mind the next time an inmate says they must urinate a lot and want to be prescribed that pill they saw on television.  Some patients legitimately have this condition and may be helped by anti-cholinergic drugs.  Far more who truly have this condition will not be helped by these medications.  And still others may not really have bladder problems at all, but want the anti-cholinergic for its abuse potential.

Do you have a good strategy to sort out these three types of patient?  Please comment!

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