A summary report published on December 4^th 2017 in the Journal of the American Geriatrics Society emphasizes that the conference–the third in a series on common geriatric syndromes like incontinence, delirium, and sleep disturbances–holds promise for pin-pointing gaps in knowledge and building a better research agenda to improve care for us all as we age.

A release from the society quotes Phillip P. Smith, MD, Associate Professor of Surgery at UConn Health, an NIA-funded Beeson scholar, and a co-author of the report, as saying, “Despite its prevalence among older adults, incontinence remains under-reported and under-treated, a reality for many of the conditions addressed through the AGS-NIA conference series, Bringing renowned leaders together to look critically at what we know, what we don’t know, and how we can bridge that divide will not only lead to better treatments but also will help model the way to high-quality, person-centered care for all older adults.”

That process begins by identifying gaps in clinicians’ understanding of serious health concerns like incontinence, according to the expert panel of conference attendees. Principal among these gaps, for example, are unanswered questions about social, health, and personal factors that contribute to urinary control failures such as overactive bladder, voiding symptoms, and urinary retention (the inability to completely or partially empty the bladder), impacting more than 30 million Americans.

Focusing on urinary incontinence, a leading cause of social isolation and distress for older adults, the panel also highlighted research questions not typically included in clinical data sets that drive new and better treatments. In this context, conference experts from many different disciplines reported on the current state of urinary incontinence research across four critical areas: basic science, translation of discoveries from the bench to the clinic, healthcare delivery, and the frequent yet under-recognized clinical overlap between incontinence and other common geriatric syndromes in the same individual–a critical focus of the AGS-NIA conference series.

“Risk factors common to all geriatric syndromes include older age, decline in functional independence, impaired mobility, and impaired cognition,” notes the conference report. “Identifying common shared risk factors and pathophysiological mechanisms [will be key to] future research efforts.”

Among other highlights, the conference report notes that behavioral therapy (forms of treatment that seek to identify and help change specific behaviors linked to health problems) has emerged as one of the most successful treatment options for addressing bladder control, though it still is not offered to most older adults. Lack of provider awareness for behavioral techniques may be one reason for the gap, along with reimbursement models that fail to account for the time it takes to teach behavioral therapy skills. Future goals for treating urinary incontinence should include improving behavioral training to make it more effective, as well as offering that training more widely.

A release by Alicia Rohan from the university quotes Dr. Richter as saying, “This study will help guide clinicians offering these treatment modalities with information to better individualize treatment for women with refractory urgency urinary incontinence. Our findings suggest that the optimal treatment for women with refractory urinary incontinence is through the use of Botox A.”

The release explains that urgency urinary incontinence is a sudden need to void resulting in uncontrollable urine loss. This disruptive condition is common and increases with age, from 17 percent of women older than 45 years to 27 percent older than 75 years in the United States. Women who are not responsive to treatment of urinary incontinence are treated with Botox A and sacral neuromodulation. However, there is limited comparative information regarding these two treatment approaches.

Botox A stops the nerve signals to cells, paralyzing the bladder muscle. Sacral neuromodulation involves the implantation of a small electrode tip near the sacral nerve to control voiding function in the lower spine. The implanted device stimulates the nerve to act as a sort of pacemaker for the bladder.

For this study, conducted at nine medical centers in the United States, the researchers randomly assigned women with refractory urgency urinary incontinence to sacral neuromodulation or an injection of Botox A, also known as onabotulinumtoxinA. Of the 364 women with an average age of 63 years, in the intention-to-treat population, 190 in the onabotulinumtoxinA group had a statistically significant greater reduction in mean daily urinary incontinence episodes over six months than did the 174 in the sacral neuromodulation group. Participants treated with onabotulinumtoxinA showed greater improvement in an overactive bladder questionnaire for symptom bother, treatment satisfaction and treatment endorsement than those treated with sacral neuromodulation.

However, there was no significant difference in quality of life or for measures of treatment preference, convenience or adverse effects. OnabotulinumtoxinA did increase the risk of urinary tract infections and need for transient intermittent self-catheterizations.

“Although there was a small difference in reduction of daily urinary incontinence episodes between the two treatment groups, other outcomes provide information that should be discussed with patients in helping them choose which treatment is best for them,” Richter said.

Stress urinary incontinence (SUI) is the involuntary loss of urine that occurs with coughing, sneezing or physical exertion. The word “stress” can be misleading since this type of involuntary urine loss has nothing to do with emotional stress. Also, another type of involuntary urine loss is called urge incontinence or  ” “overactive bladder” or “spastic bladder.” Sufferers, often women who have had children, experience a strong and sudden need to urinate with no warning. This condition is not helped by the mid-urethral sling. However, because stress incontinence happens due to weaknesses in the structures supporting the bladder and bladder outlet (urethra), the sling is useful.

Women whose symptoms persist despite trying non-surgical approaches such as pelvic floor exercises may be suitable candidates for surgery in order to improve bladder control. Surgery uses one of two common operations to insert a sling under the urethra in an effort to keep it supported. One approach is the insertion of a sling behind the pubic bone coming out via the abdomen (the bottom-to-top ‘retropubic’ route), or alternatively from side-to-side coming out through the groin (the ‘transobturator’ route).

The team of researchers included information from 81 trials in total, of which 55 made the direct comparison between the retropubic and transobturator routes. They found moderate quality evidence that at around 12 months, both routes had successfully cured symptoms in 80% of women. From the few studies that had reported 5-year data, rates of cure in both groups had fallen to around 70%.

Transobturator insertion seemed to carry a lower risk of bladder damage during the operation with around 6 women in 1000 experiencing this compared with 50 in 1000 in the retropubic groups, and fewer women (40 in 1000) in the transobturator group had persistent difficulty in being able to empty their bladder completely compared with around 70 in 1000 in the retropubic group.

In contrast, the transobturator operation led to more short-term groin pain and there is some limited evidence that women who undergo transobturator route insertion are more likely to need a repeat operation later on than women who had a retropubic insertion. The overall rate of erosion of the tape into the vagina was 2% following either surgery when the studies had completed follow-up at between 1 and 5 years. The rate of pain during sexual intercourse was also low in both groups.

Over the last few years many questions have been raised about the safety of continence surgery because it involves implanting a sling made of an artificial mesh. There have been a number of reports of women suffering pain and injury after surgery, thought to be due to the sling, which is made of non-absorbable plastic. This has led to many court actions worldwide, with cases already under way in the UK, the USA and Canada. In Scotland, the Health minister called for hospitals to consider the suspension of mesh operations until more evidence is available. An independent review set up in Scotland in 2014 to review the safety of these operations will publish its findings later this year. This latest Cochrane Review is one of a number of sources of evidence that will inform the findings of that independent review.

Lead Author, Abigail Ford from the Bradford Teaching Hospitals says, “This is a very significant review informing women about the minimally invasive surgical options available for the treatment of this very debilitating condition. It helps to clarify the pre-existing evidence on the effectiveness of these approaches and their side effects in the short term, as well as introducing longer term evidence of efficacy and safety. It helps to give women more information to make an informed choice.”

Dr. Ford continues, “Understanding this evidence in context is really important for women. They need to be aware of less invasive alternatives such as pelvic floor exercises, which should be tried first before contemplating any type of surgery. As all surgery carries some risk women must weigh up carefully how much they are troubled by their urine leakage against taking a small chance that things may go wrong as a result of surgery.”

Joseph Ogah, Consultant Gynecologist says, “We need to know more about what happens to women in the long term. This review found 35 trials carried out more than five years ago: if all the women in these trials were followed up we would know much more about how long the operations last and, crucially, whether they had developed late but important side effects. Rather than starting any new trials in this area we need to obtain long-term follow up from the existing trials.”

Mr. Ogah also says, “Although this review compares the two most common operations in current practice in the developed world, we need more robust evidence about how well they compare with the older types of surgery that they have superseded: it may be helpful to look at indirect comparisons if direct evidence is not available or reliable enough.”

While much is known about the central biological clock, little is known about the peripheral clocks in the body. This latest research challenges the long-held view that the central clock of the brain controls all the peripheral clocks in other parts of the body and that these in turn control the down-stream receptor molecules which generate specific cell activities, such as contraction, secretion and metabolism. However, researchers have found that receptors in the bladder, a muscular hollow organ in the body, exert control over the local clocks.

The control of organ function via an interaction between the peripheral clocks and the receiving receptors is an important finding for understanding the pathology and development of new treatments for common diseases of the bladder, such as bladder overactivity and irritable bowel syndrome.

The team also believes the study will help advance understanding of how aging affects organ function in the body as the normal control of daily rhythms by the clock is weakened in aging tissue.

A release from the university quotes lead author Dr Changhao Wu as sayin,g “Previously, people have believed that the brain ‘master’ clock controls the ‘slave’ peripheral clocks, but our study is the first to show that in a contractile organ, such as the bladder, its receptors also control these clocks. By influencing the receptors in the bladder, we can also change our clock genes. These clocks are crucial in maintaining our physiological rhythm and preventing unwanted activities associated with an overactive bladder.”

The American Urological Association Foundation says it’s time to talk about Overactive Bladder and has created an educational website that offers support and tools for dealing with OAB: www.ItsTimeToTalkAboutOAB.org. In fact, the American Urological Foundation is kicking off a national contest via Facebook to encourage more women to (anonymously) share their stories about living with OAB. The three most inspiring stories submitted before the 8/31/12 deadline will win a tablet PC (go to www.facebook.com/voicesofoab to enter).

OAB is not the same as stress incontinence, which is leakage due to pressure on the pelvis from laughing, exercise, or sex. This condition has been worked into TV shows as one of the humorous aspects of post-partum recovery or of growing older. But OAB is no laughing matter. Also called “urge incontinence,” OAB is more sporadic and unexpected than stress incontinence, says Dr. Lisa Hawes, a specialist in female urologic conditions. “With OAB, women have no control or warning as there is no pressure on the abdomen.” Although we don’t hear as much about it, more women suffer from this kind of incontinence than stress incontinence, points out Hawes.

We’ve all experienced having to urinate more frequently when we’re excited or nervous, but what if it was happening 24/7? Although running to the bathroom all the time isn’t a life-threatening issue, it can curtail activities and negatively impact quality of life. Areas that suffer are sleep, which affects work; self-esteem, which affects relationships; and sexual performance, since the urge to urinate is ever-present. Some people restrict themselves to their homes or familiar surroundings because they are so nervous about not finding a bathroom when they need it.

The treatment for OAB is lifestyle change, including diet, behavioral therapy, and fluid management, as well as bladder training or pelvic floor muscle exercises. Some patients may require medications, called anti-muscarinics, or other treatment options.

“Overactive bladder can be triggered by diet and anxiety,” says Dr. Hawes. “It can also be muscular in origin due to muscle hyperactivity or nerve damage. Typically OAB is slowly progressive and does not resolve without lifestyle changes or possibly medical intervention.”

Diet changes include eliminating caffeine, which increases bladder activity: no caffeinated sodas, coffee, or tea. Alcohol is both a bladder stimulant and diuretic. Artificial sweeteners increase bladder activity as well. Foods that are highly acidic, loaded with sugar, or especially spicy may need to be eliminated, one by one. Increased water intake is preferred even though it means an increase in urine. The less concentrated the urine, the less chance of irritation to the bladder.

“The first physician to approach about these issues is your primary care doctor or OB/Gyn,” advises Hawes. “Often they will initiate discussion about diet and behavior changes, physical therapy, and even first-line medications. If these efforts prove insufficient, a urologist should be consulted.”

The “It’s Time to Talk About OAB” website offers a Bladder Diary to record how much you drink, how often you go to the bathroom, and when you have leakage so you can accurately present symptoms to your healthcare provider. A free Apple or Android app is also available.

The condition is manageable, but the first step is speaking up.

“There are two types of incontinence, ‘stress’ and ‘urge,'” Dr. Marie says. “The word ‘stress’ doesn’t refer to emotional stress. It means pressure on your bladder. If you have weak muscles, that pressure causes urine to leak. This can happen when you laugh, cough, or just wait too long to go to the bathroom.”

She went on to explain that urge incontinence — also called irritable bladder syndrome, overactive bladder, or spastic bladder – is a condition in which your bladder empties even if it’s not full in spite of your attempts to hold it. This disorder is sometimes caused by diabetic neuropathy but is most often simply related to aging.

Dr. Marie says she can’t promise you a 100 percent cure, but that she can certainly help you gain more control. She deals with the problem herself and advises that your first line of defense should be to make sure you always have access to a toilet. “Just do as I do and check out the location of the bathroom everywhere you are,” she says. “Also, go often even before you feel the need!” Beyond that, she has tips for keeping the leaks at a minimum.

Often referred to as Kegels after Dr. Arnold Kegel, the gynecologist who created them in 1948, these exercises are the single most effective treatment for stress incontinence. Just as with any other muscles, you either “use it or lose it.”

Finding the muscles is easy. When you’re urinating, imagine that somebody accidentally comes into the bathroom and startles you. Your instinct will be to squeeze your muscles to stop the flow.

Dr. Marie recommends doing your Kegels three to five times a week by squeezing and holding for five seconds, then releasing and repeating for a total of ten repetitions. She says you will notice improvement in six to eight weeks and that after three to six months you may be cured, or nearly cured.

She speaks from experience. “Once I got past an initial aversion to doing Kegels, they became a routine part of my life,” she says. “I’m proud that I had the power to strengthen the muscles and alleviate my problem to a great extent.”

You can buy weights in the shape of cones that are the size of a tampon. They come in sets ranging from twenty to seventy grams. Begin by inserting the lightest one and holding it for fifteen minutes twice a day for four to six weeks. Then move up to the next heaviest weight and finally the heaviest one. However, Dr. Marie says that no research has shown that the weights are any more effective than Kegels. “In fact Kegels are often shown to be more effective than using weights,” she points out.

You knew this was coming. In the same way that you experienced extra pressure on your bladder if you were ever pregnant, carrying excess weight after menopause can make incontinence worse. Consider getting support from groups such as Weight Watchers or Overeaters Anonymous if dieting is difficult for you.

“Prescription medications can help some women with urge incontinence,” Dr. Marie says. She cautions, though, that the drugs are expensive and may have side effects such as a dry mouth, headaches, fatigue or sleepiness, constipation, and tummy aches.

They work by relaxing the smooth muscle of the bladder and blocking certain nerve receptors to the urethra to help keep it closed. Paradoxically, although this is a positive result for urge incontinence, it’s a negative for stress incontinence. Some of the commonly prescribed medications for urge incontinence include Ditropan, Detrol, Urispas, Tofranil, Bentyl, Levsin, Sanctura, Vesicare, and Enablex.

“Twenty years ago I wouldn’t have recommended surgery for stress incontinence,” Dr. Marie says. “That’s because your only option would have been a urologist whose greatest knowledge and practice was almost without exception limited to men. Today, however, I would encourage you to have a consultation with a gynecologic urologist.” She goes on to say that surgical cases have doubled recently as baby-boomer women with the proactive attitude typical of that generation have aged and demanded better treatments. There are now over 250 techniques ranging from collagen injections to minimally invasive surgery to tacking up of the bladder, vagina, and urethra to the pubic bone. Yet Dr. Marie warns that not all of these procedures have been well evaluated. “Do your research and seek a second if not a third opinion if you are considering surgery,” she advises.