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Advances in Overactive Bladder Management: From Pelvic Therapy to Pacemakers · UF Health MedEd Cast

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  Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with
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  UF Health Shands Hospital.
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  I'm Melanie Cole.
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  And today, we're highlighting advances in overactive bladder management.
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  Joining me is Dr.
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  Alex Gomelsky.
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  He's a clinical urologist with UF Health and a professor at the University
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  of Florida College of Medicine.
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  He also serves as the Mary Anne Harn Cofrin Endowed Chair, Associate Chair
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  of Clinical Affairs, and Chief of Urogynecology and Reconstructive Pelvic
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  Surgery in the Department of Urology.
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  Dr.
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  Gomelsky, thank you so much for joining us today.
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  I'd like to start with kind of a working definition, how overactive bladder is
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  currently defined, and tell us a little bit about how it's different from
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  other lower urinary tract disorders.
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  Dr. Alex Gomelsky:
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  Sure.
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  The typical diagnosis or definition of overactive bladder is urgency, which is a
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  strong desire to urinate that is difficult to postpone, that is usually accompanied
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  by urinary frequency, nighttime urination, and occasionally urgency leakage.
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  The key thing there also is that it's in the absence of other obvious problems
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  such as urinary tract infection.
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  And urgency and urge leakage are different than something, for example,
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  like stress incontinence, which is leakage that a woman may experience with
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  increases in abdominal pressure, like coughing, sneezing, laughing, running,
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  jumping, being physically active.
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  And this is different also from something like pelvic prolapse, which is poor
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  muscular support of the bladder or other pelvic organs which cause them
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  to bulge through the vaginal canal.
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  And some women can have all of the above.
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  Melanie Cole, MS: Well, thank you for that.
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  So, speak a little bit about key symptoms.
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  I mean, you just mentioned a few, but some of the diagnostic criteria that
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  help distinguish it, and why is it sometimes a little bit hard to diagnose?
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  Dr. Alex Gomelsky:
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  I think the biggest problem we have with diagnosis sometimes is just
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  having the woman describe her symptoms in such a way where we can really
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  pinpoint what bothers her the most.
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  Often in my practice, a woman will come in and say, "Well,
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  just everything makes me leak."
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  I say, "Okay, let's narrow that down."
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  And what I'm really looking for is to really get a better idea
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  about what she is doing, if anything, when the leakage occurs.
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  Is she changing positions from sitting to standing?
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  Does she have a significant sense of urgency, a "got to go, got to go"
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  sensation that she just can't postpone?
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  Is she playing pickleball or is she physically active?
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  Is she having other symptoms like difficulty emptying of the bladder?
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  Is she having burning with urination?
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  Is she having blood in the urine?
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  Is she having any element of pain with a full bladder?
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  So, all of those are important things to take into account when seeing
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  a woman with leakage and can help point me down a particular road.
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  Melanie Cole, MS: So as we think of those strategies, really, it's
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  about better history to improve that diagnostic accuracy, yes?
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  Dr. Alex Gomelsky:
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  Absolutely.
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  History is probably the most important part of our evaluation
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  Melanie Cole, MS: And are women forthcoming?
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  Because it seems to me that one of the challenges for clinicians can
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  also be with some of these sensitive issues like incontinence or overactive
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  bladder management, is that patient is not as forthcoming because
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  there's a little bit of a stigma or an embarrassment to talk about it.
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  Dr. Alex Gomelsky:
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  One hundred percent.
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  There are a lot of women that grew up in an age when these were just things that
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  you either didn't talk about, or the assumption was that maybe with having
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  children and pregnancies and getting older, that this was more of a normal
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  part of the aging process and life.
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  And so, you can live with it and tinkling a little bit when you laugh or cough.
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  You know, Mom had it, Grandma had it.
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  So, this is fairly normal.
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  I think that it has become more socialized at this point, I think
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  with social media with commercials on television, advertisements, that this
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  is not something that is necessarily normal, and it certainly isn't something
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  that you necessarily have to live with.
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  So, I think that the recognition of it has increased quite a
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  bit over the last 15, 20 years.
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  Melanie Cole, MS: I agree with you.
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  And as a 62-year-old woman, I'm right there in that category.
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  And I think that speaking to our physicians has gotten a little
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  bit less stigmatized, a little bit easier, as long as we understand
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  that you are the professional.
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  And the tools in your armamentarium are more extensive now.
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  So, what does the latest evidence tell us about the effectiveness and safety of
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  some of the available treatment options for OAB, including both established
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  and some of the emerging therapies?
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  Dr. Alex Gomelsky:
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  Oh, sure.
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  Well, this is a very exciting area in all of urology because we've seen
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  such an increase in technology here and such an increase in the number of
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  offerings that we have for these women.
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  And I think, to kind of take a step backwards, we've seen a bit of a shift
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  in our approach to these patients.
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  The American Urological Association has guidelines that will provide some
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  structure as to how you might want to approach treatment for these women.
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  And in 2025, they've undergone a bit of a revision, and the biggest change has
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  been is that in the earlier version, we had very much sort of a stepwise
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  approach to overactive bladder.
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  We would typically start with some simple things like behavior
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  changes, maybe some pelvic exercises.
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  Then, we would move on to medicine, and then we would move on to what we
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  call minimally invasive treatments.
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  The way I tell patients about it or other practitioners is that this was
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  a fixed price menu at a restaurant.
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  You have your appetizer, then you go on to the main course,
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  and then you have dessert.
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  The big change has been in that we can now offer these patients,
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  after appropriate counseling, any of those things to start out with.
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  So, the way I say now is you can have your dessert first.
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  Depending on the patient and their lifestyle, their desires, their activity
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  level, their other medical issues, you can offer them more advanced therapies early,
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  and obviously after good counseling.
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  So, the two biggest categories of treatment we have here are things like
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  medicines, and we have two separate classes of medicines, and seven or eight
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  different medications that we can offer.
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  There's two medicines in one class, and the rest of the
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  medicines are in a separate class.
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  The larger class of medicine are older medicines.
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  They've been around for a long time.
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  They are effective.
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  Many of them can be taken just once daily and are longer acting.
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  And the effect of the medicines is to relax the bladder and allow it
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  to hold urine longer and hopefully give the woman a little more warning
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  time to make it to the bathroom.
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  The typical side effects of those medicines are dry eyes,
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  dry mouth, and constipation.
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  But there is also a kind of a bit of a concern with some of those medicines
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  because there has been some association with dementia risk in the future.
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  And so, that's something that we need to be very mindful of if we're going to
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  place a patient on one of those medicines.
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  The other class of medicine has two medicines in it.
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  They're relatively new, although at least one of them is now generic, and
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  they don't have those same side effects.
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  And their side effect profiles are more favorable, and one of them can
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  even be crushed and given to older adults with swallowing difficulties.
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  There are some advantages in them, but the insurance coverage may tend
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  to be a little bit spotty on those.
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  But I think that's bound to improve in the future
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  After the medicines, we do have what we call the minimally invasive treatments.
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  And those go into two big categories.
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  There are Botox injections into the bladder, and then there's different
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  nerve modulation procedures.
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  As many people know, Botox is a toxin.
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  In its pure form, it's one of the strongest paralyzing agents known to man.
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  But in tiny, tiny doses, it can be used in different parts of the body,
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  such as the face for cosmetic purposes.
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  For muscle spasms in the underarms, it can be used to
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  control symptoms in those areas.
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  And it's been FDA-approved for use in the bladder for a long time.
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  It's injected into the bladder in tiny doses using a scope.
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  So, we look through the urethra, the urine channel, and inject it in tiny doses.
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  And typically, a few days later, the bladder begins to relax.
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  And the results may last for six to nine months with one injection
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  with really no moving parts.
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  The downside to the Botox injection is that urinary retention,
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  at least temporarily, may be possible if it works too well.
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  And there are some women that may occasionally need to
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  catheterize themselves short-term to get the bladder drained.
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  But for women that are looking for something that doesn't involve any
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  moving parts, it's a nice option.
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  It can often be done in the clinic setting or under a little
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  sedation in the outpatient center.
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  The other category is really kind of where a lot of the excitement is,
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  and that's the neuromodulation, the different nerve stimulation procedures.
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  Sacral nerve stimulation has been FDA-approved for over 25 years.
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  We target nerves that control the bladder that run underneath the tailbone, and
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  we can essentially control those nerves with something like a bladder pacemaker.
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  And that's a device that's implanted inside.
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  In fact, it looks very much like a pacemaker, and it will have
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  a battery and a remote control.
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  And it's a 15-year MRI compatible device, and the battery may need
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  to be replaced at that point.
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  This is a little bit like one of those old-time transistor
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  radios where you can tweak the settings on it for better results.
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  And we now also have tibial nerve stimulation.
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  So, this is actually based on some acupuncture techniques, but there's a
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  nerve running behind the ankle that can be stimulated with a little battery, which
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  can be placed under local anesthesia, so no general anesthesia required.
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  And this nerve communicates with the bladder nerves.
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  And so, another way that we can do some nerve stimulation, which is
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  not very invasive, but potentially improve the overactive bladder.
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  That's the exciting stuff going on.
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  Melanie Cole, MS: Wow.
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  Well, it certainly is an exciting time in your field, and that was an excellent
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  overview of the treatment options.
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  And so, Doctor, when we're thinking about patient selection and shared
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  decision-making with all of these options, and as you said, the
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  menu can be rearranged and you can jump to what used to be one
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  of the latter treatment modalities earlier if that's what is required.
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  So, you're speaking to other clinicians now.
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  How do you want them to develop these individualized treatment
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  plans that account for that shared decision-making, patient preferences,
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  symptom burden, comorbidities?
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  Because obviously, things like obesity and age and hormonal
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  factors can come into play here, and even adherence considerations.
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  How do you work with your patients?
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  Tell other clinicians what you'd like them to know about that.
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  Dr. Alex Gomelsky:
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  I think that's an excellent point.
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  Patient selection is the key in this.
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  I think talking to them and find out what they're looking for
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  and what their expectations are.
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  I'm fairly honest with my patients in where I say, you know,
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  we're looking for improvement.
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  If we get significant improvement, that's fantastic.
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  If we get a complete resolution, that's amazing.
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  But what we're looking for is an improvement in the symptoms and an
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  improvement in the quality of life.
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  For some, that may be using fewer pads.
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  For some patients, it may be being completely dry.
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  So we need to establish what their expectations are.
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  And then, as you mentioned, we want to take that woman into account.
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  Is she heavy?
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  Does she have mobility issues?
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  That's easy to tell when they walk in your office or if they come in in a wheelchair.
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  If they have difficulty transferring from their chair to the bathroom or
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  the bathroom is too far away, those are issues that may need to be addressed in
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  order to help any treatment work better.
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  I also will offer all the treatments to everybody, and I tell them, "Here
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  are the pros and here are the cons."
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  The Botox is sort of one-stop shopping.
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  There are no moving parts, and some patients prefer that.
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  They'd rather have something injected in the bladder.
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  They don't have to worry about monitoring their response with a little
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  remote control, and they enjoy that.
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  Others are a little bit more hands-on, and they like the idea of something
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  that maybe won't require repeat procedures every six to nine months.
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  Maybe they have a battery in for 15 years.
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  So, you kind of have to feel them out.
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  You have to talk to them about it.
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  I guess I'm still a little bit of a traditionalist, where I will
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  definitely try the simple stuff first, the behavior modification.
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  I offer physical therapy to all my patients, and definitely will try at
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  least one medication before moving on to the more advanced treatments.
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  I also very much believe that the treatments are additive, that it's not
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  use one treatment, get rid of it, and then try another one if not effective.
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  We look at attacking the bladder at different points.
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  And so, a combined treatment therapy may be a very good option
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  for many of these patients.
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  Melanie Cole, MS: Well, I think that's the crux here, Dr.
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  Gomelsky, is that the combined therapies and whatever works for the women.
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  So as we wrap up, and you kind of already touched on this when you were talking
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  about behavioral interventions and really trying some of the more conservative
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  measures first to see how do they compare when you think of talking to other
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  clinicians about this, when we're looking at those pharmacologic treatments, when
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  we're looking at those procedurals, when we are looking at behavioral interventions
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  and pelvic floor physical therapy and any of these other modalities, when should
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  clinicians consider escalation of care?
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  How do you want them to think of this menu?
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  Dr. Alex Gomelsky:
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  I think that trying behavioral therapy and at least one medicine,
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  I think, is very reasonable.
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  And again, I mentioned that the medicines should definitely be considered
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  for their side effect profiles, especially in our older adults.
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  I think that's a great way to start.
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  I think most women have very few contraindications to trying that first.
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  I would imagine in my practice that maybe 50% to 60% of women will see improvement
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  just with those two treatments alone.
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  And so, at that point, we can certainly consider moving on to other
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  treatments, maybe a combination of medicines if we want to give that a try.
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  So, I think that's a very reasonable start for pretty much anybody before looking to
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  do something a little bit more invasive.
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  Melanie Cole, MS: Well, that is great advice and great information.
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  Doctor, thank you so much for joining us today and really sharing your
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  incredible expertise for other clinicians.
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  Thank you again.
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  And for more information, you can visit ufhealth.org/urogynecology.
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  And to learn more about this and other healthcare topics at UF
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  Health Shands Hospital, please visit innovation.ufhealth.org.
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  That concludes today's episode of UF Health MedEd Cast with
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  UF Health Shands Hospital.
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  I'm Melanie Cole.