How to end the tyranny of an overactive bladder: Amid concerns about dementia risk from a top incontinence drug, our best doctor’s guide to what to do instead

Incontinence is one of the most common problems I encounter in my clinic. And in many cases, this is due to a condition called overactive bladder syndrome, which causes patients to constantly need to go to the toilet.

It is caused by muscle spasms in the bladder, and patients often report feeling trapped at home for fear of being caught on the road.

Millions of people with overactive bladder syndrome are prescribed daily anticholinergics, tablets that can reduce the frequency of spasms.

But research has linked anticholinergics to an increased risk of dementia. This must be worrying reading for patients.

However, not only are there alternative medicines available, but simple steps can be taken to reduce the painful symptoms of an overactive bladder.

I use these tablets for my overactive bladder – now I’m concerned about the risk of dementia. Should I get rid of them?

There is no simple answer to this; it really depends on the patient and the circumstances.

A study published in the British Medical Journal concluded that taking anticholinergic drugs increases the risk of dementia by 18 percent. This can’t be dismissed – and I wouldn’t say, “Don’t worry about it” – but it’s not a done deal either.

If someone already has cognitive impairment, he or she probably should not take anticholinergics. And we are cautious about this among people over 65 in general. They are probably more at risk. But that doesn’t mean they have to get off drugs.

As with all pills, it is about weighing the pros and cons.

Dementia concerns aside, if a patient has been taking the tablets for years and their incontinence is well controlled, it may be time to reduce the dose or take a break. In some cases, the complaints do not return, so that the medication is no longer necessary. However, they may take anticholinergics and do other things to control an overactive bladder, such as pelvic floor exercises and avoiding caffeine and alcohol, but they still have problems.

So we can suggest regular reviews. And if there are real concerns about dementia – for example due to a family history – we can discuss alternative medications and treatment options.

What are the alternative medications I could take?

First, we think that only certain anticholinergics increase the risk of a dementia diagnosis.

Patients prescribed oxybutynin hydrochloride, tolterodine tartrate or solifenacin succinate are about a third more likely to develop dementia.

But those taking darifenacin, fesoterodine fumarate, flavoxate hydrochloride, propiverine hydrochloride, and trospium chloride are not at increased risk. Darifenacin is one of the first medicines that GPs prescribe according to NHS guidelines.

Unfortunately, oxybutynin hydrochloride, tolterodine tartrate and solifenacin succinate – the three linked to dementia – are considered the most effective drugs for treating overactive bladder.

If patients are concerned about taking these tablets, they can ask their doctor about switching to a different anticholinergic.

But it’s possible they’ve already tried it to no avail, or their symptoms may worsen after switching to the new pill.

Crucially, anticholinergics are not intended to be used long term without evaluation and many patients will be advised to take a break from them.

If I want to stop taking tablets, are there drug-free ways to control overactive bladder?

The short answer is: yes. Caffeine and alcohol should be avoided as they can irritate the bladder and worsen symptoms.

Patients also cite green tea – which many people don’t know contains caffeine – spicy foods, citrus fruits, tomatoes and carbonated drinks as triggers. Obesity increases the risk of overactive bladder syndrome, and patients who lose weight often see symptoms disappear.

This can’t be done overnight, but other research shows that regular exercise also eases symptoms.

For many women, an overactive bladder is a sign of an underlying condition related to menopause called genitourinary syndrome. This is due to low estrogen levels, which leads to vaginal and vulval dryness, itching, pain during sex and symptoms of overactive bladder.

This can be treated with an estrogen cream applied to the vagina. It is therefore important that any woman with an overactive bladder is examined by a GP for signs of genitourinary syndrome of menopause. A common mistake patients make is avoiding drinking water in the hope that this will mean less urination.

However, not only does this not work, it can also cause the urine to be more concentrated, further irritating the bladder.

I’ve heard that you can retrain the bladder to end the urge to urinate – is this true?

Yes, GPs should be able to refer patients with overactive bladder for bladder exercises, also known as bladder training, on the NHS. A physical therapist or women’s health specialist will prescribe exercises that train the bladder to hold larger volumes.

Patients may initially be advised to urinate every hour. Gradually this is increased by five or fifteen minutes, until they can last up to four hours.

This usually involves learning coping techniques such as squeezing the pelvic floor when the urge to go hits and then counting to a certain number, crossing your legs, or sitting on a rolled up towel.

It may take several months for patients to notice improvement, but many people’s lives have been changed for the better by bladder training.

I’ve tried everything, but nothing seems to help. Could surgery be the solution?

Yes, but there are other, less invasive options that patients should try first.

One of these is regular Botox injections into the bladder, which help relax the organ and relieve symptoms. However, some patients find that they have difficulty emptying their bladder completely as a result of the injections.

Another is nerve stimulation, which uses an electric shock to stimulate nerves in the ankle or lower back, which can improve bladder function for some.

In extreme cases, patients may be offered cystoplasty, a procedure in which the bladder is enlarged to relieve symptoms.

However, surgery is only offered to a limited number of NHS patients, who often have to wait years. For most patients, lifestyle changes and bladder training – not surgery or medications – are the key to solving the problem.

What is the difference between a rotator cuff injury and a frozen shoulder?

Rotator cuff injuries occur when the muscles and tendons around the shoulder joint become damaged or torn. This can happen suddenly or gradually due to overuse, especially during repetitive overhead activities. Symptoms include pain when raising or lowering the arm and weakness in the shoulder.

Treatment ranges from rest and physiotherapy to surgery in severe cases.

Frozen shoulder is a condition in which the shoulder joint begins to feel thick and tight, causing progressive stiffness and reduced range of motion. The condition often goes away on its own within one to three years, although physical therapy and steroid injections can help manage symptoms.