Announcer:
You’re listening to Clinician’s Roundtable on ReachMD, and this episode is sponsored by Sumitomo Pharma. Here’s your host, Dr. Brian McDonough.
Dr. McDonough:
This is Clinician’s Roundtable on ReachMD. I'm Dr. Brian McDonough, and joining me to discuss personalized management approaches for patients with overactive bladder are doctors Gary Lemack and Paul Doghramji. Dr. Lemack is a Professor of Urology at UT Southwestern Medical Center and a urologist at North Texas VA Medical Center in Dallas. Dr. Lemack, welcome to the program.
Dr. Lemack:
Thanks so much for having me.
Dr. McDonough:
Also joining us is Dr. Paul Doghramji, who's a physician at Collegeville Family Practice and Pottstown Memorial Medical Center, as well as Medical Director of Health Services at Ursinus College in Pennsylvania. Dr. Doghramji, thanks for being here.
Dr. Doghramji:
Pleasure to be here.
Dr. McDonough:
Let's start with you, Dr. Doghramji. Can you give us an overview of overactive bladder and its symptoms?
Dr. Doghramji:
Sure. Overactive bladder is the name of a group of bladder symptoms, and there are three main symptoms. One is a feeling that you have to pass urine. The second is a need to pass urine very often or very frequently. And this can occur either during the day or it can occur at night, which we in medicine call nocturia. Sometimes there's also incontinence, which means that you leak urine when you have to go. It's a feeling that you have to go, and you actually have some leakage in it.
Dr. McDonough:
Well, sticking with you for just another moment. Dr. Doghramji, why is it so important to develop personalized treatment plans for patients with overactive bladder?
Dr. Doghramji:
Well, first of all, it's a very personal thing. A lot of men and women come in complaining of overactive bladder, and there are a variety of different things that could be going on. They could have some medications that they're taking, which can complicate things and make things a bit worse, so sometimes you have to look at that. Sometimes there are lifestyle issues that are going on that may have to be changed. So everybody's a bit different as to what's going on. So you have to look at medications. You have to also look at, if you're going to prescribe a medication, if there's going to be any drug-drug interactions. But also, you have to look at a patient's lifestyle. How much fluid are they drinking? Are they having a lot of caffeine intake? Do they need to exercise? Do they need to stop smoking? And do they need to lose weight? So these are all the different things that are important to consider when we're personalizing our attention to a patient that has overactive bladder.
Dr. McDonough:
Turning to you now, Dr. Lemack, how do you incorporate your patient’s characteristics and preferences into your management approach?
Dr. Lemack:
Yeah, so there are two different things to think about in terms of their characteristics. Like what Dr. Doghramji was sort of talking about, you have to look at the whole picture and what's going on with that patient. Urinary symptoms can be a sign of many things. It can be a sign of overactive bladder, but can be a sign of other pathology, other disease states, other infections, and so forth. And so, taking that all into account and some of their medications they're on, and other medical comorbidities they have, you have to think about those things and how they may factor in. For example, if somebody comes in with urgency and frequency, is it really a problem with bladder capacity? Or maybe it's a problem with how much urine they’re actually making during the day, and that's sometimes tough for a patient to just know on their own or to figure out. And so it's something that we can readily figure out; it doesn't always require really severe or significant and diagnostic interventions to figure it out. Sometimes it does, but many times it doesn't. But a thorough history, physical exam, and then sometimes a voiding diary can clue you in to what's going on.
As far as their desires go of what they're looking for, that's probably the most important thing, because everybody's different. Everybody has different expectations of their interventions and what they want out of it. Somebody may be satisfied, going from 15 down to 10 times a day, and they're delighted. Somebody still going 15 times a day and knocked down to three or four times a day may be incredibly frustrated. And the same goes with incontinence. So gauging their expectations of what they want out of treatment is really important as you design what kind of therapy you're going to offer.
Dr. McDonough:
For those just tuning in, you're listening to Clinician’s Roundtable on ReachMD. I'm Dr. Brian McDonough, and I'm speaking with Drs. Gary Lemack and Paul Doghramji about patient-centered care in overactive bladder.
So now that we've discussed the importance of personalizing management plans, let's look more closely at the available treatment options. Dr. Lemack, can you tell us about the latest advancements in behavioral interventions and pharmacotherapy?
Dr. Lemack:
Let's talk a little bit about behavioral therapy first. I wouldn't say that there's anything groundbreaking in terms of what's new out there now, at least from my perspective, from a behavioral standpoint. So we always talk about fluid intake—not only what they're taking in, but how much they're taking in. A lot of patients come in and are told by a lot of different doctors that they may need to be drinking a lot of water every day and so forth. And for the most part, that may actually be quite valid. But if you see that a patient comes in with a liter bottle of water and they tell you you're taking six liters a day of fluid, then that's a warning sign. And we need to correct that behavior and tell them when it's good and when it's not good, and give them specific advice about how much fluid they should be taking in and the types of fluid. So in terms of behavioral things, other dietary things, spicy foods, citrusy fruits, acidic food, alcohol, tobacco, caffeine, carbonated beverages, artificial sweeteners, those are all the ones we say to try to avoid. And then be on a very time voided schedule, so they're going regularly, and they're not caught off guard by those sudden urges. So those are most important things.
In terms of pharmacotherapy, we can certainly talk about that. Anticholinergic or antimuscarinic medications have been around for decades and really have been the workhorse in taking care of these patients and offering them therapy, but are unfortunately associated with significant side effects—dry mouth, dry eyes, constipation, and more recently, the recognition that cognitive effects can be noted by many of the antimuscarinics. So that has brought about a new era of therapy in beta agonists. And there are beta agonists available—mirabegron and vibegron are both available and have similar efficacy to the anticholinergic medications, but definitely a much reduced side effect profile. So that's another nice thing that we have in our armamentarium currently.
Dr. McDonough:
And Dr. Doghramji, how can we determine when to use each of these treatment options based on patient needs and preferences?
Dr. Doghramji:
A lot of patients will approach the symptom of overactive bladder initially with their primary care providers. And generally speaking, the first thing that we do is, as already discussed, go through lifestyle changes. And so everybody will want to know about what kind of things that they can do in their lives to make things a little bit better. As already discussed, limiting certain fluids, also keeping a bladder diary, and a lot of other things that can be done with lifestyle changes.
But then there are the medications that have been discussed, and those are important for one to know, because these medications can be quite effective once prescribed with the right dosages for a patient with expectation. The patient should know that some of these medications may take several days to several weeks for them to take effect. But a lot of times, these medications can have certain side effects and a patient doesn't want them, so in that instance, a patient may want to go to a urologist like Dr. Lemack and see if there's some other treatments that can be discussed, including, by the way, injections, which can sometimes be of some benefit to some patients with overactive bladder. There's also nerve stimulation, which can also be somewhat helpful. So there are other things that can be done in a specialist’s office that are not done. But initially, it's a good idea to go through lifestyle changes and certain medications and give it a trial for patients to see if it'll help them.
Dr. McDonough:
To close out our program, Dr. Lemack, do you have any final take-home points for our audience?
Dr. Lemack:
Yeah. The bottom line is that in the past, this was something that a lot of people didn't like to talk about and didn't bring up, and they just hid it. And especially with incontinence, it was a taboo subject. And the good news over the last 20 years or so that I've been doing this is people are more willing to talk about it, and shouldn't be afraid to talk about it, and there are treatment options. People just assume it's a sign of aging, and it's not. And I think the one thing we can do is get that word out that there's lots of options out there. And don't just accept it because of the because of the way it is. It's not one size fits all. There might be multiple different things going on, and so get it checked out.
But rest assured, if it's overactive bladder and that's been diagnosed and it's nothing more serious than that, which most of the time it's not, then plenty of different options out there. As Dr. Doghramji mentioned, there's other options besides just medications and lots of things we have up our sleeve, so bring it up, talk about it, and then frame your expectations about what you're looking for, and kind of go from there.
Dr. McDonough:
With those key takeaways in mind, I want to thank my guests, Drs. Gary Lemack and Paul Doghramji, for joining me to discuss the importance of developing personalized management plans for patients with overactive bladder. Dr. Lemack, Dr. Doghramji, it was great having you both on the program.
Dr. Lemack:
Thank you.
Dr. Doghramji:
Thank you.
Announcer:
This episode of Clinician’s Roundtable was sponsored by Sumitomo Pharma. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
