You’ve likely seen those ubiquitous TV commercials for drugs that treat overactive bladder. Perhaps you’re even one of more than an estimated 25 million American adults who have the condition.

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Dr. John J. "Jack" Smith, III

“We’ve all had that experience of putting the key in the door and making a run for the bathroom – knowing we should’ve gone half an hour ago,” said Dr. John J. “Jack” Smith, III, a urologist with Novant Health Pelvic Health Center in Winston-Salem. “But patients with overactive bladder don’t really have any warning that’s coming on. The urge happens that fast.”

Smith said the ads and catchy jingles (“Gotta go, gotta go, gotta go …”) may help destigmatize this very common problem – one that impacts twice as many women as men. But pharmaceutical therapies aren’t the only tool in his arsenal.

Physicians have been using Botox “off label” – and with excellent results – for many years to treat urinary incontinence. (The phrase means the FDA has determined that the benefits of using a drug for a use beyond its intended use outweighs the potential risks.) Smith has been using it for more than two decades. The FDA approved it for use with overactive bladder, a condition that refers to both urgency and frequency, in 2013.

The drug works by reducing the muscle contractions that cause leaks and urgency.

It’s highly effective – it works for well over 80% of those who try it, Smith said – but it isn’t the first treatment a doctor will try. It’s a tertiary treatment, which Smith explained is the third treatment insurance companies will allow physicians to try if the first two fail to get results. The proper order:

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  1. Behavioral changes. Eliminate colas and other sugary drinks; use timed-voiding and fluid management. “Timed voiding is using the clock during the day to void on a two- to three-hour interval rather than waiting for the urge signal, which may be too late for some to get to the bathroom,” Smith said. “Fluid management refers to drinking in blocks of time and avoiding sipping.”
  2. Prescription medications. But, some of these drugs can have serious side effects, such as confusion and dementia in older patients. Other potential side effects are constipation, dry mouth and blurred vision.
  3. Botox injections. There are other tertiary treatments available, such as PTNS (or posterior tibial nerve stimulation), however this can require 12 weeks of therapy! Also, sacral nerve stimulation involves a two-part process in an outpatient center. So, Botox is generally the preferred treatment of those.

Botox tends to work “rather dramatically,” Smith said. He ought to know. He does over 200 of these procedures a year and was even involved in clinical trials in the United States which led to Botox being approved by the FDA.

He describes the procedure as simple. He first ensures the patient doesn’t have a urinary tract infection. Then, he inserts a small catheter in the bladder and fills the bladder with 2 or 3 ounces of lidocaine, a local anesthetic. He allows 15 to 20 minutes for the lidocaine to numb the area and then uses “a very small telescope with an injection needle to inject Botox into the lower half of the bladder,” he said. The injection portion takes less than four minutes.

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“The patient doesn't have to have anyone accompany them,” he said. “There's no other anesthesia. They can get up off the table and drive themselves home.”

Patients generally see results within seven to 10 days. The treatment is also effective for men who have symptoms around frequency and urgency not related to prostate conditions.

“I’ve had patients describe the results as ‘life-altering,’” Smith said. “Some patients had stopped going to church and social events – including weddings. Their social circles had completely shrunk.” Botox gives them their lives back.

Repeat injections are necessary, but only twice a year. “I tell people it’s like going to the dentist to get your teeth cleaned,” Smith said. “You may not really want to go, but you do it and feel the benefits afterwards. And you don’t have to think about it again for another six months.”

The number of Smith’s patients who return for a second Botox treatment six months later is well over 75%, he reported.

If behavioral changes or pharmaceuticals work for your overactive bladder, great. If they don’t, the third treatment may just be the charm.