7 Things I Tell Every Patient Over 55 Who Is Offered A Bladder Tablet

An overactive bladder tablet reduces the volume of the signal that the bladder sends to the brain. In pharmacological terms it works on the efferent limb of the reflex — the messenger, not the message.

That is a well-designed intervention for a bladder that is telling the brain it is full when it is not. The physiology it was built for is a detrusor over-contracting in a normally-holding bladder, and for that patient it does the job it was designed for.

The patients I see over sixty are usually not that patient. They have bladders that genuinely cannot hold what they used to hold, and nerves reporting that accurately. Quieting an accurate report is not the same intervention as removing the reason for it.

The standard workup at this age is an ultrasound, a urine culture and sometimes a pressure study. Every one of those tests is worth doing and I order them myself.

The ultrasound is looking at the bladder as a container: capacity, shape, residual volume. The culture is looking for infection. The pressure study is looking at how the detrusor coordinates. Between them they rule out most of the common alternative diagnoses.

What they do not do — what no test in the standard pathway does — is look at the surface of the wall itself. So a patient with real deposit on that wall collects three normal results and is told the bladder is fine. Which is not the sentence that was proven.

Nearly every patient I see over sixty has already restricted their evening fluids, and most of them have restricted their daytime fluids too. The theory is intuitive and the effect is the opposite of what they wanted.

Concentrated urine is more irritating to an aging bladder lining. A wall that was already reporting early reports earlier. Then the patient wakes with a dry mouth, drinks a glass, gets up anyway, and adds dehydration to the original problem.

The older kidney is worse at concentrating urine efficiently to begin with. Restriction on top of that is a bad combination.

Anticholinergic side effects on the older class of bladder tablets are known and they are on my radar in every one of my patients. Dry mouth is not a nuisance in an eighty-year-old — it is a fall risk if it wakes him and he gets up in the dark, it is a dental problem, and the mental fog is a functional issue that gets missed as "just aging".

There are newer classes with a very different side-effect profile. There is a dose conversation to be had. The choice is your prescriber's, and the data that helps that choice is yours to bring in.

I prescribe them and they work — for the patient whose problem is leaking on a cough, a sneeze or standing up. They strengthen the muscles that hold urine in and that is exactly the treatment for stress incontinence.

Most of my referrals over sixty do not have that problem. They have an urgency problem — a bladder announcing itself long before it is full. Strengthening the outlet does not change when the announcement arrives. So six weeks of exercises later, no change at night, and a patient who thinks he has failed.

Here is the item that separates the patient who gets better from the patient who ends up on a fourth prescription.

The bladder measures fullness by wall stretch. As it fills, the wall extends. At a certain stretch the signal for the trip to the toilet goes up. The whole system depends on the wall being able to stretch.

Urine is not sterile filtrate. It carries mineral salts, calcium oxalate, urate, phosphate. Over fifty or sixty years a fraction of that settles out of solution onto the lining of the bladder and bonds to it as a thin, pale, chalk-coloured film. Tissue carrying that film does not stretch. A bladder that cannot stretch signals full at roughly a third of its capacity.

That is a full-feeling bladder holding very little urine, which is exactly what my patients describe — the urgency is convincing, and then almost nothing comes out, and they wonder whether they are imagining it. They are not. They are describing a coated wall.

The one that makes me angry, and not at my patient.

Age is a risk factor. It correlates with prevalence and it correlates with almost every condition I treat. It is not, on its own, a mechanism. When a patient of sixty-seven mentions this and is told gently that it is common at his age, what he hears is that nothing can be done. He stops asking.

Something physical changed between fifty and sixty-seven. Age is the clock it happened on, not the thing that happened.

My specialty exists precisely because 'it's your age' is a way of not answering a question that has a physical answer.