If you suffer from an overactive bladder (OAB), you’re no stranger to those alarming gotta-go-now moments that can strike day or night.

Lifestyle approaches are often effective and should always be your first line of defense. If these fail, there are medications—but they have lots of drawbacks, including dry mouth, constipation and dizziness. So what if lifestyle approaches don’t work for you and medications either don’t provide relief or you can’t stand the side effects?

Then it’s time for what doctors call “third-line” treatments. One is Botox, which was approved for this condition in 2013. Another is a kind of bladder “pacemaker” called sacral neuromodulation (SNM). It has been available since the 1990s, but the technology has improved and it’s gaining adherents among patients and doctors.

Is either approach right for you? And if so, which one? The good news for women struggling with this serious problem is that there is now a head-to-head clinical comparison of Botox and SNM. To learn more, we spoke with Cheryl Iglesia, MD, director of the female pelvic medicine and reconstructive surgery division at MedStar Washington Hospital Center in Washington, DC.


Before looking at the pros and cons of SNM and Botox, it’s important to understand OAB. Bladders are considered overactive when the muscles contract to squeeze out pee when you’re trying to hold it in. Sometimes nerves mix up the signals the bladder sends to the brain, so your bladder contracts when it should be relaxed and filling up with urine.

For people with OAB—slightly more women than men are affected—social gatherings, traveling and sitting through a meeting or movie can become an ordeal even when you know where to find the nearest bathroom. OAB goes hand-in-hand with incontinence—involuntary leakage—which just compounds the embarrassment. For women, menopause makes both conditions more likely.


The best first approach is to try lifestyle changes, including Kegel exercises to strengthen the pelvic floor and help stop leaks. Diet changes (such as cutting out caffeine) and mind-body approaches such as visualization may also help. While lifestyle changes work for many patients, those who can’t find relief from their symptoms with medication—or who can’t tolerate the side effects—have two other options, both of which are covered by insurance…

Botulinum toxin (often sold under the brand name Botox). Given as a series of injections directly to the bladder, Botox temporarily paralyzes your muscles so that they no longer contract involuntarily. For many patients, Botox works at reducing OAB symptoms. But success comes at a price. There’s an increased risk for urinary infections. And for about one in six patients the bladder becomes so relaxed that they have problems emptying it completely. They require catheters to drain their urine—at least for a few weeks. You’ll also need to get another shot every six to nine months, on average.

Sacral neuromodulation (SNM) works like a bladder pacemaker. Doctors implant a device at the base of your spine that sends a mild electric current to nerves that control the bladder. The current restores the normal signals between the brain and the bladder so you’ll only feel the need to go to the bathroom when your bladder is actually full. While SNM has been around for 20 years, the two-step treatment has become easier and less invasive than it used to be.

The first step is a “testing phase.” During an outpatient procedure, a temporary electrode is placed under the skin near the tailbone. The electrode is attached to a wire that leaves the body through the skin over your tailbone and hooks up to a stimulator the size of a battery pack that you carry around. During this two-week phase, you’ll be asked to keep a diary describing how often and how urgently you have to urinate. You’ll also have to stay hooked up most of the time, except for when you bathe.

If the trial is a success—you’re making much fewer runs to the bathroom—a surgeon will replace the temporary electrode and stimulator and implant permanent ones. This part of the process takes less than one hour and is generally performed under local anesthesia with sedation. Once the surgery is over, you or your doctor can adjust the device with a hand-held controller to maximize its effectiveness and comfort level. Then you’ll need to check in with your doctor every six to 12 months to make sure that the device is working well. Depending on the settings, the device will need to be replaced about every five years.

For many women and men, SNM can be a game-changer. One long-term study found that significant improvement in OAB symptoms was sustained over two-and-a-half years—of the 96 women followed, 85 chose to keep the devices implanted. The results are comparable to medications but without the side effects of the drugs.


When researchers compared the two treatments in a recent clinical trial, they found that both worked equally well in reducing symptoms and the Botox injections were slightly better at reducing daily leaking. But unlike Botox, if SNM isn’t treating your OAB, you can simply have the device removed without any lingering side effects.

That doesn’t mean SNM is risk-free. Medtronic, maker of the InterStim System used for SNM, did its own clinical study. Results: Out of the 219 men and women in the study, 52% experienced adverse effects ranging from temporary pain at the site of implantation (the most common) to occasional electric shocks (reprogramming the device usually fixes this problem).

What’s best for you? The choice is yours, of course, but it’s worth noting that in one study of 272 patients using SNM for one year, only seven chose to have the devices removed. If your battle with OAB has made you desperate and nothing else seems to help, SNM may be a way to get your life back.

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