Overactive bladder syndrome (OBS) is highly prevalent, and even more so with age. It is characterized by the presence of urinary urgency, and may be associated with incontinence, increased voiding frequency, and nocturia.

People suffering with OBS often have a combination of factors that contribute to their chronic bladder wall inflammation. Whatever the cause of the inflammation, chronic bladder wall inflammation is likely to stimulate nerve endings in the bladder wall to transmit signals to the brain. These nerves have stretch receptors attached to their terminal end. If the stretch receptors fire signals to the brain, the signal will be interpreted in the brain as stretch, even if irritation, not stretch, was the stimulus that caused the stretch receptor attached to that nerve to fire. When patients feel sensations as if they have a full bladder, they will have the urge to void urine.

Now, assuming the bladder is not in fact full of urine, what is making the bladder wall inflamed? In order to effectively resolve this condition, it is necessary to understand all of the contributing factors. Here are some of the most commonly observed triggers in a functional medicine practice.

1. Urinary Tract Infection

Often seen but frequently underappreciated, undiagnosed urinary tract infection (UTI) is a common driver of OBS. These patients often have an underlying bladder wall inflammation, which could be caused by a current or previous infection.

a) Active Urinary Tract Infection

In elderly people, chronic, low-grade urinary tract infections are extremely common and often missed, especially if the patients’ capacity to discern sensory signals is impaired or their capacity for communication is impaired.

With infection, it’s common that bacteria will form a biofilm that makes them adherent to the bladder wall. The first problem with a biofilm is that it makes the bacterial infection difficult to eradicate, as organisms deep in the biofilm become dormant, so they don’t consume the antibiotic. When the antibiotic course is over, with enough time and random reactivation, the surviving bacteria gradually regrow the size if the original, active bacterial colony. That revitalized colony will still be susceptible to the same antibiotic or natural agents, since the surviving organisms will not have encountered the previous round of antibiotic and won’t have formed resistance. That means that when a patient tells me that the same antibiotic always helps them get over their UTI, we should suspect a biofilm.

From the perspective of OBS, the concern is that infections cause inflammation. At the same time, the organisms at the base layer of the biofilm, do not become dormant. Instead, they come in contact with the wall of the bladder, irritating the bladder wall causing inflammation.

It is worth noting that biofilm-based infections are typically characterized by strong adherence to the bladder wall and a highly organized biofilm matrix in which the pathogenic organisms are embedded. This mean that patients may have lower abdominal pain immediately above the pubic bone, commonly referred to as suprapubic pain. Also, they frequently experience a burning sensation upon urination, but a negative urine culture, since the organisms involved in the infection are not coming down into the urine. It may be useful to take a biofilm disruptor before doing a urinalysis (UA), but often the UA remains negative. Treating the UTI, despite the negative UA, is often useful.

It is also important to understand that some organisms are “viable but not culturable.” Biofilm researchers refer to these as VBNC’s. William Costerton, the father of biofilm research, used to describe scraping infectious exudate out of diabetic foot wounds and trying to culture it, often unsuccessfully. Successful culture depends on finding the correct culture medium for growing a particular organism. Standard culture media often won’t grow what’s growing in the patient.

The inflammatory exudate that is released during this inflammatory process will be consumed by the organisms in order to survive. So, the infectious agents are instigating inflammation of the bladder wall directly, which will benefit their survival, hence a vicious cycle is formed.

If there is an active infection, the first step is to address the infection, but equally important is to address the biofilm component of the infection. Thyme, Pectasol-C (modified citrus pectin with stevia), N-Acetyl-L-Cysteine, ginger, oregano, quercetin, Berberine, artemisia, garlic, and a host of other agents have biofilm disrupting properties.

The general assumption is that it would not be beneficial to repeat the use of the same agent that didn’t fully eradicate a UTI on previous attempts. However, the opposite is often the case when biofilms are present. The fact that an agent or combination of agents knocked down the bacterial colony count suggests that it was at least partly effective. The task is to determine if using that same approach, combined with biofilm disruptors, would be more effective if tried again. Using a biofilm disruptor that degrades the structural integrity of the biofilm will increase the penetrance of the medication or natural product used to kill the infectious agent (pathogen).

b) Biofilm with Residual Organisms

Some patients present with a low level of chronic inflammation that is driven by a biofilm-based infection in which a small enough number of pathogenic organisms persist embedded in the biofilm.

This might not be considered an infection if the pathogen counts are not high enough. For example, a patient who was treated with an antibiotic several months ago for a UTI, may now have a very low pathogen count, which is rising slowly. This kind of gradual reemergence may be seen in other infections such as sinus infections and diverticulitis. In all of these instances, the key point is that the same antibiotic will work to knock back the infection each time, as presented above. Therefore, the treatment should be a combination of substances to address the pathogenic organisms coupled with biofilm disruptors.

If the white blood cell count is low, as is common with chronically ill patients, it can be essential to raise it. Coriolus Extract may be helpful in this situation.

c) Restoring Healthy Urinary Tract Microflora

Over 30 years of clinical research supports the effectiveness of the 2 patented probiotic bacterial strains, Lacticaseibacillus rhamnosus GR-1® and Limosilactobacillus reuteri RC-14®, that maintain and balances vaginal microbiome and urinary tract health. A special manufacturing process protects these probiotic strains from stomach acid, enhances probiotic bacterial survival to the lower intestine and into the vaginal tract, facilitating the restoration and maintenance of microflora in the vaginal and urinary tract.

In one randomized clinical trial, 82% of women studied had healthy vaginal flora after 28 days of use at 1.6 billion CFU per day of a probiotic (formulated with L. rhamnosus, GR-1® and L. reuteri, RC-14®) compared to 50% before supplementation. Whereas in the control group (taking 10 billion CFU of common strain, L. rhamnosus GG) there was no improvement in the percentage of women with healthy vaginal flora.

These two strains, GR-1 and RC-14 are the most clinically published strains for vaginal health worldwide, and, as registered trademarks of Chr. Hansen A/S, are only available for purchase as Fem-Dophilus.

We also recommend taking UT Intensive, which is a powerful blend of whole fruit cranberry extract and D-mannose designed to promote a healthy urinary tract.

Cranberry is one of the most widely studied, time-tested, natural remedies for supporting urinary tract health. Unlike many commercially available cranberry products, which are made from juice or contain individual isolated, health-promoting phytochemicals, the cranberry extract in UT Intensive™ is made from the whole fruit—juice, skins, flesh, and seeds—and therefore contains the full complement of phytochemicals, organic acids, fatty acids and phenolics.

Mannose is a type of sugar found in various fruits and vegetables. Its naturally occurring isomer, D-mannose, is similar in structure to certain urinary tract receptors, and thus, functions in a way which helps maintain a healthy environment in the urinary tract. Although mannose is a sugar, it is eliminated from the body instead of impacting calorie intake or metabolism and does not interfere with blood sugar regulation.

2. Histamine Dysregulation

Some patients may have problems with histamine elevation, which drives bladder wall mast cell degranulation. Inhibition of histamine release by the mast cells and improved histamine clearance can be accomplished with Mast Cell Assist and HistaGest-DAO. Many patients who carry chronic infections have an inadequate Th1 response and consequently a Th2 dominance. (See Th1/Th2 description below.) For these patients, it becomes important to use Perilla Extract to inhibit interleukin-4 (IL-4), an inflammatory cytokine that plays an important role in the development of certain immune disorders, particularly allergies and some autoimmune diseases. Astragalus Extract has also been shown to be useful to downregulate histamine release and chronic pain.


3. Oxalate Excess

Oxalates are naturally occurring molecules that are found in plants and humans.  Because oxalates help to get plants to dispose of extra calcium, many plant foods are high in oxalates. Oxalates foods travel through your digestive tract, bind with calcium, magnesium, potassium, and other extra build-ups of minerals in your intestines then leave your body through stool or urine.  

For some people, this can cause problems because oxalates perpetuate inflammatory conditions, interfere with normal connective tissue maintenance and repair, and tend to increase scarring and inhibit recovery from injury. Oxalate excess can cause urinary tract issues, including urinary urgency, high urinary frequency, bladder or urethral pain, incontinence, kidney pain, kidney stones, pelvic floor pain, and prostatitis. When the oxalate load is high enough to overwhelm the kidneys, the urinary tract may become irritated by the high levels of sharp, corrosive oxalate crystals that pass through. This may cause frequent urination, incontinence and pain. It also may lead to pain and sensitivity in the internal and external genitalia.


4. Neuropathic Pain

Some patients present with a pattern of pain sensitization. If a painful neuropathy is part of the picture, percutaneous electrical stimulation treatments, known as Urgent PC, offer bladder confidence and control without drugs or surgery. It is a low risk, in-office procedure that works for both men and women suffering from overactive bladder, urinary urgency, urinary frequency, and urge incontinence. Urgent PC may be combined with acupuncture for an ever greater and long-lasting effect.


5. Imbalanced T-lymphocyte Polarization

When encountering a pathogen, our immune system activates the Th1-type cells and Natural Killer (NK) cells that activate proinflammatory responses responsible for killing the intracellular pathogens.  However, excessive proinflammatory responses can lead to uncontrolled tissue damage, so there needs to be a mechanism to counteract this.  The Th2-type lymphocytes have more of an anti-inflammatory response, but they are associated with the promotion of IgE antibodies and eosinophilic responses characteristic of allergy and atopy.  In excess, Th2 responses will counteract the Th1 mediated microbicidal action. The optimal scenario would therefore seem to be that humans should produce a well-balanced Th1 and Th2 response, suited to the immune challenge.

Unfortunately, some patients have a chronic susceptibility to infections. They would benefit from promoting their Th1 and NK cell function with Th1 Support and Innate Immune Support respectively.

Th2 dominance is a barrier to adequate Th1/NK cell activation. If the patient is Th2 dominant, downregulating Th2 will be suitable as well. In some patients, inflammation of the bladder wall epithelia will drive the production of Th2-promoting inflammatory molecules (cytokines), making it difficult to mount an adequate Th1/NK cell response with which to eradicate pathogens. In this situation, adding Th2 Modulator would help restore proper Th1/Th2 lymphocyte polarization.

If you have been suffering with persistent overactive bladder syndrome despite initial therapy, or you have been told that you have a refractory case, a comprehensive evaluation of the above factors it recommended to avoid major problems.