ArcaMax

DEAR DR. ROACH: I am in relatively good health for an 82-year-old male. For the past six years, I have been having trouble with an overactive bladder. I need to urinate at least every two hours. Often there is a sudden urge, and I can barely make it to the bathroom. In the morning when I wake up, I generally have to urinate in small amounts two or three times during the first hour of waking up, even though I had to go at least three times during the night. It could probably due to the pills wearing out.

My family doctor started me on oxybutynin. This did not work, so a urologist started me on tamsulosin as he thought the issue might be due to an enlarged prostate. This did not work, so now I am on fesoterodine and mirabegron, which help more than the first two.

I have heard of Botox, but I guess these shots have to be repeated at least every year. Do you recommend any other meds or treatment? I know there are many internet supplements that say they help, but I am sure that many are just scams. -- R.V.

ANSWER: Symptoms of an overactive bladder include frequent urination, urgency and sometimes incontinence. (A urine infection needs to be ruled out first.) An OAB can sometimes be mistaken for prostate enlargement, so it's not unreasonable to try a medication for the prostate like tamsulosin. A urologist can do testing that can identify whether this is a prostate issue or a bladder issue.

The two medication treatment types that are mainly prescribed for an OAB are antimuscarinic agents (like oxybutynin and fesoteridine) and beta-3 agonists (like mirabegron). When used in combination, the results are usually better than either drug alone. Side effects are usually tolerable.

If this combination is working well, you might not need additional treatment. Botulinum toxin (Botox) is an option but is not well-tolerated by most men within six years of treatment. Pelvic floor exercises and sacral neuromodulation are additional treatments, but I would be sure that the urologist had done the necessary tests to confirm the diagnosis.

Unfortunately, the supplements that are marketed for the treatment of an OAB lack convincing evidence for effectiveness and safety, so I do not recommend any.

DEAR DR. ROACH: My son, age 52, had recent lab results showing that his Lipoprotein(a) level was elevated, at 172 nmol/L. He is in very good health after a recent ablation for atrial fibrillation. We would appreciate any information regarding this reading. -- W.H.

ANSWER: Lp(a) is a risk factor for heart disease that is independent of a person's total, HDL or LDL cholesterol. A level of 172 nmol/L (about 72 mg/dL) is a moderately high level that puts your son at an increased risk of blockages in his arteries. This is a different heart problem than AFib, which is a rhythm problem due to electrical conduction problems within the heart.

Lp(a) must be considered along with all of his other heart risk factors, including his "regular" cholesterol levels, blood pressure, family history, smoking status, presence of diabetes, and others. Not all people with levels in his range need treatment, but if his doctor were on the fence about medication, a moderately high Lp(a) level would often get a physician to recommend medication. Medication is only used when attempts to improve diet, exercise, stress levels, sleep and other factors have been inadequate to lower the person's risk into a desirable range.

Although statins do not reduce Lp(a) levels, they do reduce the risk of heart attacks and death in people who are at an increased risk for heart disease, due to a combination of factors that include high Lp(a). Other options include ezetimibe and PCSK-9 inhibitors. (An oral version of the latter has recently been proven to be effective at lowering cholesterol. I suspect it will be available in the next year or two.)

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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