Overactive Bladder

1. Overactive Bladder Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Hospital Adjunct Professor of Urology SUNY-Downstate Medical Center

2. Prevalence of OAB (USA) 17% of adults OAB (33.3 million) Hampel, Urologe A 2003;42:776; Stewart, World J Urol 2003;20:327; http://www.census.gov/cgi-bin/ipc/idbrank.pl

3. Prevalence of OAB (USA)Wet versus Dry 37% Wet (12 million) 63% Dry (21 million) OAB Hampel, Urologe A 2003;42:776; Stewart, World J Urol, 2003;20:327; http://www.census.gov/cgi-bin/ipc/idbrank.pl

4. Prevalence of OAB by Age Stewart, World J Urol, 2003;20:327

5. Prevalence of OAB Compared to Other Chronic Conditions http://www.cdc.gov/nchs/fastats/default.htm; http://www.diabetes.org/diabetes-basics/diabetes; Hu T, et al. Urology. 2004;63(3):461-465.

6. 40 34% 30 26% 20 Increased Risk (%) 10 0 Falls Fractures Falls and Fractures Brown et al. JAGS. 2000;48(7): 721-725.

7. Impact of Urinary Incontinence on Quality of Life • Physical • Limitations or cessation of physical activities • Psychological • Guilt/depression • Loss of self-respect and dignity • Fear of: • Being a burden • Lack of bladder control • Urine odor • Apathy/denial • Sexual • Avoidance of sexualcontact and intimacy Quality of Life • Occupational • Absence from work • Decreased productivity • Social • Reduction in social interaction • Alteration of travel plans • Increased risk of institutionalization of frail older persons • Domestic • Requirements for specialized underwear, bedding • Special precautions with clothing 7

8. Overactive Bladder: “urgency, with or without urge incontinence usually with frequency and nocturia…if there is no proven infection or other pathology” ICS, 2002

9. Urgency “...a sudden compelling desire urge to pass urine, which is difficult to defer.” ICS, 2002

10. OAB: A New Paradigm • Urgency is not an all-or-none phenomena; it can be graded • Urgency should be redefined: • “...a sudden compelling desire urge to pass urine, which is difficult to defer.” • There are at least two types of urgency

11. A New OAB Paradigm • OAB is a symptom complex, not a syndrome • OAB has a differential diagnosis • OAB can be classified by urodynamics

12. Types of Urgency • Type 1 - An intensification of the normal urge to void (69%) • Type 2 - A sudden urge that is a different sensation (31%) • Some patients report a constant feeling of the need to void – not really urgency • May have different etiologies • May respond differently to treatment Blaivas et al, Two Types of Urgency. Neurourol Urodyn. 2009;28(3):188

13. Urge Incontinence Incontinence associated with urgency

14. Normal Urge to Void • A subtle sensation, gradual in onset, felt in the suprapubic area as fullness or in the penis, vagina or urethra as a tingling • If patient waits too long > urgency

15. Urgency Perception Grade • Type 0 - no urge • Type 1 - mild urge (can delay for > 1H) • Type 2 - moderate urge (can delay for 10 – 60 minutes) • Type 3 - severe urge (can delay for < 10 minutes) • Type 4 - precipitous urge (must void immediately) Blaivas et al, Urgency Perception Score, J Urol, 2007

16. Urgency • Type 4 - “...a sudden compelling desire to pass urine, which is difficult to defer.” and / or • Type 3 - A short warning time between the first and a severe urge and / or • Type 2 - Waiting too long

17. All of these sensations need to be put into context by relating them to bladder volume • If a patient experiences all of the UPS sensations of the course of 2 hours & the bladder volume is only 90 ml, that is OAB • If she experiences all of the UPS sensations of the course of 2 hours and the bladder volume is 300 ml, the bladder is probably normal • The bladder diary is the best method for evaluating sensations related to volume

18. OAB Bladder Diary Instructions Why did you urinate? (0) Convenience (no urge or desire) (1) Mild urge (can delay urination for an hour) (2) Moderate urge (can delay > 10 but <60 min) (3) Severe urge (can delay for < 10 min) (4) Desperate urge (must go immediately) Incontinence grade. Grade 1 - some drops Grade 2 - moderate loss (wet underpants) Grade 3 - extensive loss (wet outer clothes)

19. OAB Diary

20. volume

21. OAB Diary

22. volume

23. OAB Diary

24. volume

25. Clinical Presentation of OAB • Lower urinary tract symptoms (LUTS) – the physician elicits OAB symptoms • “I have OAB” – the patient self diagnoses • The physician probes a reluctant patient who admits she has OAB symptoms

26. Differential Diagnosis(non-neurogenic) • Urinary tract infection • Urethral obstruction: • Pelvic organ prolapse • Post-op • Urethral diverticulum • Stricture • Primary bladder neck

27. Differential Diagnosis(non-neurogenic) • Mixed stress & urge incontinence • Foreign body • Bladder cancer • Bladder stones

28. Synergy Stroke Parkinson’s MS (supraspinal) Spina bifida Dyssynergy SCI MS (spinal) Spina bifida Other spinal conditions Differential Diagnosis(neurogenic)

29. Urodynamic Classification • During filling: • Type 1 - 4 based on control mechanisms • + / - low bladder compliance • During voiding: • normal Q / p • urethral obstruction • impaired detrusor contractility Flisser, J. Urol 169: 529-534, 2003

30. Urodynamic Classification • Type I: symptoms of overactive bladder, no IDC at urodynamics • Type II: IDC present; patient is aware and can abort the IDC • Type III: IDC patient aware, cannot abort but can temporarily maintain continence by contracting the sphincter • Type IV: IDC, no awareness or control Flisser, J. Urol 169: 529-534, 2003

31. OAB Classification • Type I: symptoms of overactive bladder, no IDC at urodynamics

32. 1st urge = 80 ml Capacity = 346 ml FSF = 66 ml severe urge = 105 ml FSF = 66 ml, Voluntary detrusor contraction HMR

33. OAB Classification • Type I: symptoms of overactive bladder, no IDC at urodynamics • Type II:IDC present; patient is aware and can abort the IDC

34. HO Preventsincontinence Involuntary detrusor contraction Aborts detrusor contraction Asked to hold:contracts sphincter

35. OAB Classification • Type I: symptoms of overactive bladder, no IDC at urodynamics • Type II: IDC present; patient is aware and can abort the IDC • Type III:IDC patient aware, cannot abort but can temporarily maintain continence by contracting the sphincter

36. incontinent Involuntary Contraction Can’t hold any longer Trying to hold BA

37. OAB Classification • Type I: symptoms of overactive bladder, no IDC at urodynamics • Type II: IDC present; patient is aware and can abort the IDC • Type III: IDC patient aware, cannot abort but can temporarily maintain continence by contracting the sphincter • Type IV:IDC, no awareness or control

38. Rbn Voi Incontinent IDC

39. Type 4 OAB Without Obstruction

40. Qmax = 18 ml/S RS IDC (pdet@Qmax = 12 cm H20)

41. Type 2 OAB Impaired Detrusor Contractility (DHIC)

42. Incontinent Involuntary detrusor contractions Sphincter relaxation AL

44. Type 3 OABObstruction due to urethral Diverticulum in a woman

45. J T Urethral obstruction Qmax = 1 ml/S IDC (detmax = 48 cm H20) BG

46. Type 2 OABGrade 4 prolapseNormal voiding mechanics

47. Involuntary detrusor contraction cough Involuntary detrusor contraction IC

48. bladder catheter thigh cystocele IC

49. cystocele IC

50. Cystocele IC