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The Overactive Bladder. Raji Gill, D.O., M.Sc. Clinical Assistant Professor of Surgery Division of Urology Tulsa Regional Medical Center & Cancer Treatment Centers of America. 2002 ICS Terminology: Overactive Bladder. OAB defined based on symptoms

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the overactive bladder

The Overactive Bladder

Raji Gill, D.O., M.Sc.

Clinical Assistant Professor of Surgery

Division of Urology

Tulsa Regional Medical Center

&

Cancer Treatment Centers of America

2002 ics terminology overactive bladder
2002 ICS Terminology: Overactive Bladder

OAB defined based on symptoms

  • Urgency, with or without urge incontinence, usually with frequency and nocturia
  • In the absence of pathologic or metabolic conditions that might explain these symptoms

ICS = International Continence Society (www.icsoffice.org)

oab symptoms
OAB Symptoms
  • Frequency
  • 8 or more visits to the toilet per 24 hours
  • Urination at night
  • • 2 or more visits to toilet during sleeping hours
  • Urgency
  • Sudden, strong desire to urinate
  • Urge Incontinence
  • Sudden & involuntary loss of urine

OAB

types of urinary incontinence
Types of Urinary Incontinence
  • Urge
    • urine loss accompanied by urgency resulting from abnormal bladder contractions
  • Mixed symptoms
    • combination of stress and urge incontinence
  • Stress
    • urine loss resulting from sudden increased intra-abdominal pressure (eg, laugh, cough, sneeze)

Sudden increase

in intra-abdominal

pressure

Uninhibited

detrusor

contractions

Urethral pressure

differential diagnosis oab and stress incontinence
Differential Diagnosis:OAB and Stress Incontinence

Medical History and Physical Examination

Symptom Assessment

Overactive

Symptoms

Stress incontinence

bladder

Urgency (strong, sudden desire to

Yes

No

void)

Yes

No

Frequency with urgency

(>8 times/24 h)

No

Yes

Leaking during physical activity;

eg, coughing, sneezing, lifting

Amount of urinary leakage with

Large

Small

(if present)

each episode of incontinence

Often no

Yes

Ability to reach the toilet in time

following an urge to void

Waking to pass urine at night

Usually

Seldom

Abrams P, Wein AJ. The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.

estimated prevalence of oab in comparison with other selected chronic conditions 1990s data
Estimated Prevalence of OAB in Comparison With Other Selected Chronic Conditions: 1990s Data

Condition

Millions of Americans

Chronic Sinusitis

37

Arthritis

33

Heart Conditions*

21

OAB

17

Asthma

15

Osteoporosis

10

Diabetes

9

Alzheimer’s Disease

5

*

Excludes hypertension

Payne CK. Campbell’s Urology Updates. 1999;1:1-20.

Evans DA et al. Milbank Q. 1990;68:267-289.

Bureau of the Census, Population Estimate Data, 1995.

National Institutes of Health. Osteoporosis and Related Bone DiseasesNational Resource Center. Osteoporosis Overview.

National Center for Health Statistics. Vital Health Stat. 10(199):1998.

prevalence of oab in the us

40

Men

35

Women

30

25

Prevalence (%)

20

15

10

5

0

18–24

25–34

35–44

45–54

55–64

65–74

75+

Prevalence of OAB in the US
  • Overall, 16.6% had symptoms of OAB
  • Prevalence of OAB increased with age

Age (years)

Adapted from Stewart W et al. WHO/ICI 2001. Poster.

prevalence of oab wet versus dry
Prevalence of OAB: Wet versus Dry

12.2 million (6.1% of the population)

Wet

(37% of OAB)

OAB

Dry

(63% of OAB)

21.2 million (10.5% of the population)

Adapted from Stewart W et al. WHO/ICI 2001. Poster.

diagnosis of oab
Diagnosis of OAB
  • A presumptive diagnosis of OAB can be based on
    • patient history, symptom assessment
    • physical examination
    • urinalysis
  • Initiation of noninvasive treatment may not require an extensive further workup

Fantl JA et al. Urinary Incontinence in Adults: Acute and Chronic Management.

Clinical Practice Guideline No. 2, 1996 Update. Rockville, MD: Agency for Health

Care Policy and Research; March 1996. AHCPR publication 96-0682.

a hidden condition
A Hidden Condition*
  • Many patients self-manage by voiding frequently, reducing fluid intake, and wearing pads
  • Nearly two-thirds of patients are symptomatic for 2 years before seeking treatment
  • 30% of patients who seek treatment receive no assessment
  • Nearly 80% are not examined

* Survey conducted by Gallup Group (European Study).

barriers to treatment
Barriers to Treatment
  • Patient misconceptions and fears:

“Part of normal aging or everyday life”

“Not severe or frequent enough to treat”

“Too embarrassing to discuss”

“Treatment won't help”

screening and diagnosing oab
Screening andDiagnosing OAB
  • Assess history, symptoms, and test results
  • Establish a diagnosis

“Do you have bladder problems that are troublesome, or do you ever leak urine?”

YES

oab screening can help diagnose other causes of bladder symptoms
Local pathology

infection

bladder stones

bladder tumors

interstitial cystitis

outlet obstruction

Metabolic factors

diabetes

polydipsia

Medications

diuretics

antidepressants

antihypertensives

hypnotics & sedatives

narcotics & analgesics

Other factors

pregnancy

psychological issues

OAB Screening Can Help Diagnose Other Causes of Bladder Symptoms

Fantl JA et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; March 1996. AHCPR publication 96-0682.

differential diagnosis physical examination
Differential Diagnosis:Physical Examination
  • Perform general, abdominal (including bladder palpation), and neurologic exams
  • Perform pelvic and/or rectal exam in females and rectal exam in males
  • Observe for urine loss with vigorous cough

Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; January 1996. AHCPR publication 96-0686.

differential diagnosis laboratory tests
Differential Diagnosis: Laboratory Tests
  • Urinalysis
    • to rule out hematuria, pyuria, bacteriuria, glucosuria, proteinuria
  • Blood work if compromised renal function is suspected or if polyuria (in the absence of diuretics) is present

Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; January 1996. AHCPR publication 96-0686.

care pathway
Care Pathway

Working diagnosis?

Yes

OAB?

Yes

No

Treat if:

Frequency and urgency, with or without urge incontinence, and normal urinalysis

Consider referral to specialist

>8 weeks tx Failed

Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.

suggested reasons for referral
Symptoms do not respond to initial treatment within 2 to 3 months

Hematuria without infection on urinalysis

Recurrent symptomatic UTI

Symptoms suggestive of poor bladder emptying

Pelvic bladder, vaginal, or urethral pain

Evidence of complicated neurologic or metabolic disease

Failed previous incontinence surgery

Elevated PVR volume

Radical pelvic surgery

Symptomatic prolapse

Prostate problems

Surgery planned (2nd opinion)

Suggested Reasons for Referral

Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.

treatment options
Treatment Options
  • Behavioral therapy
  • Medication
  • Combined therapy: behavioral and pharmacologic therapy
  • Minimally invasive therapies
    • Botulinum A-toxin
    • Neuromodulation
  • Surgery
pharmacotherapy
Pharmacotherapy
  • Anticholinergic Agents
    • Oxybutynin (Ditropan)
    • Oxybutynin transdermal (Oxytrol)
    • Tolterodine (Detrol)
    • Solifenacin (Vesicare)
    • Trospium chloride (Sanctura)
    • Darifenacin (Enablex)
oxybutynin ditropan
Oxybutynin (Ditropan)
  • Immediate and long acting form
  • Immediate – TID dosing
  • Long acting XL – once a day, 5 or 10 mg.
  • Side effects – dry mouth, constipation, headache
  • Approved for pediatric use (age 6 or older)
oxybutynin transdermal oxytrol
Oxybutynin Transdermal (Oxytrol)
  • 3.9 mg patch, twice weekly
  • Similar in effects to po
  • Side effects – less dry mouth but erythema/pruitis
tolterodine detrol
Tolterodine (Detrol)
  • Immediate 2 mg. and long acting LA 4 mg dosing
  • Side effects profile similar to oxybutynin
solifenacin vesicare
Solifenacin (Vesicare)
  • 5 – 10 mg daily dose
  • Side effects – dry mouth, constipation
trospium chloride sanctura
Trospium Chloride (Sanctura)
  • Quaternary amine as opposed to tertiary amine
  • 20 mg BID dose
  • Theoretically harder to pass through blood/brain barrier with less side effects
  • Not metabolized by liver
  • 60% excreted in the urine unchanged
darifenacin enablex
Darifenacin (Enablex)
  • M3 selective anticholinergic
  • 7.5 mg or 15 mg once a day
  • Side effects – constipation and dry mouth