OVERACTIVE BLADDER Date of Publication: June 20, 2017

Home , Overactive bladder, Stress incontinence, Urinary incontinence

Disease/Medical Condition

(also known as “OAB” and “overactive bladder syndrome”)

Is the initiation of non-invasive dental hygiene procedures* contra-indicated? No

■ Is medical consult advised? No, assuming patient/client is already under medical care1 for OAB, which is well controlled2.

Is the initiation of invasive dental hygiene procedures contra-indicated?** No

■ Is medical consult advised? ...... See above. ■ Is medical clearance required? ...... No ■ Is antibiotic prophylaxis required? ...... No ■ Is postponing treatment advised? ...... No, unless OAB symptoms (i.e., voiding urgency and frequency) are such that the patient/client is unable to be still long enough for the dental hygiene visit to proceed even with reasonable accommodation (e.g., need for repeated, frequent trips to toilet during the duration of the clinical encounter to the extent care may be compromised). In such case, the patient/client should be advised to seek medical attention to improve control to a level conducive to undergoing dental hygiene procedures.

Oral management implications

■ Medication history of drugs used to treat OAB should prompt the dental hygienist to ask appropriate follow-up questions to ensure the patient/client’s comfort during dental hygiene visits. As well, anticholinergic drug use, often coupled with fluid restriction, may cause xerostomia. ■ Some patients/clients with OAB wear diapers/pads in light of urge incontinence. The wearing of a diaper/pad during a dental hygiene visit may provide sufficient comfort/confidence to the patient/client (and by extension, the dental hygienist) that the patient/client can sit still for the duration of the visit (or perhaps only have to go to the restroom once or twice during the visit). ■ The dental hygienist should be empathetic and respectful to the patient/client with OAB. The patient/client should be encouraged to void the bladder just prior to sitting down in the dental chair. As well, the patient/client should be informed it is permissible – indeed, desirable – to excuse himself/herself during a visit should a need arise to use the restroom. During the visit, the dental hygienist should periodically check on the comfort level of the patient/client. ■ The dental hygienist should be aware that falls (with resultant fractures, particularly in older adults) might result from sudden rushing of patients/clients to the restroom. Therefore, preventive measures (pre-appointment voiding, intra- appointment voiding before the patient/client is in extremis, ensuring unobstructed passage to the clinic’s restroom, etc.) are desirable.

1 While primary care practitioners (e.g., family physicians) investigate and care for many patients/clients with OAB, sometimes referral to an urologist may be required. 2 Bladder retraining (including timed voiding, prompted voiding, and increasing bladder capacity and awareness), pelvic floor exercises (“Kegels”, sometimes taught by physiotherapists), biofeedback, vaginal wall weight training, reduction in caffeine and alcohol intake, restriction of fluid intake, reduction in spicy foods, and maintenance of a healthy weight are non-pharmacologic measures that can reduce the urge to frequently urinate. For severe OAB or severe urge incontinence that isn’t controlled by oral medications, exercises, and lifestyle measures, other treatment modalities are botulinum toxin injections (into the bladder wall), electrical sacral nerve stimulation, augmentation cystoplasty (i.e., surgery to make the bladder bigger), and urinary diversion (i.e., surgery to make another way to store and pass urine). Acupuncture may help some patients/ clients.

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Disease/Medical Condition

OVERACTIVE BLADDER

(also known as “OAB” and “overactive bladder syndrome”)

Oral management implications (cont’d)

■ A new medication used to treat OAB, mirabegron3, is not an anticholinergic and hence does not tend to reduce salivary flow in most patients. With appropriate medical consultation, this alternative OAB drug may be a consideration for some patients/ clients to reduce drug-related xerostomia and its sequelae.

Oral manifestations

■ While OAB itself does not directly cause oral manifestations, its management often does. ■ Hyposalivation and xerostomia are side effects of anticholinergic medications used to treat OAB, including most bladder relaxants as well as tricyclic antidepressants. Such bladder relaxants include solifenacin, tolterodine, darifenacin, fesoterodine, trospium, flavoxate, and oxybutynin. Tricyclics include imipramine and doxepin. ■ Xerostomia may also result from severe fluid restriction.

Related signs and symptoms

■ Overactive bladder syndrome is a chronic condition of the lower urinary tract characterized by strong, sudden urges to urinate, and usually with urinary frequency and nocturia4. These urges may occur even when there is only a very small amount of urine in the bladder. Sometimes this can lead to urine leakage before the affected person can get to the toilet — this is known as urge (or urgency) incontinence5. ■ Overactivity (i.e., sudden involuntary contractions) of the bladder’s detrusor muscle can be caused by a variety of conditions, including multiple sclerosis, Parkinson’s disease, stroke , dementia, diabetic neuropathy, spinal cord injury, cystitis (bladder infection), bladder stones, benign prostatic hypertrophy (BPH), previous radiation therapy of the pelvis (e.g., for prostate cancer), and bladder tumours. However, the most common form of OAB is idiopathic – that is, the cause is unknown. ■ Risk factors include advanced age, previous pelvic surgery, multiple pregnancies, and obesity. ■ Overactive bladder affects 14% to 18% of Canadians, with a higher prevalence in women, especially in younger people. OAB is common in older adults of both genders, with prevalence after age 60 years increasing to between 20% and 30%. ■ OAB may or may not result in urinary incontinence. About 60% of patients/clients have dry OAB (i.e., no leakage, which is more common in men) while 40% have wet OAB (more common in women). ■ Embarrassment is common when affected individuals leak urine. ■ Even without incontinence, OAB can be debilitating, given its interference with activities of daily living and quality of life. A continual need to drop everything and race to the restroom is very disruptive.

3 At the time of writing this fact sheet, mirabegron (a beta-3 adrenergic agonist) is increasingly being prescribed to treat OAB, given its favourable tolerability profile (including reduced frequency of dry mouth) compared with traditional anticholinergic medications. Side effects of this medication may include increased blood pressure; inflammation of the nose, pharynx, and sinuses; and urinary tract infections (UTIs). 4 Urinary frequency (voiding 8 or more times per 24-hour period) and nocturia (awakening more than once a night to void) are often associated with OAB. Patients/clients often compensate by toilet mapping. 5 In contrast to urge incontinence, stress urinary incontinence (SUI) is caused by weakness in the pelvic floor muscles that surround and support the urethra and bladder. In stress incontinence, leakage of urine is prompted by coughing, straining, jumping, or other activity that increases pressure in the abdomen. 50% of persons with urinary incontinence have SUI. In some persons, mixed incontinence occurs, which is a combination of urge and stress incontinence. cont’d on next page...

Disease/Medical Condition

OVERACTIVE BLADDER

(also known as “OAB” and “overactive bladder syndrome”)

Related signs and symptoms (cont’d)

■ Falls and fractures are a risk resulting from hurrying to the bathroom, particularly in older persons. ■ Significant social, psychological, occupational, domestic, sexual, physical, and financial problems can result from OAB. These include sleep disruption, depression, anxiety, and urinary tract infections. ■ Some persons with OAB suffer silently because they do not ask for professional help. ■ Constipation may occur secondary to anticholinergic medications use to treat OAB.

References and sources of more detailed information

■ Wallace KM, Drake MJ. Overactive bladder. F1000Research. 2015;4:F1000 Faculty Rev-1406. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754030/ ■ Canadian Agency for Drugs and Technologies in Health https://www.cadth.ca/sites/default/files/cdr/clinical/SR0362_BotoxOAB_CL_Report_e.pdf ■ Canadian Continence Foundation http://www.canadiancontinence.ca/pdfs/en-incontinence-a-canadian-perspective-2014.pdf ■ HealthLinkBC https://www.healthlinkbc.ca/health-topics/av2014 ■ MedicineNet.com http://www.medicinenet.com/overactive_bladder/article.htm ■ Mayo Clinic http://www.mayoclinic.org/diseases-conditions/overactive-bladder/home/ovc-20311819 ■ RDH Magazine http://www.rdhmag.com/articles/print/volume-36/issue-7/contents/beware-of-overactive-bladders.html

* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.

** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.

Date: April 9, 2017