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Overactive Bladder Syndrome Management and Treatment Options Janine Arnold Nicholas Mcleod Ruban Thani-Gasalam Prem Rashid

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Overactive Bladder Syndrome Management and Treatment Options Janine Arnold Nicholas Mcleod Ruban Thani-Gasalam Prem Rashid CLINICAL Overactive bladder syndrome Management and treatment options Janine Arnold Nicholas McLeod Ruban Thani-Gasalam Prem Rashid When compared with demographically matched Background controls, patients with OBS have:10,11 Overactive bladder syndrome is a symptom-based clinical diagnosis. It is • significantly less work productivity characterised by urinary urgency, frequency and nocturia, with or without urge • less sexual satisfaction and more erectile urinary incontinence. These symptoms can often be managed in the primary care dysfunction setting. • higher rates of depressive symptoms Objective • significantly poorer mental health This article provides a review on overactive bladder syndrome and provides advice • poorer quality of sleep. on management for the general practitioner. Postmenopausal women with urge incontinence Discussion have a significantly higher risk of falling and Overactive bladder syndrome can have a significant effect on quality of life, and sustaining a fracture than women without urge affects 12–17% of the population. Prevalence increases with age. The management incontinence.4 of overactive bladder syndrome involves exclusion of underlying pathology. First line treatment includes lifestyle interventions, pelvic floor exercises, bladder Causes training and antimuscarinic agents. Failure of conservative management The symptoms of OBS have many potential causes necessitates urology referral. Second line therapies are more invasive, and include and contributing factors. Normal storage of urine botulinum toxin, neuromodulation or surgical interventions such as augmentation is dependent on spinal reflex mechanisms that cystoplasty or urinary diversion. activate sympathetic and somatic pathways to the Keywords urethral outlet and tonic inhibitory systems in the overactive urinary bladder; urological diseases; urinary incontinence brain that suppress the parasympathetic excitatory outflow to the urinary bladder.4 The normal bladder fills like a compliant balloon, with pressure lower than urethral resistance. Overactive bladder syndrome (OBS) is a Initiation of urination decreases urethral resistance symptom complex consisting of urinary and phasic contraction of the detrusor muscle urgency, usually accompanied by frequency empties the bladder.4 and nocturia, with or without urgency Overactive bladder symptoms are usually urinary incontinence (Table 1). It is not associated with involuntary contractions of explained by metabolic (eg. diabetes) or local the detrusor muscle, which can result in urge pathological factors (eg. infection, stones, incontinence, depending on the response of the urothelial cancer).1–5 Urgency is the key sphincter.4 The most common cause of OBS is symptom of OBS.6 detrusor overactivity (DO);2,12 64% of all patients with OBS have DO on cystometry, and 69% of Clinical significance men and 44% of women with urgency have DO.1 In Australia, prevalence of urinary incontinence has Detrusor overactivity is thought to result not only been reported at 42% and the incidence of urge- from efferent (motor) hyper function/dysfunction but only incontinence at 16%.7 Worldwide prevalence also most likely by afferent (sensory) noise. Patients of OBS is 12.8% for women and 10.8% for men.8 with OBS seem to respond to antimuscarinic The prevalence of all incontinence increases with treatment irrespective of the presence of DO.13 age.7,8 Appropriate management can decrease both Risk factors for OBS include vaginal birth morbidity and costs.9 delivery,14 with 40% of parous women experiencing 878 Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 41, NO. 11, NOVEMBER 2012 Overactive bladder syndrome – management and treatment options CLINICAL urge urinary incontinence, older age, obesity and anticholinergic medications in a patient with different types of incontinence, so that the most chronic constipation.15 Childhood urinary symptoms increased PVR may worsen bladder function and effective method of treatment can be selected. in women have been found to be independently potentiate urinary retention.18 Urodynamic investigations should also be used to associated with adult lower urinary tract symptoms, A frequency/volume chart can exclude 24-hour demonstrate the presence of specific abnormalities specifically urgency, frequency and nocturia.16 polyuria due to diabetes insipidus, and nocturnal before undertaking complex reconstructive polyuria. It is an invaluable tool in OBS as it gives urological procedures.20 Diagnosis a better picture of the pattern of voiding than can Urine cytology, performed on three voided Overactive bladder syndrome is a diagnosis of be obtained from the symptoms alone.1 Three-day specimens obtained on three separate days, exclusion. A focused history, including past history voiding diaries are as reliable as seven-day diaries.2 has a variable sensitivity for the detection of of urogenital disorders, in combination with physical Information obtained should include number of urothelial carcinoma.21 Urine cytology is effective examination of the genitourinary system and relevant voids in daytime, night time, 24 hour period, volume for screening for high grade lesions (sensitivity at pelvic examinations should be performed as there of urine over 24 hours, maximum voided volume, least 90%, specificity 98–100%) and carcinoma in are multiple conditions that can cause or contribute average voided volume, median maximum voided situ. However, it is unreliable for detection of well to symptoms of overactive bladder.4,17 Initial and volume, and nocturnal urine volume. An assessment differentiated, low grade lesions.21 secondary investigations are listed in Table 2. of severity of incontinence in terms of leakage Cystoscopy is indicated in patients with Postvoid residual volume (PVR)2 is best episodes and pad usage2 can also be obtained. sterile haematuria and risk factors for bladder measured with ultrasound (bladder scan or formal Secondary investigations should be considered in cancer, and in patients with recurrent urinary tract ultrasound), with the upper limit of normal being patients with neurological disease, refractory OBS, infections. Carcinoma in situ and other intravesical 30 mL.2 An initially raised PVR requires confirmation or those in whom initial investigations raise the abnormalities can be assessed via cystoscopy. before being considered significant2 as it can be suspicion of an underlying problem that may require The possibility of prostate cancer should also be subject to error. further evaluation or treatment19 (Table 3). considered in men and assessed based on prostate- Increased PVR may contribute to urinary Urodynamic testing aims to demonstrate specific antigen, digital rectal examination findings frequency and nocturia, and commencing incontinence objectively and differentiate between and relevant risk factors.4 Table 1. Definitions of overactive bladder syndrome Table 3. Indications for urodynamic assessment17 Detrusor overactivity A urodynamic observation characterised by involuntary spontaneous or provoked detrusor Suspicion of occult diagnosis that may contractions during the filling phase2,12 alter management • Bladder outlet obstruction Nocturnal polyuria An excess (>20–30%) proportion of urine excretion at night2 • Detrusor hyperactivity with impaired contractility Polyuria >40 mL urine/kg body weight during 24 hours • Impaired bladder compliance • Dysfunctional voiding Postvoid residual volume The volume of fluid remaining in the bladder at the completion of micturition2 • Mixed incontinence Risk of upper urinary tract A sudden, compelling desire to void that is Urgency deterioration difficult to defer2,6 • History of pelvic irradiation Urinary frequency >8 micturitions/24 hours • Radical pelvic surgery (abdomino- perineal resection, radical Urgency urinary incontinence Involuntary loss of urine associated with urgency2 hysterectomy) • Spina bifida • Neurogenic voiding dysfunction (eg. Table 2. Investigations for overactive bladder syndrome multiple sclerosis, spinal cord injury) Initial investigations42 Other • Urinalysis to exclude infection, haematuria and glycosuria • Failed or unsatisfactory response to • Urinary tract ultrasound and measurement of postresidual volume empiric medical therapy • Frequency/volume chart for at least 3 days • Uncertain diagnosis • Bladder diary for a minimum of 3 days • Unaware incontinence • Prior lower urinary tract surgery (eg. Secondary investigations19 transurethral resection of prostate, • Urine cytology anti-incontinence surgery) • Urodynamic testing • Irreversible, potentially morbid • Cystoscopy intervention planned (ie. • Imaging of upper urinary tract or spine augmentation cystoplasty) Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 41, NO. 11, NOVEMBER 2012 879 CLINICAL Overactive bladder syndrome – management and treatment options Treatment Medical noninvasive through stimulation of muscarinic receptors in the Principles of treatment are to reduce urinary pharmacotherapy detrusor muscle by acetylcholine.12 Antimuscarinic incontinence by changing patient behaviour and In the primary care setting, patients presenting agents act during the filling/storage phase of the teaching continence skills.22 with typical overactive bladder symptoms can be micturition cycle by inhibiting afferent (sensory) input Up to one-third of women with urge only treated empirically with an antimuscarinic agent and from the bladder, and directly inhibiting smooth muscle incontinence can undergo spontaneous resolution obtain clinical
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