OAB can have a significant negative impact on qual­ity of life, Several studies have confirmed the negative impact of OAB, Learning Objectives: including an increased risk of falls and fractures, as well as especially with urge incontinence, on sexual activity. Women 1. To be able to define overactive bladder. interference with social and physical activities and sleep. with frequency and/or urge incontinence, are less sexually active. 2. To understand the relevant medical history regarding overactive Psychosocial and physical well-being is often lower in OAB Scores in sexual QOL are lower in women with OAB than in bladder, and which tests are beneficial in the routine evaluation of patients, as are interference with task completion, sleep, work- age-matched controls. More than half of patients with idiopathic the condition. related activities, and sex and intimacy. Brown et al reported that urge incontinence scored as “depressed” on validated in a cohort of 6,000 community-dwelling older women followed for questionnaire, with nearly 7% being diagnosed with major 3. To understand the definition and role for behavioral modification. 36 months, 55% of patients experienced at least one fall and 8.5% depression. Urge incontinence was more highly associated 4. To understand the impact of overactive bladder on quality of life, sustained a fracture. Multivariate analysis demonstrated that OAB with depression than was stress incontinence, likely due to the and what factor exacerbate the condition. was an independent risk factor for both falls and fractures. The unpredictable nature of urge leakage. rush to the toilet during urgency predisposed women to falls they Although women with OAB often avoid sexual activity, it is not would not otherwise have, and fractures were sustained that may usually due to pain, but rather due to urgency and incontinence. not otherwise have occurred. Other factors that adversely affect Dyspareunia is more typical of bladder pain syndrome and pelvic QOL in OAB sufferers include depression, anxiety, interference pain syndromes. with physical activity (with secondary weight gain), social isolation, Continuing Medical Education Project: sexual avoidance, and reduced workplace productivity. Overactive Bladder in Women Craig V. Comiter, MD REFERENCES for Question one: 4. Ouslander JG. Management of overactive bladder. N Engl J Med. 2004 Feb 19; Associate Professor of Urology 1. Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl AJ. Short forms 350(8):786-99. Director FPMRS Fellowship to assess life quality and symptom distress for urinary incontinence in women: the 5. Wein AJ. Diagnosis and treatment of the overactive bladder. Urology. 2003 Nov;62 Stanford University incontinence impact questionnaire and the urogenital distress inventory. Neurourol and (5 Suppl 2):20-7. Urodynam 1995;14:131-139. 6. Ouslander JG. Management of overactive bladder. N Engl J Med. 2004 Feb 19; 2. Jackson S, Donovan J, Brookes S, Eckford S, Swithinbank L, Abrams P. The Bristol 350(8):786-99. Female Lower UrinaryTract Symptoms questionnaire: development and psychometric 7. Rosenberg MT: Overactive bladder made ridiculously simple? Int J Clin Pract 2006, testing. Br J Urol, 1996; 77: 805–812. 60:631–633. 3. Dwyer PL, Rosamilia A. Evaluation and diagnosis of the overactive bladder. Clin REFERENCES for question four: Obstet Gynecol. 2002 Mar;45(1):193-204. Disclosure record for Craig Vance Comiter, M.D. QUESTION 1: In a woman who complains of bothersome 4. Wein AJ. Diagnosis and treatment of the overactive bladder. Urology. 2003 Nov; 1. Payne CK. Epidemiology, pathophysiology, and evaluation of urinary incontinence Last reviewed/edited this information on February 16, 2011. 62(5 Suppl 2):20-7. and overactive bladder. Urology. 1998;51(suppl 2A):3-10. Coloplast: Consultant; Curant: Consultant or Advisor frequency every hour in the day, and occasional urinary 5. Ouslander JG. Management of overactive bladder. N Engl J Med. 2004 Feb 19; 2. Rosenberg MT, Overactive bladder: recognition requires vigilance for symptoms. leakage, which of the following tests are helpful at the 350(8):786-99. Cleve clin j med 2007; 74suppl 3:S21-9. 6. Sampselle CM. Teaching women to use a voiding diary. Am J Nurs 2003; 103:62–64. 3. Culligan PJ, Heit M. Urinary incontinence in women: evaluation and management. initial visit? Am Fam Physician 2000; 62:2433–2444, 2447, 2452. A. Urinalysis REFERENCES for question two: 4. Wein AJ. Pathophysiology and categorization of voiding dysfunction. In: Wein AJ, 1. Payne CK. Conservative Management of Urinary Incontinence: Behavioral and Pelvic Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 9th ed. B. Lower urinary tract symptoms (LUTS) questionnaire Floor Therapy, Urethral and Pelvic Devices. In: Wein AJ, Kavoussi LR, Novick AC, Philadelphia, PA: Saunders Elsevier; 2007:1973–1985. C. Bladder diary Partin AW, Peters CA, eds. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Saunders 5. Baigis-Smith J, Smith DAJ, Rose M, et al. Managing urinary incontinence in Elsevier; 2007, pp. 2124-2146. community-residing elderly persons. Gerontologist 1989;229:33. D. Urodynamic studies 2. Burgio KL, Whitehead WE, Engel BT. Urinary incontinence in the elderly: bladder- 6. McDowell BJ, Burgio KL, Dombrowski M, et al. Interdisciplinary approach to the E. Post void residual urine measurement sphincter biofeedback and toileting skills training. Ann Intern Med 1985:104: 507-515. assessment and behavioral treatment of urinary incontinence in geriatric outpatients. 3. Burgio KL: Behavioral treatment of urinary incontinence, voiding dysfunction, and J Am Geriatr Soc 1992;40:370–4. QUESTION 2: In women with OAB, which of the following overactive bladder. Obstet Gynecol Clin N Am 36 (2009) 475–491 7. Johnson TM, Burgio KL, Goode PS, et al. Effects of behavioral and drug therapy on 4. Kegel AH. Stress incontinence of urine in women: physiologic treatment. J Int Coll nocturia in older incontinent women. J Am Geriatr Soc 2005;53:846–50. is an example of behavioral therapy? Surg 1956;25:487–99. A. Pessary to correct cystocele 5. Burgio KL, Whitehead WE, Engel BT. Urinary incontinence in the elderly: bladder REFERENCES for question five: sphincter biofeedback and toileting skills training. Ann Intern Med 1985;104:507–15. 1. Brown JS, Vittinghoff E, Wyman JF, et al. Urinary incontinence: does it increase risk B. Incontinence pads 6. Burgio KL, Robinson JC, Engel BT. The role of biofeedback in Kegel exercise training for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr C. Vaginal electromyography biofeedback training Soc. 2000;48:721-725. for stress urinary incontinence. Am J Obstet Gynecol 1986;157: 58–64. D. Discussion of normal bladder and sphincter function 7. Burgio KL, Goode PS, Locher JL, et al. Behavioral training with and without 2. Yu HJ, Chen FY, Huang PC, et al. Impact of nocturia on symptom-specific quality of biofeedback in the treatment of urge incontinence in older women: a randomized life among community-dwelling adults aged 40 years and older. Urology 2006;67:713–8. E. Use of oxybutynin on an “as needed” basis controlled trial. JAMA 2002;288:2293–9. 3. Zorn BHh, Montgomery H, Pieper K, et al: Urinary incontinence and depression. 8. Goode PS, Burgio KL, Locher JL, et al. Effect of behavioral training with or without J Urol 1999, 162:82-4. QUESTION 3: Which symptoms are considered typical pelvic floor electrical stimulation on stress incontinence in women: a randomized 4. Das AK, Carlson AM, Hull M, et al: Improvement in depression and health-related for patients with overactive bladder? controlled trial. JAMA 2003;290:345–52. quality of life after sacral nerve stimulation therapy for treatment of voiding dysfunction. 9. Andersson KE. Antimuscarinics for treatment of overactive bladder. Lancet Neurol Urology 2004, 64:62-8. A. Dysuria 2004; 3:46–53 5. Stach-Lempinen B, Hakala AL, Laippal P, et al: severe depression determines quality of life in urinary incontinent women. al Neurourol Urodyn 2003:22: 563-8. B. Straining REFERENCES for question three: 6. Melville J Delaney K, Newton K, et al: Incontinence severity and major depression C. Urge incontinence 1. Newman DK, Giovannini D. The overactive bladder: a nursing perspective. Am J in incontinent women. et al Obstet Gynecol 2005: 106:585-92. D. Bladder pain Nurs 2002; 102:36–45. 7. Moghaddas F, Lidfeldt J, Nerbrand C, et al. prevalence of urinary incontinence in 2. Abrams P. Describing bladder storage function: overactive bladder syndrome and relation to self-reported depression, intake of serotonergic antidepressants, and hormone E. Frequency detrusor overactivity. Urology. 2003 Nov;62(5 Suppl 2):28-37; therapy in middle-aged women: a report from the Women’s Health in the Lund Area 3. Dwyer PL, Rosamilia A. Evaluation and diagnosis of the overactive bladder. Clin study. Menopause 2005; 12: 318-24. QUESTION 4: Factors that may exacerbate OAB Obstet Gynecol. 2002 Mar;45(1):193-204. symptoms include: A. Diuretics B. Heart failure C. Venous insufficiency Physician Accreditation Statement Physician Credit Statement D. Constipation The University of North Texas Health Science Center at Fort Worth The University of North Texas Health Science Center has E. All of the above Office of Professional and Continuing Education is accredited by requested that the AOA Council on Continuing Medical Education the American Osteopathic Association to award continuing medical approve this program for 1 hour of AOA Category 2B CME credits. QUESTION 5: OAB can adversely affect quality of life education to physicians. Approval is currently pending. (QOL). Which of the following is not typically related to OAB? The University of North Texas Health Science Center at Fort Worth The University of North Texas Health Science Center at Fort Worth A. Sleep disturbance Office of Professional and Continuing Education is accredited designates this enduring material for a maximum of 1 AMA PRA B. Social activities interference by the American Council for Continuing Medical Education Category 1 Credit(s)™. C. Fall risk (ACCME) to provide continuing medical education for physicians. Physicians should claim only the credit commensurate with the D. Fracture risk extent of their participation in the activity. E. Pain with intercourse indicated in the setting of complex symptoms in the face of Urgency: a sudden compelling desire to void that is difficult Discussion of Question One failed empiric therapy, where a question remains regarding the Discussion of Question three to defer. pathophysiology of the voiding dysfunction. A. Urinalysis (correct) The history is the most important component in the initial Nocturia: The patient complains that she has to awaken during Urinalysis is absolutely indicated in the workup of overactive E. Post void residual urine measurement (incorrect) evaluation of the patient with OAB – typified by symptoms of the night at least once (but possibly more than once) to pass urine. bladder (OAB), as the practitioner must rule out easily treatable Measurement of post void residual urine is not absolutely frequency, urgency (with or without incontinence), frequency, and or serious causes of symptoms other than idiopathic OAB, defined indicated for the diagnosis and empiric treatment of OAB. If nocturia. Screening for OAB is simple, accurate, and requires as urgency, with or without incontinence, typically with frequency the history (neurogenic bladder dysfunction, radical pelvic minimal time from a provider. Some questions that may be useful and nocturia. Pyuria, in the presence of OAB symptoms may surgery, previous incontinence surgery) or physical examination have been proposed by Newman and Giovannini inquire about Discussion of Question four indicate bacterial cystitis. Short course treatment with oral (suprapubic mass) raise suspicion of incomplete bladder symptoms suggestive of OAB: All of the choices are correct. Diuretic use, congestive heart antibiotics would be indicated. Care should be taken not to treat emptying, then post void residual testing may be helpful. Sudden urges to go to the bathroom that are difficult to ignore? failure, venous insufficiency with subsequent lower extremity asymptomatic bacteriuria, as OAB may coexist with choric but edema, and constipation can all lead to bothersome lower urinary Frequency of urination more than eight times in a 24-hour period? asymptomatic bacteriuria. Hematuria may be a sign of either tract symptoms, including frequency, urgency, nocturia, and upper tract or lower tract pathology, and transitional cell carcinoma Uncontrollable urges to urinate that may result in wetting? urge incontinence. Discussion of Question two of the bladder can present with microhematuria and irritative lower Leakage of urine on the way to the bathroom? The primary care physician should undertake a systematic urinary tract symptoms. If hematuria were noted, and persisted Behavioral interventions are strongly recommended as part of Need to awaken two or more times during the night to urinate? work-up of the patient presenting with symptoms suggestive on repeat urinalysis, then a workup for an upper or lower tract the initial treatment plan for OAB. Avoidance of places that may not have a nearby restroom? of overactive bladder. The purpose of evaluation of the patient source of bleeding would be indicated. An intravenous urogram A. Pessary to correct cystocele (incorrect) Try to make sure you know where the bathroom is when in an suspected to have overactive bladder is to: 1) identify transient, or CT scan of the kidneys and ureters would be suggested to rule A pessary is a device used to provide support for prolapsed pelvic unfamiliar place? reversible causes; 2) exclude serious/ progressive disease; out renal mass, or renal pelvic or ureteral tumor, and to assess for organ, or is occasionally used to support the bladder neck for the 3) identify curable proximate causes; 4) classify the type of nephrolithiasis. A cystoscopic examination with urine cytology Use of absorbent pads to protect your clothes? treatment of stress urinary incontinence. Device placement is incontinence; and 5) identify a neurologic or other primary cause would be the test of choice for transitional cell carcinoma of the outside the realm of behavioral therapy. The International Continence Society has proposed specific when present. bladder. Glycosuria may signify diabetes mellitus, a disease nomenclature to help with defining certain signs and symptoms commonly associated with bothersome LUTS. B. Incontinence pads (incorrect) commonly encountered in the primary care setting: In most instances, the diagnosis of OAB is based upon symptom Incontinence pads are useful for collecting the urine in those with assessment and physical examination, with urinalysis as the only B. Lower urinary tract symptoms (LUTS) questionnaire (correct) stress incontinence, urge incontinence, or mixed incontinence, but A. Dysuria (incorrect) mandatory laboratory test. Initiation of noninvasive therapy may Screening for OAB typically requires very little time from the does not address the symptoms of overactive bladder. Dysuria is difficult to define and of uncertain meaning and it then be indicated, in the absence of other treatable conditions provider, as a self-administered screening questionnaire can be is recommended that this term should not be used in relation such as infection, bladder stones, transitional cell carcinoma, C. used in most clinical settings. It should be noted, however, that Vaginal electromyography biofeedback training (incorrect) to lower urinary tract dysfunction, unless a precise meaning bladder pain syndrome or diabetes. Certain medications may cause a screening tool does not diagnose OAB or urinary incontinence. Biofeedback is a teaching technique that helps patients learn is stated. Dysuria is precisely defined as “abnormal urination”. or exacerbate LUTS such as diuretics, narcotics, antidepressants, Instead, it can help to facilitate the discussion, and may identify by giving them precise, instantaneous feedback of their pelvic More often, however, it is used to describe the stinging/burning hypnotics, analgesics, sedatives, sleep aids and cold medicines. symptoms that may be easily treatable with behavioral or floor muscle activity. The original device designed by Kegel sensation characteristic of urinary infection. It is suggested that pharmacological treatments. The onset, duration, severity, consisted of a perineometer. Most current biofeedback systems other descriptive words should be used instead. During the patient interview, a neurologic history should be taken and bother associated with LUTS can be elucidated via a few are computerized, with a visual monitor display. They are used to explore the possibility of dementia, Parkinson disease, spinal Patients with OAB generally feel they cannot hold on to their key questions. to measure pelvic floor muscle activity by manometry or cord injury or stenosis, multiple sclerosis, or stroke. Functional and electromyography, using vaginal or anal probes or surface urine or else they will leak. Those with bladder pain syndrome cognitive assessment are particularly useful in older adults. The A more detailed lower urinary tract symptoms (LUTS) electrodes. Mean reductions of incontinence ranging from may be able to hold onto their urine, but void frequently to gastrointestinal history is vital, because constipation may contribute questionnaire for women may be useful for several reasons: 60-85% have been achieved. relieve or prevent the pain of holding. to LUTS, and treatment for OAB may exacerbate constipation. to distinguish urge incontinence from stress incontinence (and B. Straining (incorrect) M Diet, especially fluid intake, may be associated with urinary thereby help to direct proper treatment); to determine the effect D. Discussion of normal bladder and sphincter function (correct) Straining describes the use of muscular effort to initiate, maintain symptoms. Excessive alcohol or caffeine intake may relate to LUTS of the complaints on the woman’s quality of life, and to help Patient education is perhaps the most important aspect of or improve the urinary stream during voiding. Although such an in certain patients. quantify the symptoms and the bother from the symptoms. behavioral therapy is. Patients with overactive bladder symptoms “obstructive” symptom may be bothersome to the patient, it is not Validated questionnaires are particularly helpful in accurately may have little understanding of normal lower urinary tract A history of prior surgery, especially genitourinary surgery (such typically part of the OAB symptom complex. measuring response to therapy. Examples of such questionnaires function. Counseling regarding normal function, with explanation as hysterectomy or incontinence procedures) is important to elicit. are the Incontinence Impact Questionnaire-7 item version (IIQ-7), of normal bladder capacity and expected voided volume allows C. Urge incontinence (correct) Immobility following certain procedures, with ensuing lower the Urogenital Distress Inventory-6 item version (UDI-6), and the patient to model his or her own behavior. Urge incontinence is the accidental urinary leakage that is extremity edema can be a transient cause of OAB symptoms. Other causes of lower extremity edema or fluid retention should the Bristol Female LUTS Questionnaire. E. Use of oxybutynin on an “as needed” basis (incorrect) either immediately preceded by or occurs simultaneously with urgency. This is characteristic of “wet” OAB. If there is no frank be sought based on clinical suspicion, as recumbent or nocturnal C. Bladder diary (correct) The guiding principle of pharmacotherapy for treating OAB is incontinence, the patient may be considered to have “dry” OAB. fluid mobilization may contribute to polyuria and secondary Certainly requesting that the patient record her voiding pattern inhibition of the uninhibited bladder contraction. Antimuscarinics frequency, urgency, or incontinence. Likewise, when a diuretic (frequency and voided volume) poses no risk, and can provide are the preferred medications. Antimuscarinics likely act through D. Bladder pain (incorrect) is taken can strongly affect voiding behavior. invaluable information. Bladder diary recordings for four days the motor pathway -- central and/or peripheral blockade of Bladder pain refers to suprapubic or retropubic discomfort, and appear sufficient, and a full week of recording may not be facilitation and stimulating inhibition of the detrusor contraction; usually increases with bladder filling, and may persist after voiding. necessary. Objective data regarding voided volume, functional and/or a sensory pathway that modulates afferent innervations Urethral pain refers to discomfort where the individual indicates bladder capacity (which typically correlates well with the first (via central or peripheral pathways). Devices, biofeedback, and the urethra as the site. Discussion of Question five morning void – get reference), frequency of urination, and drug therapy, while non-surgical approaches to treat OAB and Painful bladder syndrome describes the complaint of suprapubic A. Sleep disturbance (correct) frequency of incontinence episodes can be obtained. High 24-hour incontinence, are actually outside of standard behavioral therapy. pain during bladder filling, typically in the presence of other voided volume may indicate excess fluid intake, which can B. Social activities interference (correct) symptoms (e.g. increased daytime and night-time frequency), contribute to frequency. Small volume voids with a low maximum in the absence of urinary infection or other obvious pathology. C. Fall risk (correct) voided volume usually indicates early sensation of urgency or even detrusor overactivity. Bladder pain syndrome is usually characterized by pain with D. Fracture risk (correct) bladder filling relieved by voiding. D. Urodynamic studies (incorrect) E. Pain with intercourse (correct) Urodynamics are not indicated at the initial visit. Rather E. Frequency (correct) OAB can adversely affect sleep, and increases the risk of falls and empiric behavioral therapy with or without pharmacotherapy Frequency: the subjective complaint by the patient that she fractures. Patients with OAB will often avoid social activities and is recommended following the initial evaluation. Detailed is bothered by voiding too frequently. sexual encounters due to fear of incontinence or the need to void. urodynamic studies (uroflowmetry, measurement of post void residual volume, and filling and voiding cystometry) would be CME/CECredit Request Form Complete online at www.RegisterWithUNT.com

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