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Alexandra L Millman, Douglas C Cheung, Cian Hackett and Dean Elterman

Overactive bladder in men: a practical approach

Overactive bladder (OAB) is a significant older patients is important due to comorbid source of morbidity in males, with a mobility limitations, excess urine production, prevalence of 10–16%, and with only a small and psychological and pharmacological fraction of these being treated.1–3 OAB results factors. in considerable and progressive deleterious effects on the productivity and quality of life Physical examination. The physical exam (QoL) of patients, leading to a substantial should reflect the patient’s symptoms, economic burden of disease, related aiming to exclude other diagnoses. The to increased absenteeism, worry about European Association of (EAU) interruption and scheduling of meetings, recommends focused abdominal (palpable early retirement, and permanent disability.4,5 bladder), genital, rectal, and neurological Symptoms of OAB are often attributed to examination.6 In particular, a digital rectal bladder outflow obstruction (BOO) in males, exam is imperative to rule out the presence resulting in misdiagnosis and delays in of prostatic hypertrophy, malignancy, and treatment. Given its prevalence, QoL impact, poor rectal tone. Identification of high-risk and the availability of initial non-invasive and neurological causes of OAB (for example, well-tolerated management options, OAB , myelodysplasia, multiple is often best addressed in the primary care sclerosis) is key as these patients are at risk setting. of upper tract deterioration/renal failure.

INITIAL WORK-UP Investigations. Recommendations for History. The International Continence the investigation of patients differ across Society (ICS) defines OAB as a symptom guidelines, although urinalysis is universally complex primarily dominated by urinary recommended. Other investigations to urgency with or without urge incontinence, consider, based on clinical context and usually associated with urinary frequency availability, are urine microscopy, culture, and in the absence of other blood glucose, PSA, flow rate, and post- pathology. In contrast, bladder outlet void residual volume. In some patient obstruction (BOO) customarily presents presentations, these tests may identify with weak or intermittent stream, hesitation, conditions that may require specialist straining, and incomplete emptying. Patients referral: , recurrent infection, stone may present in practice with a spectrum of disease, bladder outlet obstruction, stricture, AL Millman, MD, MPH, resident; DC Cheung, voiding complaints and symptoms of both fistulous disease, or malignancy. MD, MBA, resident; D Elterman, MD, MSc, OAB and BOO may be found in any given FRSCS, assistant professor, Division of Urology, Department of , University of Toronto, patient (in part due to coexistent disease MANAGEMENT Ontario, Canada. C Hackett, MD, resident, and/or overlapping pathophysiology). If one Behavioural changes. Conservative lifestyle Department of Family Medicine, University of symptom complex is more bothersome to management strategies represent the Alberta, Alberta, Canada. the patient, that should be addressed first. cornerstone of initial treatment and include Address for correspondence A thorough history includes a detailed scheduled/double voiding, pelvic floor muscle Alexandra Millman, University of Toronto, Urology, 5th Floor, Room 503G, 149 College voiding history (for example, storage and training, fluid restriction, dietary changes (for Street, Toronto, M5T 1P5, Canada. voiding symptoms, incontinence, haematuria), example, limiting , alcohol, spicy Email: [email protected] sexual history, fluid intake, pad use, voiding foods, and other bladder irritants), and Submitted: 21 August 2017; Editor’s response: diary, risk factors, and contributing medical smoking cessation. These should be tailored 8 September 2017; final acceptance: conditions. A short, validated questionnaire, to a patient’s presentation and impact on their 15 October 2017. the OAB-V3, can be used to screen for quality of life. Although not specific to males, ©British Journal of General Practice 2018; 68: 298–299. OAB symptoms (Table 1), which may aid in several patient resources are available free- DOI: https://doi.org/10.3399/bjgp18X696593 bringing this complaint to the attention of of-charge online; for example, the British the clinician. Special consideration for frail Association of Urological Surgeons has a

298 British Journal of General Practice, June 2018 gravis, tachyarrhythmias, and pre-existing a Table 1. The 3-item OAB Awareness Tool (OAB-V3) (positive screen≥ 4) . If an initial trial of How bothered have you been Not at A little Quite A great A very anticholinergic medication is unsuccessful, a by … all bit Somewhat a bit deal great deal subsequent trial of a different anticholinergic 1. Frequent during 0 1 2 3 4 5 daytime hours? (or dose escalation) remains warranted as patients can respond differently to different 2. A sudden urge to urinate with 0 1 2 3 4 5 formulations. little or no warning? Alternatively, beta-3 agonists (for example, 3. Urine loss associated with a 0 1 2 3 4 5 ) are well tolerated and the strong desire to urinate? authors’ experience with using them as a aAdapted from Coyne et al.7 OAB = overactive bladder. first-line agent is excellent; however, the cost-effectiveness of these agents remains unproven, and availability may be limited. handout on bladder retraining (https://tinyurl. Unfortunately, studies show the majority of REFERENCES com/OABresource1), the EAU’s website patients do not remain on pharmacological 1. Cheung WW, Khan NH, Choi KK, et al. discusses self-management strategies Prevalence, evaluation and management of treatment long term because of adverse (https://tinyurl.com/OABresource2), and overactive bladder in primary care. BMC Fam effects, efficacy concerns, and spontaneous Pract 2009; 10: 8. Brigham and Women’s Hospital has improvement.10 Close follow-up regarding 2. Onukwugha E, Zuckerman IH, McNally D, et published an extensive list of bladder irritants symptoms, adherence/compliance, and al. The total economic burden of overactive and potential substitutes (https://tinyurl.com/ bladder in the : a disease- BladderIrritants). tolerance of medications is warranted; the specific approach. Am J Manag Care 2009; EAU and NICE recommend 4- to 6-week 15(4 Suppl): S90–S97. Herbal remedies. Herbal remedies are an follow-up after starting or adjusting new 3. Irwin DE, Milsom I, Kopp Z, et al. Prevalence, therapy. severity, and symptom bother of lower under-represented but important treatment urinary tract symptoms among men in the consideration as up to three-quarters of EPIC study: impact of overactive bladder. Eur OAB sufferers seek out complementary Further therapies. Failure of empirical Urol 2009; 56(1): 14–20. and alternative medicines. Gosha-jinki-gan, pharmacotherapy generally warrants 4. Malmsten UG, Molander U, Peeker R, et al. hachi-mi-jio-gan, and ganoderma lucidum specialist referral for further investigation. , overactive bladder, and other lower urinary tract symptoms: a have been suggested to offer some benefit to The specialist toolbox includes further longitudinal population-based survey in men patients; however, limited data exist on these diagnostic testing with and aged 45–103 years. Eur Urol 2010; 58(1): treatments and National Institute for Health urodynamics, and invasive treatment 149–156. and Care Excellence (NICE) guidelines do not options including intravesical injections, 5. Reeves P, Irwin D, Kelleher C, et al. The recommend their use.8,9 current and future burden and cost of neuromodulation, catheterisation, urinary overactive bladder in five European countries. diversion, and bladder augmentation. Eur Urol 2006; 50(5): 1050–1057. Pharmacological treatments. Many Intravesical onabotulinumtoxinA injections 6. Gratzke C, Bachmann A, Descazeaud A, practitioners initiate therapy with alpha- are performed via cystoscopy under local et al. EAU guidelines on the assessment adrenergic blockers (for example, tamsulosin, anaesthetic and may provide relief from of non-neurogenic male lower urinary silodosin) or 5-alpha-reductase inhibitors tract symptoms including benign prostatic OAB symptoms for 6–9 months. Sacral (for example, finasteride, dutasteride) due obstruction. Eur Urol 2015; 67(6): 1099–1109. neuromodulation involves implanting a to the high prevalence of concurrent BOO 7. Coyne KS, Zyczynski T, Margolis MK, et al. device that sends electrical signals via the Validation of an overactive bladder awareness worsening OAB symptomatology. In these sacral nerve roots to normalise bladder and tool for use in primary care settings. Adv cases, combination or sequential addition Ther 2005; 22(4): 381–394 of anticholinergic therapy can be successful bowel function. 8. Jones C, Hill J, Chapple C. Management and should be considered. of lower urinary tract symptoms in men: CONCLUSION summary of NICE guidance. BMJ 2010; 340: However, in males with predominant c2354. OAB symptoms, a trial of alpha-adrenergic Male OAB is an under-recognised/under- 9. Chughtai B, Kavaler E, Lee R, et al. Use of blockers and/or 5-alpha reductase treated entity with significant QoL impact on herbal supplements for overactive bladder. inhibitors may be foregone: monotherapy patients. With a careful history and focused Rev Urol 2013; 15(3): 93–96. with anticholinergics or beta-3 agonists has physical examination, concomitant BOO 10. Goldman HB, Anger JT, Esinduy CB, et al. been shown to be safe and efficacious. It is should be evaluated along with rare but Real-world patterns of care for the overactive bladder syndrome in the United States. recommended to avoid (immediate important alternative diagnoses. Patients Urology 2016; 87: 64–69. release), as it has the most side effects; the should be counselled regarding conservative authors often start with either and pharmacological management fumarate or hydrobromide. The strategies, with specialist referral reserved risk of acute urinary retention is minimal for complex or refractory cases. Provenance and should not preclude anticholinergic use in a primary care setting. These Freely submitted; externally peer reviewed. medications are contraindicated in closed- Competing interests angle glaucoma, gastrointestinal diseases Discuss this article The authors have declared no competing (ileus, bowel stenosis, severe inflammatory Contribute and read comments about this interests. bowel disease, toxic megacolon), myasthenia article: bjgp.org/letters

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