A practical primary care approach to overactive bladder Matt T. Rosenberg, MD,1 Erik S. Witt,1 Jack Barkin, MD,2 Martin Miner, MD3 1Mid Michigan Health Centers, Jackson, Michigan, USA 2Department of Surgery, University of Toronto, Humber River Regional Hospital, Toronto, Ontario, Canada 3Departments of Family Medicine and Urology, Miriam Hospital, Brown University, Providence, Rhode Island, USA ROSENBERG MT, WITT ES, BARKIN J, MINER M. able to identify confounding conditions that could either A practical primary care approach to overactive be the cause of the symptoms or, in fact, make them worse. bladder. Can J Urol 2014;21(Suppl 2):2-11. The algorithm presented in this paper describes a simplified, yet complete, approach to the patient presenting with lower The evaluation and treatment of overactive bladder (OAB) urinary tract symptoms (LUTS) consistent with OAB. In starts in the primary care office and can be accomplished the paper, we explain the disease itself, its prevalence and efficiently, effectively and, most importantly, safely. With impact, the evaluation as well as the different treatment appropriate knowledge of the disease and an understanding modalities that are available for the patient. Appropriate of what to look for the primary care physician (PCP) can follow up, therapy adherence techniques and referral readily make the empiric diagnosis and initiate treatment. recommendations are also discussed. The key for the PCP is to be able to distinguish the uncomplicated patient from the complicated one and know Key Words: overactive bladder, primary care when to refer, if necessary. It is also essential to be able to approach Introduction to identify the at-risk patient as well as present all of the therapeutic options. Most importantly, this education The evaluation and treatment of overactive bladder should show the PCP when it is appropriate to refer and (OAB) has often been considered the domain of the the “red flags” to watch out for. It is for all of these reasons specialist, the urologist or urogynecologist, but not the that we present a practical approach to the evaluation primary care physician (PCP). One explanation may be and treatment of OAB. historical as extensive testing was done in the initial work up. Another reason may be because the majority of PCPs Definition of disease have limited training in urologic disease, thus referral has been easier than delving into something outside of OAB is a syndrome or symptom complex defined their comfort level. Recently, the American Urological as: “Urgency, with or without urgency incontinence, Association (AUA) put out new guidelines describing usually with frequency and nocturia.2 Urgency is a a simplified approach advocating an evaluation that sudden, compelling need to void which is difficult to 1 does not require testing in the uncomplicated case. This defer. Frequency is defined as voiding more than 8 times truly does put the PCP in the position of the gatekeeper per day. Nocturia is voiding more than once per night. for OAB. Unfortunately, the PCP is spread very thin Incontinence is defined as the involuntary loss of urine. with a multitude of disease states to deal with as well It is referred to as urge incontinence (UI) when preceded as less and less time to spend with the patient. Add by urgency and stress urinary incontinence (SUI) when that to the limited urologic training and the result is an this loss occurs while coughing, sneezing, laughing, or under-diagnosed and under-treated disease. However, as a result of other physical activities.3 These symptoms OAB is not just a quality-of-life issue, there are also describe failure of the bladder to store urine, one of its serious ramifications such increased fall and fracture basic functions. Another way to define bladder storage risk, infections and skin breakdown from wet clothing. issues is to describe them as “irritative symptoms”. This is Education for the PCP is the key to assistance for the a useful distinctive for the PCP when trying to differentiate many that needlessly suffer from bladder issues. This those symptoms caused by bladder dysfunction, storage education should clarify the simple approach necessary or irritative issues, from those symptoms caused by the prostate, obstructive or voiding issues. Obstructive Address correspondence to Dr. Matt T. Rosenberg, Mid symptoms describe difficulty with the act of voiding Michigan Health Centers, 214 N West Avenue, Jackson, MI which include poor flow, hesitancy or intermittency. 49201 USA Obstructive symptoms are generally caused by the © The Canadian Journal of Urology™; 21(Supplement 2); June 2014 2 A practical primary care approach to overactive bladder enlarging prostate, which is commonly referred to as they will need invasive procedures or surgery. Some have benign prostatic hyperplasia (BPH).3 Combined, the the perception that there is a lack of available or effective symptoms arising from the bladder or the prostate are treatment.6 They alter their lifestyle and develop coping called LUTS or Lower Urinary Tract Symptoms. mechanisms such as using diapers or other absorbent products, wearing dark, baggy clothing, carrying extra sets Prevalence of clothing or only traveling where they know bathrooms are readily accessible.7 One study found that less than In a 2011 study in the United States Coyne et al half of the patients with probable OAB discussed the demonstrated that the prevalence of OAB symptoms is symptoms with a PCP and it was the patient who generally greater than 30%. They found that 1 in 3 adults greater initiated the conversation. Additionally, only a small or equal to 40 years of age reported symptoms of OAB percentage of eligible patients are prescribed medication.8 at least “sometimes”. Although women appeared to have a higher prevalence from ages 40-70, after the Primary care approach age of 70 the levels were essentially the same.4 To put this into perspective, patients suffer of OAB symptoms The key in the PCP approach to OAB is to be able more commonly than diabetes, asthma, coronary artery to provide a simple evaluation as well as having disease or chronic sinusitis just to name a few.5 effective and safe treatment options. This starts with acknowledging symptoms and then elucidating the Treatment gaps cause. Treatment can be empiric once other urologic and non urologic causes of the LUTS symptoms are ruled out Most patients wait long periods after symptom onset to or dealt with. The algorithm presented here, Figure 1, seek treatment and many do not approach the PCP at all. offers a logical and practical approach in evaluating the Unfortunately many are embarrassed or are fearful that patient with symptoms consistent with OAB. Figure 1. Practical approach in evaluating the patient with symptoms consistent with overactive bladder (OAB). 3 © The Canadian Journal of Urology™; 21(Supplement 2); June 2014 ROSENBERG ET AL. Understanding symptoms Therefore, knowing flow of urine offers key insights into the role of the prostate in the patient’s problem.10 It is essential to recognize that symptoms consistent Understanding normal bladder or prostate activity with OAB could be medically or urologically based. subsequently helps the PCP understand when urinary Therefore a good understanding of the function of function runs afoul. If the patient has any of the the genitourinary organs (bladder and prostate) is symptoms of urgency, urge incontinence, frequency, crucial. In order to understand abnormal function of nocturia, hesitancy and/or decreased flow it is essential the urinary tract it is helpful to understand normal. to try to elicit if the primary issue at hand is volume or As mentioned earlier the bladder has the function flow. If it is volume, focus should be on the bladder. urine storage. It must also void this urine when an Volume per void can be readily attained with a bladder adequate amount is attained. The bladder normally hat, or urine collection vehicle, that the patient can use holds 300 mL-500 mL of fluid. It should be able to store in the privacy of their home. This would be kept in the this amount at a comfortable and low pressure. When form of a voiding diary that will be discussed in further 300 mL-500 mL is reached emptying should occur with detail later. If the primary problem is flow, then focus an adequate and comfortable bladder contraction leaving should be on obstruction which is generally the prostate a minimal residual. Abnormal function of the bladder is in men, or maybe a prolapsed bladder in women.3 seen as voiding frequently of small amounts (frequency), Defining flow may seem difficult without a flow meter, having an uncontrollable urge (urgency), not having but, in fact, adequate flow is exhibited with the “arc” of enough time or warning to reach the bathroom such that the void, not mL/sec. Most patients will understand an there is some leakage (urgency urinary incontinence), “arc” as opposed to a “dribble”. If volume and flow are or incomplete emptying. Therefore, knowing the normal then the focus should be on why the patient has voided volume associated with the symptoms offers the enhanced fluid production which may be caused by key insights into the bladder function and assists in a medical condition or a medication. identifying its role in the patient’s symptoms. The bladder should also provide adequate outlet resistance. Basic work up: identifying LUTS Decreased resistance results in incontinence.3 The normal function of the prostate is the production The screening for OAB symptoms requires minimal of fluid for seminal emission. As the male ages the time from a PCP as a self-administered screener or prostate increases in size. By the sixth decade of questionnaire can be used in most clinical settings. These life 50% of men will have some degree of prostate tools are not meant to diagnose OAB or incontinence, hyperplasia and by the eighth decade this will increase rather to identify symptoms that may need treatment to 90%.9 If this enlargement compresses the prostatic and to help rule out other significant or serious causes urethra then there is the possibility of obstruction of LUTS.3,11 Understandably, they may not always be of urinary flow as well as retention.