Overactive bladder

Last updated
Overactive bladder
Other namesOveractive bladder syndrome
Illu bladder.jpg
Specialty Urology
Symptoms Frequent feeling of needing to urinate, incontinence
Complications UTIs, anxiety
Usual onsetMore common with age [1]
DurationChronic
TypesAge-related, or Secondary to other illness
CausesOld age; detrusor muscle injury; over-consumption of water and caffeine; UTI; pelvic injury
Risk factors Old age, obesity, caffeine, constipation
Diagnostic method Based on symptoms after ruling out other possible causes [2] [1]
Differential diagnosis Other neurological conditions [2] [1]
Treatment Pelvic floor exercises, bladder training, drinking moderate fluids, weight loss, [3] medications, Botox, surgery
Medication Anticholinergic drugs, β3 agonists
Prognosis Often but not always incurable
Frequency~40% of elderly adults, increasing with age

Overactive bladder (OAB) is a common condition where there is a frequent feeling of needing to urinate to a degree that it negatively affects a person's life. [2] The frequent need to urinate may occur during the day, at night, or both. [4] Loss of bladder control (urge incontinence) may occur with this condition. [1] This condition is also sometimes characterized by a sudden and involuntary contraction of the bladder muscles, in response to excitement or anticipation. This in turn leads to a frequent and urgent need to urinate.

Contents

Overactive bladder affects approximately 11% of the population and more than 40% of people with overactive bladder have incontinence. [5] [6] Conversely, about 40% to 70% of urinary incontinence is due to overactive bladder. [7] Overactive bladder is not life-threatening, [1] but most people with the condition have problems for years. [1]

The cause of overactive bladder is unknown. [1] Risk factors include obesity, caffeine, and constipation. [5] Poorly controlled diabetes, poor functional mobility, and chronic pelvic pain may worsen the symptoms. [1] People often have the symptoms for a long time before seeking treatment and the condition is sometimes identified by caregivers. [1] Diagnosis is based on a person's signs and symptoms and requires other problems such as urinary tract infections or neurological conditions to be excluded. [2] [1] Uroflowmetry is also a good diagnostic aid. [8]

The amount of urine passed during each urination is relatively small. [1] Pain while urinating suggests that there is a problem other than overactive bladder. [1]

Specific treatment is not always required. [1] If treatment is desired pelvic floor exercises, bladder training, and other behavioral methods are initially recommended. [3] Weight loss in those who are overweight, decreasing caffeine consumption, and drinking moderate fluids, can also have benefits. [3] Medications, typically of the anti-muscarinic type, are only recommended if other measures are not effective. [3] They are no more effective than behavioral methods; however, they are associated with side effects, particularly in older people. [3] [9] Some non-invasive electrical stimulation methods appear effective while they are in use. [10] Injections of botulinum toxin into the bladder is another option. [3] Urinary catheters or surgery are generally not recommended. [3] A diary to track problems can help determine whether treatments are working. [3]

Overactive bladder is estimated to occur in 7–27% of men and 9–43% of women. [1] It becomes more common with age. [1] Some studies suggest that the condition is more common in women, especially when associated with loss of bladder control. [1] Economic costs of overactive bladder were estimated in the United States at US$12.6 billion and 4.2 billion Euro in 2000. [11]

Signs and symptoms

Overactive bladder is characterized by a group of four symptoms: urgency, urinary frequency, nocturia, and urge incontinence. Urge incontinence is not present in the "dry" classification. [12]

Urgency is considered the hallmark symptom of OAB, but there are no clear criteria for what constitutes urgency and studies often use other criteria. [1] Urgency is currently defined by the International Continence Society (ICS), as of 2002, as "Sudden, compelling desire to pass urine that is difficult to defer." The previous definition was "Strong desire to void accompanied by fear of leakage or pain." [13] The definition does not address the immediacy of the urge to void and has been criticized as subjective. [13]

Urinary frequency is considered abnormal if the person urinates more than eight times in a day. This frequency is usually monitored by having the person keep a voiding diary where they record urination episodes. [1] The number of episodes varies depending on sleep, fluid intake, medications, and up to seven is considered normal if consistent with the other factors.[ citation needed ]

Nocturia is a symptom where the person complains of interrupted sleep because of an urge to void and, like the urinary frequency component, is affected by similar lifestyle and medical factors. Individual waking events are not considered abnormal, one study in Finland established two or more voids per night as affecting quality of life. [14]

Urge incontinence is a form of urinary incontinence characterized by the involuntary loss of urine occurring for no apparent reason while feeling urinary urgency as discussed above. Like frequency, the person can track incontinence in a diary to assist with diagnosis and management of symptoms. Urge incontinence can also be measured with pad tests, and these are often used for research purposes. Some people with urge incontinence also have stress incontinence and this can complicate clinical studies. [1]

It is important that the clinician and the person with overactive bladder both reach a consensus on the term, 'urgency.' Some common phrases used to describe OAB include, 'When I've got to go, I've got to go,' or 'When I have to go, I have to rush, because I think I will wet myself.' Hence the term, 'fear of leakage,' is an important concept to people. [15]

Causes

The cause of OAB is usually unclear, and indeed there may be multiple causes. [16] It is often associated with overactivity of the detrusor urinae muscle, a pattern of bladder muscle contraction observed during urodynamics. [17] It is also possible that the increased contractile nature originates from within the urothelium and lamina propria, and abnormal contractions in this tissue could stimulate dysfunction in the detrusor or whole bladder. [18]

If bladder spasms occur or there is no urine in the drainage bag when a catheter is in place, the catheter may be blocked by blood, thick sediment, or a kink in the catheter or drainage tubing. Sometimes spasms are caused by the catheter irritating the bladder, prostate or penis. Such spasms can be controlled with medication such as butylscopolamine, although most people eventually adjust to the irritation and the spasms go away. [19]

Diagnosis

Diagnosis of OAB is made primarily on the person's signs and symptoms and by ruling out other possible causes such as an infection. [1] Urodynamics, a bladder scope, and ultrasound are generally not needed. [1] [20] Additionally, urine culture may be done to rule out infection. The frequency/volume chart may be maintained and cystourethroscopy may be done to exclude tumor and kidney stones. If there is an underlying metabolic or pathologic condition that explains the symptoms, the symptoms may be considered part of that disease and not OAB.[ citation needed ]

Psychometrically robust self-completion questionnaires are generally recognized as a valid way of measuring a person's signs and symptoms, but there does not exist a single ideal questionnaire. [21] These surveys can be divided into two groups: general surveys of lower urinary tract symptoms and surveys specific to overactive bladder. General questionnaires include: American Urological Association Symptom Index (AUASI), Urogenital Distress Inventory (UDI), [22] Incontinence Impact Questionnaire (IIQ), [22] and Bristol Female Lower Urinary Tract Symptoms (BFLUTS). Overactive bladder questionnaires include: Overactive Bladder Questionnaire (OAB-q), [23] Urgency Questionnaire (UQ), Primary OAB Symptom Questionnaire (POSQ), and the International Consultation on Incontinence Questionnaire (ICIQ).

OAB causes similar symptoms to some other conditions such as urinary tract infection (UTI), bladder cancer, and benign prostatic hyperplasia (BPH). Urinary tract infections often involve pain and hematuria (blood in the urine) which are typically absent in OAB. Bladder cancer usually includes hematuria and can include pain, both not associated with OAB, and the common symptoms of OAB (urgency, frequency, and nocturia) may be absent. BPH frequently includes symptoms at the time of voiding as well as sometimes including pain or hematuria, and all of these are not usually present in OAB. [13] Diabetes insipidus causes high frequency and volume, though not necessarily urgency.

Classification

There is some controversy about the classification and diagnosis of OAB. [1] [24] Some sources classify overactive bladder into two different variants: "wet" (i.e., an urgent need to urinate with involuntary leakage) or "dry" (i.e., an urgent need to urinate but no involuntary leakage). Wet variants are more common than dry variants. [25] The distinction is not absolute; one study suggested that many classified as "dry" were actually "wet" and that people with no history of any leakage may have had other syndromes. [26]

OAB is distinct from stress urinary incontinence, but when they occur together, the condition is usually known as mixed incontinence. [27]

Management

The usual first suggested treatment for a person with overactive bladder is a combination of lifestyle changes, exercises to strengthen the person's pelvic floor, and manage how much the person drinks and when during the day ("fluid management"). Patients who continue to experience incontinence episodes, or who express a desire for medication along with therapy, may be treated with several classes of drugs, notably anticholinergics. Patients who prove resistant to medications and therapy may then be treated with neurological interventions, such as treatment with botulinum toxin (Botox) and other minimally-invasive surgical procedures, such as sacral neuromodulation. As a last resort if all other treatment options fail, invasive surgical procedures may be performed. [28] [29]

Lifestyle and behavioral therapy

Behavioral and lifestyle changes are commonly recommended as the first-line option for treating overactive bladder. These include bladder training, which involves scheduled voiding (urination) and gradually increasing the time between bathroom visits. Pelvic floor exercises, known as Kegel exercises, can help strengthen the muscles that control urination. Fluid management, which focuses on avoiding excessive caffeine and alcohol intake, is advised to reduce the rate at which the bladder fills and minimize irritation to the bladder. Weight management and maintaining a healthy diet contribute to overall bladder health, especially when weight loss is able to reduce abdominal compression of the bladder. Adopting these behavioral and lifestyle changes can often improve the condition and enhance the effectiveness of other treatment approaches. [28] [30]

Most patients are not able to eliminate incontinence and other symptoms of OAB with lifestyle and behavioral modifications alone. However, numerous studies have demonstrated that these therapies are effective in improving quality of life, and some data shows that they increase the likelihood that medications can keep the OAB under control. [28]

Medications

Medications are a common treatment option for people with overactive bladder syndrome. A number of antimuscarinic drugs (e.g., darifenacin, hyoscyamine, oxybutynin, tolterodine, solifenacin, trospium, fesoterodine) are frequently used to treat overactive bladder. [17] Long term use, however, has been linked to dementia. [31] β3 adrenergic receptor agonists (e.g., mirabegron, vibegron) may be used, as well. [32]

Patients taking oxybutynin and other anticholinergic drugs experience a 70% reduction of incontinence episode frequency, on average. Approximately 1 in 4 patients experience complete dryness while taking oxybutynin. Therefore, medication management alone is sufficient for a substantial minority, but not the majority, of patients with overactive bladder. [33]

Comparison of overactive bladder medication
AgentTraits
Oxybutynin (short-acting)
  • well known by physicians
  • available in market longer than other drugs for OAB
  • many studies provide support of effectiveness
  • available as generic in places including the United States
  • more side effects than alternatives, including dry mouth and constipation
  • severe dry mouth more often reported
  • user takes 2-3 pills a day
Oxybutynin (extended release)
  • fewer side effects than short-acting Oxybutynin
  • 1 pill per day
Oxybutynin (transdermal patch)
  • no pill
  • patch changed every 3–4 days
  • lower rate of dry mouth as compared to pill form
  • patch commonly causes skin irritation which can be severe
Oxybutynin (Topical medication)
  • fewer side effects than short-acting Oxybutynin
  • topical gel applied to abdomen, arms, or thighs daily
  • new on market
  • little existing research on this drug
Tolterodine (short-acting)
  • fewer side effects than short-acting Oxybutynin
  • 2 pills per day
  • 10% of Caucasians and 19% of black people have a genetic difference which causes them to lack a certain enzyme. Lack of this enzyme makes the drug less effective.
Tolterodine (extended release)
  • fewer side effects than short-acting Oxybutynin
  • 1 pill per day
  • 10% of Caucasians and 19% of black people have a genetic difference which causes them to lack a certain enzyme. Lack of this enzyme makes the drug less effective.
Solifenacin
  • 1 pill per day
  • More effective for some symptoms than Tolterodine
  • higher rates of constipation and dry mouth than tolterodine
  • less researched for safety and efficacy than Tolterodine and Oxybutynin
Trospium (short acting)
  • severe dry mouth less common than with oxybutynin
  • less researched for safety and efficacy than Tolterodine and Oxybutynin
Trospium (extended release)
  • 1 pill per day
  • little existing research on this drug
Darifenacin
  • 1 pill per day
  • less researched for safety and efficacy than Tolterodine and Oxybutynin
Fesoterodine
  • same metabolite as Tolterodine, but does not require that enzyme to be active
  • it may avoid drug interactions of Tolterodine
  • little existing research on this drug

Procedures

Botulinum toxin A (Botox) is approved by the Food and Drug Administration in adults with neurological conditions, including multiple sclerosis and spinal cord injury. [34] Botulinum Toxin A injections into the bladder wall can suppress involuntary bladder contractions by blocking nerve signals and may be effective for up to 9 months. [35] [36] The growing knowledge of pathophysiology of overactive bladder fueled a huge amount of basic and clinical research in this field of pharmacotherapy. [37] [38] [39]

Overactive bladder may be treated with electrical stimulation, which aims to reduce the contractions of the muscle that tenses around the bladder and causes urine to pass out of it. Both invasive and non-invasive electrical stimulation procedures may be used to treat overactive bladder. [10]

Invasive surgeries

If non-invasive and pharmacological approaches are not helpful, some people may be eligible for a surgical procedure to treat overactive bladder. Surgical options may include urinary diversion, sacral neuromodulation, or augmentation cystoplasty. [40]

One surgical intervention, called a cystoplasty, involves the enlargement of the bladder using tissue taken from the patient's ileum, which is part of the small intestine. This procedure is rarely performed, and is only done for patients who have proven resistant to all other forms of treatment. This procedure can greatly enlarge urine volume in the bladder. [41]

Prognosis

Because overactive bladder is most commonly associated with aging, the majority of patients experience symptoms (with or without incontinence) for the rest of their lives. A minority of age-related OAB cases may be cured or indefinitely suppressed by medications and behavioral modification. If the OAB is due to a different condition, such as a urinary tract infection, then symptoms should resolve after the underlying problem has been treated. [30]

Epidemiology

Earlier reports estimated that about one in six adults in the United States and Europe had OAB. [42] [43] The number of people affected with OAB increases with age, [42] [43] thus it is expected that OAB will become more common in the future as the average age of people living in the developed world is increasing. However, a recent Finnish population-based survey [44] suggested that the number of people affected had been largely overestimated due to methodological shortcomings regarding age distribution and low participation (in earlier reports). It is suspected, then, that OAB affects approximately half the number of individuals as earlier reported. [44]

The American Urological Association reports studies showing rates as low as 7% to as high as 27% in men and rates as low as 9% to 43% in women. [1] Urge incontinence was reported as higher in women. [1] Older people are more likely to be affected, and the number of symptoms increases with age. [1]

See also

Related Research Articles

<span class="mw-page-title-main">Interstitial cystitis</span> Medical condition

Interstitial cystitis (IC), a type of bladder pain syndrome (BPS), is chronic pain in the bladder and pelvic floor of unknown cause. It is the urologic chronic pelvic pain syndrome of women. Symptoms include feeling the need to urinate right away, needing to urinate often, and pain with sex. IC/BPS is associated with depression and lower quality of life. Many of those affected also have irritable bowel syndrome and fibromyalgia.

<span class="mw-page-title-main">Benign prostatic hyperplasia</span> Noncancerous increase in size of the prostate gland

Benign prostatic hyperplasia (BPH), also called prostate enlargement, is a noncancerous increase in size of the prostate gland. Symptoms may include frequent urination, trouble starting to urinate, weak stream, inability to urinate, or loss of bladder control. Complications can include urinary tract infections, bladder stones, and chronic kidney problems.

<span class="mw-page-title-main">Cystoscopy</span> Medical procedure; endoscopy of the urinary bladder via the urethra

Cystoscopy is endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope.

<span class="mw-page-title-main">Urinary incontinence</span> Uncontrolled leakage of urine

Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geriatric health care. The term enuresis is often used to refer to urinary incontinence primarily in children, such as nocturnal enuresis. UI is an example of a stigmatized medical condition, which creates barriers to successful management and makes the problem worse. People may be too embarrassed to seek medical help, and attempt to self-manage the symptom in secrecy from others.

<span class="mw-page-title-main">Hematuria</span> Medical condition

Hematuria or haematuria is defined as the presence of blood or red blood cells in the urine. "Gross hematuria" occurs when urine appears red, brown, or tea-colored due to the presence of blood. Hematuria may also be subtle and only detectable with a microscope or laboratory test. Blood that enters and mixes with the urine can come from any location within the urinary system, including the kidney, ureter, urinary bladder, urethra, and in men, the prostate. Common causes of hematuria include urinary tract infection (UTI), kidney stones, viral illness, trauma, bladder cancer, and exercise. These causes are grouped into glomerular and non-glomerular causes, depending on the involvement of the glomerulus of the kidney. But not all red urine is hematuria. Other substances such as certain medications and foods can cause urine to appear red. Menstruation in women may also cause the appearance of hematuria and may result in a positive urine dipstick test for hematuria. A urine dipstick test may also give an incorrect positive result for hematuria if there are other substances in the urine such as myoglobin, a protein excreted into urine during rhabdomyolysis. A positive urine dipstick test should be confirmed with microscopy, where hematuria is defined by three or more red blood cells per high power field. When hematuria is detected, a thorough history and physical examination with appropriate further evaluation can help determine the underlying cause.

<span class="mw-page-title-main">Urinary retention</span> Inability to completely empty the bladder

Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include loss of bladder control, mild lower abdominal pain, and a weak urine stream. Those with long-term problems are at risk of urinary tract infections.

Nocturia is defined by the International Continence Society (ICS) as "the complaint that the individual has to wake at night one or more times for voiding ". The term is derived from Latin nox – "night", and Greek [τα] ούρα – "urine". Causes are varied and can be difficult to discern. Although not every patient needs treatment, most people seek treatment for severe nocturia, waking up to void more than 2 or 3 times per night.

Percutaneous tibial nerve stimulation (PTNS), also referred to as posterior tibial nerve stimulation, is the least invasive form of neuromodulation used to treat overactive bladder (OAB) and the associated symptoms of urinary urgency, urinary frequency and urge incontinence. These urinary symptoms may also occur with interstitial cystitis and following a radical prostatectomy. Outside the United States, PTNS is also used to treat fecal incontinence.

<span class="mw-page-title-main">Darifenacin</span> Medication for urinary incontinence

Darifenacin is a medication used to treat urinary incontinence due to an overactive bladder. It was discovered by scientists at the Pfizer research site in Sandwich, UK under the identifier UK-88,525 and used to be marketed by Novartis. In 2010, the US rights were sold to Warner Chilcott for US$400 million.

<span class="mw-page-title-main">Solifenacin</span> Chemical compound

Solifenacin, sold as the brand name Vesicare among others, is a medicine used to treat overactive bladder and neurogenic detrusor overactivity (NDO). It may help with incontinence, urinary frequency, and urinary urgency.

Diurnal enuresis is daytime wetting. Nocturnal enuresis is nighttime wetting. Enuresis is defined as the involuntary voiding of urine beyond the age of anticipated control. Both of these conditions can occur at the same time, although many children with nighttime wetting will not have wetting during the day. Children with daytime wetting may have frequent urination, have urgent urination or dribble after urinating.

<span class="mw-page-title-main">Neurogenic bladder dysfunction</span> Medical condition

Neurogenic bladder dysfunction, often called by the shortened term neurogenic bladder, refers to urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination. There are multiple types of neurogenic bladder depending on the underlying cause and the symptoms. Symptoms include overactive bladder, urinary urgency, frequency, incontinence or difficulty passing urine. A range of diseases or conditions can cause neurogenic bladder including spinal cord injury, multiple sclerosis, stroke, brain injury, spina bifida, peripheral nerve damage, Parkinson's disease, multiple system atrophy or other neurodegenerative diseases. Neurogenic bladder can be diagnosed through a history and physical as well as imaging and more specialized testing. In addition to symptomatic treatment, treatment depends on the nature of the underlying disease and can be managed with behavioral changes, medications, surgeries, or other procedures. The symptoms of neurogenic bladder, especially incontinence, can severely degrade a person's quality of life.

Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. The term is more commonly applied to men – over 40% of older men are affected – but lower urinary tract symptoms also affect women. The condition is also termed prostatism in men, but LUTS is preferred.

Urologic diseases or conditions include urinary tract infections, kidney stones, bladder control problems, and prostate problems, among others. Some urologic conditions do not affect a person for that long and some are lifetime conditions. Kidney diseases are normally investigated and treated by nephrologists, while the specialty of urology deals with problems in the other organs. Gynecologists may deal with problems of incontinence in women.

Urogynecology or urogynaecology is a surgical sub-specialty of urology and gynecology.

<span class="mw-page-title-main">Urodynamic testing</span> Assessment of bladder and urethra performance

Urodynamic testing or urodynamics is a study that assesses how the bladder and urethra are performing their job of storing and releasing urine. Urodynamic tests can help explain symptoms such as:

<span class="mw-page-title-main">Underactive bladder</span> Bladder syndrome

Underactive bladder syndrome (UAB) describes symptoms of difficulty with bladder emptying, such as hesitancy to start the stream, a poor or intermittent stream, or sensations of incomplete bladder emptying. The physical finding of detrusor activity of insufficient strength or duration to ensure efficient bladder emptying is properly termed "detrusor underactivity" (DU). Historically, UAB and DU have been often used interchangeably, leading to both terminologic and pathophysiologic confusion.

Dyssynergia is any disturbance of muscular coordination, resulting in uncoordinated and abrupt movements. This is also an aspect of ataxia. It is typical for dyssynergic patients to split a movement into several smaller movements. Types of dyssynergia include Ramsay Hunt syndrome type 1, bladder sphincter dyssynergia, and anal sphincter dyssynergia.

<span class="mw-page-title-main">Surgery for benign prostatic hyperplasia</span> Type of surgery

If medical treatment is not effective, surgery may need to be performed for benign prostatic hyperplasia.

<span class="mw-page-title-main">Vibegron</span> Medication

Vibegron, sold under the brand name Gemtesa, is a medication for the treatment of overactive bladder. Vibegron is a selective beta-3 adrenergic receptor agonist.

References

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