Download Current management of overactive bladder: Insight from developing

Basic Research Journal of Medicine and Clinical Sciences ISSN 2315-6864 Vol. 2(6) pp. 66-71 August 2013
Available online http//www.basicresearchjournals.org
Copyright ©2013 Basic Research Journal
Review
Current management of overactive bladder: Insight
from developing country
1,2
1
Dwi Ngestiningsih , Santoso , Rejeki Andayani Rahayu
2
1
Dept of Biochemistry Faculty of Medicine Diponegoro University Semarang, Indonesia.
Division Geriatry Dept of Internal Medicine Faculty of Medicine Diponegoro University Semarang, Indonesia.
2
*Corresponding author email: [email protected]; Tel: +62-821-330-10495
Accepted 21 August, 2013
Overactive bladder (OAB) is a chronic, debilitating and highly prevalent condition occurred in all age,
especially among elderly affecting quality of life such as socioeconomic, psychological, occupational,
domestic, physical and sexual functioning. The management of OAB can be nonpharmacologic
interventions, pharmacologic interventions or combination of both. There are several substances
involving smooth muscle relaxants, tricyclic antidepressants herbal medicine that can be used to
encourage this OAB but still uncovered, this is a challenge for clinicians to investigate further
regarding herbal medicine for OAB in order to suppress cost of OAB management because herbal
medicine especially in Indonesia is cheaper than synthetic substances. The successful of management
of OAB is influenced by many factors, especially from developing country such as Indonesia is the
compliance of patients. The comprehensive and better understanding of this disorder is needed in
order to manage OAB comprehensively. This article discuss about the comprehensive approach for
managing OAB based on the clinical experience among developing country.
Keyword: Overactive bladder. Elderly, herbal medicine
INTRODUCTION
Overactive bladder (OAB) defined as urgency with or
without urge incontinence which is usually featured with
frequency and nocturia in the absence of other pathologic
or metabolic conditions that might explain the symptoms
is a chronic, debilitating and highly prevalent condition
occurred in all age. Its incidence is increased among
elderly (MacDiarmid, 2008, Kirby et al., 2006; Dalyana,
2006).
In more than six European countries, it was noticed that
this condition affects approximately 17.000 people aged
40 years. In addition, it was reported that 16,9% women
and 16% men above 18 years also suffered from OAB
(Dalyana, 2006). The severity and nature of the
condition’s symptoms may be determined by gender (eg,
OAB without urge incontinence is more common in men
than in women).
Epidemiological studies demonstrated that there is
correlation between incidence of OAB with quality of life
such as socioeconomy, psychological, occupational,
domestic, physical and sexual functioning (MacDiarmid,
2008; Kirby et al., 2006; Dalyana, 2006; Mullins and
Subak, 2005; Tapia et al., 2013; Thomas and Culley,
2008).
There is a few number of studies regarding the
socioeconomic impact related with OAB. In United
Kingdom annual cost of National Health Service (NHS)
in order to cure the symptoms of urinary tract related
disorders is approximately 536 million poundsterling, in
adition, out of pocket fee from patients arround 207
million poundsterling for pampers and other services
(Kirby et al., 2006; Tapia et al., 2013).
In US, the total costs associated with overactive
bladder were estimated at US$ 12 billion. These
expenses comprise indirect costs such as lost
productivity, and direct costs, involving diagnosis,
treatment, and routine care (Mullins and Subak, 2005).
Treatment of OAB include nonpharmacologic
interventions, pharmacologic interventions or combination
of
both.
Nonpharmacologic
treatment
usually
include ”bladder retraining” which generally consists of
Santoso et al. 67
patient education, scheduled voiding, and urgesuppression techniques (Ouslander, 2004; Sandhu et al.,
2006; Sussman, 2007).
A range of drugs have been used in the past for the
management of OAB from smooth muscle relaxants to
tricyclic antidepressants (Staskin, 2005; Pranarka, 2006).
The successful of management of OAB is influenced by
a lot of factors. One of important factor, especially from
developing country such as Indonesia is the compliance
of patients. Shyness and also false paradigm that urinary
related problem is normal for elderly are two of reasons
for them to not seek medical help (Pranarka, 2006;
Sussman, 2007).
Despite the considerable impact this condition has on
patient’s quality of life, OAB remains underrecognized
and undertreated as a result of patient embarrassment
and reluctance to seek medical help, as well as a lack of
proactive questioning by physicians (Pranarka, 2006;
Sussman, 2007).
A better understanding of the negative effects of urinary
symptoms on the economic outcomes and quality of life
of patients with OAB as well the comprehensive
treatment strategies is important in order to optimize
treatment of potential pharmacologic therapies and the
utilization of outcomes data together with clinical
assessment to determine the true strengths and
limitations of the class of medication (Thomas and Culley,
2008).
Despite the importance of objective assessment as well
subjective in the management of OAB, few studies
include subjective assessment as a primary end point.
Future studies with a greater emphasis on subjective
assessment using instruments that have undergone
validation studies, such as OAB questionnaires, are
needed in order to gain a better understanding related to
OAB for optimizing management of OAB, particularly
among elderly patients (Thomas and Culley, 2008).
happened when its volume is not full enough. As
consequence, the patient complains urge and unable to
control contraction of bladder.
The symptoms of OAB are usually related to
unidentified causes involuntary contraction of detrusor
muscle defined as detrusor hyperactivity (Andersson and
Wein, 2004; Erdem and Chu, 2006; Gormley, 2008).
There are two theory related to detrusor hyperactivity,
first is the myogenic theory. This theory depicts that the
increase of detrusor muscle excitability result increase of
involuntary pressure of the bladder. Second theory is the
neurogenic theory that explain that in OAB, there is
impairment of central inhibitory tract or pheripheral
afferent terminal sensitization affect on primitive urination
reflexes which is stimulate overactivity of detrussor
(Sandhu et al., 2006).
In OAB, it is believe that detrusor muscle hyperactivity
causes lack of inhibitory contraction, as a result urgency
of urination. The weakness of detrusor muscle causes
uncomplete emptying of the bladder and increase
frequency of mixturition (Sandhu et al., 2006; Erdem and
Chu, 2006).
There are several factors which influence of incidence
OAB. They are classified into two categories. First of all
systemic factors involving metabolic status such as
Diabetes, medication or substances causing increase of
urine production such as diuretics, caffeine, alcohol, and
neurological abnormalities resulted in damage of nerves
that control urination such as stroke, infection or injury of
brain or spinal cord, multiple sclerosis, and heavy metal
intoxications. Second category is lower urinary tract such
as infection, inflammation, malignancy, abnormalities or
conditions causing urinary flow obstruction such as
benign prostate hyperplasia, urinary tract stones(Sandhu
et al., 2006).
Diagnosis of OAB
Pathophysiology of OAB
The two functions of the bladder are to store and void
urine. The process of micturition involves neural circuits
in the brain and spinal cord that coordinate the anatomic
components of the lower urinary tract (Andersson and
Wein, 2004). However, the direct connection and
contribution of these elements are not completely
understood.
Normally, as bladder volume increases, involuntary
contraction of the detrusor muscle are often associated
with overactive volume f urine voided, and the experience
of each urination (Tapia et al., 2013; Andersson and
Wein, 2004).
Among OAB patients, their bladder transmit false
impulses to the brain, resulted in immature contraction
The diagnosis of OAB is recognized from history taking,
complete physical examination especially on the
abdomen and genital and Neurology examination for
identification of sensory problems (Kirby et al., 2006;
Tapia et al., 2013; Sandhu et al., 2006).
Overactive bladder symptoms include feeling always
want urination, Have experienced urinary urgency,
frequency, and nocturia (Tapia et al., 2013; Sandhu et al.,
2006).
Overactive bladder without urgency incontinence
overactive bladder, often called dry which is about about
two-thirds of patients with these disorders. Whereas if the
urinary urgency, it is often referred to as overactive
bladder wet (Dalyana, 2006).
Physical examintation is important in order to determine
the cause of OAB such as assessment of pelvic floor for
68. Basic Res. J. Med. Clin. Sci.
women to identify stress incontinence, palpation of
suprapubic region for determining bladder enlargement
and mass, digital rectal examination in men should be
considered to assess the size and consistency of the
prostate (Dalyana, 2006).
Laboratory examination from urine sample to check for
infection, glucose levels and urodynamic tests, to see the
function of the bladder and the ability of his emptying
completely, uroflowmetry, the measurement of residual
urine. Are important as routine examination (Dalyana,
2006; Tapia et al., 2013; Sandhu et al., 2006).
Additional laboratory examination such as cystometry
to measure bladder pressure during charge. This
procedure can identify the presence of involunter muscle
contraction that can indicate the level of pressure which
is someone feel like urinating and can measure the
pressure needed for bladder emptying, Electromyography
to determine the coordination of nerve impulses in the
muscles of the bladder and urine sphincter, urodynamics
video using x-ray or ultrasound waves to get a picture of
the bladder during charging and discharging. This test is
usually combined with the cystometry and cystoscopy.
Used to see abnormalities on lower urinary tract for
example a tumor or urinary tract stones, urinary bladder
diary for 3 days to assess symptoms both before and
after the experimental treatment should be considered in
order to diagnose OAB (Sandhu et al., 2006; Tapia et al.,
2013; Dalyana, 2006).
Management of OAB
Regarding management of OAB, comprehensive
approach is more effective and efficient. In general, the
management of OAB divided into two approaches, first is
non pharmacological treatment involves the life style
changes, bladder training, and pelvic floor exercises and
pharmacological treatment (Sandhu et al., 2006;
Ouslander, 2004).
Life style changes involve locate the easiest way for
toilet, drink sufficient water, avoid caffeine due to its
diuretic effect. In some people the alcohol can worsen the
symptoms of overactive bladder, especially when
combined with caffeine (Ouslander, 2004; Sandhu et al.,
2006).
Bladder training also called bladder drill has the
purpose to slow down the stretch the bladder so that it
can enlarge the volume of the bladder and the patient
can remove the urine is only 5 – 6 times in 24 hours. At
the same time will reduce the hyperactivity of the bladder
muscles. The principle of this exercise is try to stifle and
refrain using several ways such as sitting on hard chairs,
counting backwards from 100, doing some pelvic floor
exercises (Ouslander, 2004; Sandhu et al., 2006;
Sussman, 2007; Thomas and Culley, 2008).
This exercise takes several weeks. During this training
exercise the bladder should be recorded in a note to
monitor the progression. After a few months usually
patient will have normal sense of wanting to urinate or go
to the toilet.
The successful of bladder training may be depend on
the support of the doctors, nurses or coaches and also
the intake of enough water (Ouslander, 2004; Sandhu et
al., 2006; Sussman, 2007; Thomas and Culley, 2008).
Pelvic floor exercises is the main approach for stress
incontinence. This exercise includes exercise to
strengthen muscles surrounded the lower part of the
bladder, uterus and rectum and also suppresion the
pelvic ground when sitting from lying to standing. It
remains unclear whether pelvic floor exercises can help
urinary urgency without stress incontinence. However,
pelvic floor exercises can help if it is done in conjunction
with bladder training (Ouslander, 2004; Sandhu et al.,
2006).
Another approach is usage of absorbent pad,
acupuncture and electrical stimulation. Patient may need
to use diapers (absorbent pads) to protect clothing and
when unable to urinate (Thomas and Culley, 2008; Oki et
al., 2006).
Emmon and Otto demonstrated that among 85 women
with OAB treated with acupuncture for 4 weeks has a
meaningful effect for the improvement of OAB involving
on bladder capacity, urgency, frequency and quality of life
equivalently to pharmacological therapy and physical
therapy or behavior changes (Ouslander, 2004; Emmons
and Otto, 2005).
A mild electrical pulse applied through the vagina or
anus or use patches on the skin, can be used to stimulate
the nerves that control the bladder and sphincter
muscles.
In addition, minor surgery in order to provide electrical
stimulation can be applied by attaching an electrical wire
near the coccyx. In this procedure there are two stages,
first the wire is placed and connected with a temporary
stimulator that can be taken for a few days. If his
condition improves, it will proceed with the second step.
Second the electric wire is placed close to the tail bone is
connected to the stimulator and permanent that is placed
under the skin (Oki et al., 2006). Figure 1.
There are several substances which can be used for
treatment of OAB (Thomas and Culley, 2008; Andersson
and Wein, 2004; Asimakopoulos et al., 2012; Staskin,
2005; Wagg and Cohen, 2002).
Antimuscarinic
Drug commonly used is antimuscarinic which is also
commonly referred to anticholinergic. Belonging to this
group are: oxybutynin, tolterodine, trospium chloride,
Santoso et al. 69
Figure 1. Electric Stimulator (Oki et al., 2006).
solifenacin and propiverine. These medications work by
way of block nerve impulses to bladder that will result in
the relaxation of the muscles of the bladder and will
increase the capacity of the bladder (Oki et al., 2006;
Ouslander, 2004; Hood and Andersson, 2013).
These medicines may improve symptoms in some
cases. This improvement will vary on each individual. We
recommend a try given the drug for a month or so, if it
helps then the medication be continued for six months or
more then the medication is stopped and seen how
existing symptoms without medication (Asimakopoulos et
al., 2012).
The side effects of this drug are frequent but only a
light weight and can be tolerated. Frequent side effects
are dry mouth, dry eyes, constipation and blurred vision
(Asimakopoulos et al., 2012, Hood and Andersson,
2013).
Oxybutynin
Oxybutynin is the non-selective antimuscarinic that have
activity relaxing the muscles of the bladder and local
anesthesia. This dosage can be detached immediately (5
mg TID), off slow (5 or 10 mg O.D.) and transdermal
patches (39 cm 2 patch in a dose of 36 mg per patch)
that will release 2.4 mg oxybutynin per day for 3-4 days
(Oki et al., 2006).
Multicenter Study on Assessment of Transdermal
Therapy in Overactive Bladder With Oxybutynin
(MATRIX), has evaluated the effects of oxybutynin
transdermal system (OXY-TDS; 3.9 mg/h) towards the
quality of life and safety of the drug. On the research for 6
months to adult patients including 699 2878 age 75 years
or old. This study demonstrated that the OXY-TDS
improves quality of life and can be well tolerated and
safe. OXY-TDS seems to constitute an ideal OAB
therapy in the elderly. The granting of two times per week
can improve patient compliance and in some patients
aged prefers to wear a 'patch' rather than a pill (Emmons
and Otto, 2005).
Tolterodine
Tolterodine is an antagonist of muscarinic agent which is
available in the form of short-acting and long-acting.
Various clinical test showed that 2 mg or 4 mg per day
will be just as effective as administering oxybutynin 5 mg
or 10 mg per day (Oki et al., 2006).
Propiverine dan trospium
The drug is effective for OAB and drug side effects are
minimal compared to oxybutynin short-acting (Oki et al.,
2006, Wagg and Cohen, 2002, Asimakopoulos et al.,
2012, Hood and Andersson, 2013).
Estrogen
Local vaginal preparations are more effective than oral
estrogens, but existing data about its effectiveness
limited (Emmons and Otto, 2005, Hood and Andersson,
2013).
Antagonis Alpha-adrenergic
These agents are very useful in men with benign prostate
enlargement. Serious side effects are postural
hypotension. The dose used is raised gradually to
overcome the effects of tolerance (Hood and Andersson,
2013).
70. Basic Res. J. Med. Clin. Sci
Imipramine
An antidepressant effect of anticholinergic and tricyclic
with alpha-adrenergic. It may have the effect reflex
against Central bladder emptying so it is recommended
to mix the urgency incontinence--stress. Its use should be
carefully because side effects of postural hypotension
and cardiac conduction disturbances (Hood and
Andersson, 2013).
Darifanacin and solifenacin
A antimuscarinic future with selective receptor antagonist
Action M3 and less systemic effect anticholinergic (Jha
and Parsons, 2006).
Capsaicin and resiniferatoxin
An promised intravesical agent to overcome the increase
of reflexes of detrusor muscle in neurogenic bladder.
function in men with benign prostate obstruction
(Kajiwara and Mutaguchi, 2008). Another herbal medicine
is Ganoderma lucidum is well tolerated and there is an
improvement of symptoms of OAB. The recommended
dose of extract of Ganoderma lucidum is 6 mg in men
with lower urinary tract symptoms (Noguchi et al., 2008).
In addition, surgery approach can be considered when
pharmacological or changes of life style are failed in
order to manage OAB (Gormley, 2008, Erdem and Chu,
2006). The aim of surgical treatment is to increase the
ability of the filling of the bladder and reduce pressure on
the bladder. By Stimulation of the nervus Sacralis which
is done by installing pacemaker under the skin of the
abdomen and connected by a small cable that is placed
near the coccyx area sacralis. Modulation of nerve
impulses can improve the symptoms of OAB. Another
surgery procedure is augmentation cystoplasty. This
reconstruction procedure used to increase bladder
capacity, by using a portion of the intestine to replace
most of the bladder. On the procedure required a
catheter to empty the bladder (Gormley, 2008).
CONCLUSION
Botulinum Toxin (Botox)
There are some subtype botulinum toxin antigen which is
already known, namely: A, B, C1, D, E, F, and G. Types
A and B are used in urology. Botulinum toxin in action by
way of inhibiting the release of acetylcholine from the
nerve endings kolinergik interacting with the protein
complex that is used to populate the acetylcholine
vesicles. Effects of botulinum toxin was losing muscle
contraction and muscle atrophy at the site of the injection.
Chemical denervation are reversible and the regeneration
of the axon will occur within approximately 3-6 months.
Administration of botulinum toxin in sufficient quantities
will inhibit the release of acetylcholine and other
neurotransmitters. The molecules cannot pass through
the brain barrier so it has no effect on the CNS. The use
of botulinum toxin is rising quickly, used to treat
neurogenic detrusor idiopathic overaktivitas and by
means of the injection of (Sahai et al., 2007; MacDiarmid,
2008).
To sum up, OAB is multicausal condition influencing the
activity of detrussor muscle result in the urgency and
frequency of urination with consequence on patients
quality of life involving psychological and socioeconomic
problems. The comprehensive and better understanding
of this disorders is needed in order to manage OAB
comprehensively.
Future Prospect and Suggestion
Regarding pharmacological theurapeutic approach, there
are several substances involving herbal medicine that
can be used to encourage this OAB but still uncovered,
this is a challenge for clinicians to investigate further
regarding herbal medicine for OAB in order to suppress
cost of OAB management because herbal medicine
especially in Indonesia is cheaper than synthetic
substances.
Herbal medicine
Acknowledgement
Despite of synthetic substances, there are some herbal
medicine used for the treatment of OAB. One of the most
popular is a traditional Chinese medicine using Goshajinki-gan (Ogushi and Takahashi, 2007). Previous study
demonstrated that Goshi-jinki-gan ma be a new potential
therapeutic agent for OAB without deterioration of voiding
This study is based on the experience of clinical practice
in Sub Division of Geriatry Dept of Internal Medicine,
Faculty of Medicine Diponegoro University - Dr. Kariadi
Hospital Semarang Indonesia. We would like to thank to
all people in Division of Geriatry Dept of Internal Medicine,
Faculty of Medicine Diponegoro University - Dr. Kariadi
Santoso et al. 71
Hospital Semarang Indonesia for the opportunity to carry
this study in this hospital. Lastly we send our gratitude to
our team and staff of Dept of Biochemistry Faculty of
Medicine Diponegoro University, Semarang Indonesia.
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