Download The Overactive Bladder

The Overactive Bladder
Raji Gill, D.O., M.Sc.
Clinical Assistant Professor of Surgery
Division of Urology
Tulsa Regional Medical Center
&
Cancer Treatment Centers of America
2002 ICS Terminology:
Overactive Bladder
OAB defined based on symptoms
 Urgency, with or without urge incontinence,
usually with frequency and nocturia
 In the absence of pathologic or
metabolic conditions that might
explain these symptoms
ICS = International Continence Society (www.icsoffice.org)
OAB Symptoms
Frequency
• 8 or more visits to the toilet per 24 hours
Urination at night
• 2 or more visits to toilet
during sleeping hours
Urgency
Urge Incontinence
• Sudden, strong
desire to urinate
• Sudden & involuntary
loss of urine
OAB
Urge
Types of Urinary Incontinence
urine loss
accompanied by
urgency resulting
from abnormal
bladder contractions
Stress
urine loss resulting from
sudden
increased intra-abdominal
pressure (eg, laugh, cough,
sneeze)

Mixed symptoms
– combination of stress
and urge
incontinence
Sudden increase
in intra-abdominal
pressure
Uninhibited
detrusor
contractions
Urethral pressure
Differential Diagnosis:
OABMedical
andHistory
Stress
Incontinence
and Physical Examination
Symptom Assessment
Overactive
bladder
Yes
Stress incontinence
Frequency with urgency
(>8 times/24 h)
Yes
No
Leaking during physical activity;
eg, coughing, sneezing, lifting
No
Yes
Amount of urinary leakage with
each episode of incontinence
Ability to reach the toilet in time
following an urge to void
Waking to pass urine at night
Large
(if present)
Small
Often no
Yes
Usually
Seldom
Symptoms
Urgency (strong, sudden desire to
void)
Abrams P, Wein AJ. The Overactive Bladder:
A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.
No
Estimated Prevalence of OAB in Comparison
With Other Selected Chronic Conditions: 1990s
Data
Condition
Millions of Americans
Chronic Sinusitis
37
Arthritis
33
Heart Conditions*
21
OAB
17
Asthma
15
Osteoporosis
10
Diabetes
9
Alzheimer’s Disease
5
* Excludes hypertension
Payne CK. Campbell’s Urology Updates. 1999;1:1-20.
Evans DA et al. Milbank Q. 1990;68:267-289.
Bureau of the Census, Population Estimate Data, 1995.
National Institutes of Health. Osteoporosis and Related Bone Diseases
National Resource Center. Osteoporosis Overview.
National Center for Health Statistics. Vital Health Stat. 10(199):1998.
Prevalence of OAB in the US
40
Men
Women
• Overall, 16.6%
had symptoms
of OAB
• Prevalence of
OAB increased
with age
Prevalence (%)
35
30
25
20
15
10
5
0
18–24 25–34 35–44 45–54 55–64 65–74
Age (years)
Adapted from Stewart W et al. WHO/ICI 2001. Poster.
75+
Prevalence of OAB:
Wet versus Dry
12.2 million (6.1% of the population)
Wet
(37% of OAB)
OAB
Dry
(63% of OAB)
21.2 million (10.5% of the population)
Adapted from Stewart W et al. WHO/ICI 2001. Poster.
Diagnosis of OAB

A presumptive diagnosis of OAB can be
based on
– patient history, symptom assessment
– physical examination
– urinalysis

Initiation of noninvasive treatment may not
require an extensive further workup
Fantl JA et al. Urinary Incontinence in Adults: Acute and Chronic Management.
Clinical Practice Guideline No. 2, 1996 Update. Rockville, MD: Agency for Health
Care Policy and Research; March 1996. AHCPR publication 96-0682.
A Hidden Condition*
Many patients self-manage by voiding
frequently, reducing fluid intake, and
wearing pads
 Nearly two-thirds of patients are
symptomatic for 2 years before seeking
treatment
 30% of patients who seek treatment receive
no assessment
 Nearly 80% are not examined

* Survey conducted by Gallup Group (European Study).
Barriers to Treatment

Patient misconceptions and fears:
“Part of normal aging or everyday life”
“Not severe or frequent enough to treat”
“Too embarrassing to discuss”
“Treatment won't help”
Screening and
Diagnosing OAB
“Do you have bladder problems that are
troublesome, or do you ever leak urine?”
YES

Assess history, symptoms, and test results

Establish a diagnosis

OAB Screening Can Help Diagnose
Other Causes of Bladder Symptoms
Local pathology

– infection
–
–
–
–

– diuretics
– antidepressants
bladder stones
bladder tumors
interstitial cystitis
outlet obstruction
Metabolic factors
– diabetes
– polydipsia
Medications
– antihypertensives
– hypnotics & sedatives
– narcotics & analgesics

Other factors
– pregnancy
– psychological issues
Fantl JA et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical
Practice Guideline No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and
Research; March 1996. AHCPR publication 96-0682.
Differential Diagnosis:
Physical Examination
Perform general, abdominal (including
bladder palpation), and neurologic exams
 Perform pelvic and/or rectal exam in
females and rectal exam in males
 Observe for urine loss with vigorous cough

Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference
Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; January
1996. AHCPR publication 96-0686.
Differential Diagnosis:
Laboratory Tests

Urinalysis
– to rule out hematuria, pyuria, bacteriuria,
glucosuria, proteinuria

Blood work if compromised renal function
is suspected or if polyuria (in the absence of
diuretics) is present
Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick
Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy
and Research; January 1996. AHCPR publication 96-0686.
Care Pathway
Working diagnosis?
Yes
OAB?
Yes
No
Treat if:
Consider
referral to
specialist
>8 weeks tx
Failed
Frequency and urgency, with or
without urge incontinence, and
normal urinalysis
Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.
Suggested Reasons for Referral





Symptoms do not respond to
initial treatment within 2 to 3
months
Hematuria without infection
on urinalysis
Recurrent symptomatic UTI
Symptoms suggestive of poor
bladder emptying
Pelvic bladder, vaginal, or
urethral pain







Evidence of complicated
neurologic or metabolic
disease
Failed previous incontinence
surgery
Elevated PVR volume
Radical pelvic surgery
Symptomatic prolapse
Prostate problems
Surgery planned (2nd opinion)
Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.
Treatment Options
Behavioral therapy
 Medication
 Combined therapy: behavioral and
pharmacologic therapy
 Minimally invasive therapies

– Botulinum A-toxin
– Neuromodulation

Surgery
So when the Drug Rep. visits,
which drug do I use?
Pharmacotherapy

Anticholinergic Agents
–
–
–
–
–
–
Oxybutynin (Ditropan)
Oxybutynin transdermal (Oxytrol)
Tolterodine (Detrol)
Solifenacin (Vesicare)
Trospium chloride (Sanctura)
Darifenacin (Enablex)
Oxybutynin (Ditropan)
Immediate and long acting form
 Immediate – TID dosing
 Long acting XL – once a day, 5 or 10 mg.
 Side effects – dry mouth, constipation,
headache
 Approved for pediatric use (age 6 or older)

Oxybutynin Transdermal
(Oxytrol)
3.9 mg patch, twice weekly
 Similar in effects to po
 Side effects – less dry mouth but
erythema/pruitis

Tolterodine (Detrol)
Immediate 2 mg. and long acting LA 4 mg
dosing
 Side effects profile similar to oxybutynin

Solifenacin (Vesicare)
5 – 10 mg daily dose
 Side effects – dry mouth, constipation

Trospium Chloride (Sanctura)
Quaternary amine as opposed to tertiary
amine
 20 mg BID dose
 Theoretically harder to pass through
blood/brain barrier with less side effects
 Not metabolized by liver
 60% excreted in the urine unchanged

Darifenacin (Enablex)
M3 selective anticholinergic
 7.5 mg or 15 mg once a day
 Side effects – constipation and dry mouth
