overactive%20bladder
OVERACTIVE BLADDER

Overactive bladder or non-neurogenic overactive bladder is a syndrome characterized by urinary urgency, frequency, nocturia and urgency incontinence.
It is not a disease but a symptom complex that generally is not a life-threatening condition. It is also known as bladder spasms.
Urgency is the complaint of sudden, compelling desire to pass urine that is difficult to deny. It is considered a hallmark symptom of overactive bladder.
Frequency is usually micturition of >7 episodes during waking hours.
Nocturia is the interruption of sleep one or more times because of the need to void.
Urgency incontinence is the involuntary leakage of urine associated with a sudden compelling desire to void.

Diagnosis

  • Bladder symptoms should be carefully elicited
    • Presence of storage symptoms associated with overactive bladder (OAB) [eg urgency, urgency incontinence, frequency, nocturia]
    • Storage problems (stress incontinence episodes)
    • Bladder emptying problems (hesitancy, straining to void, prior history of urinary retention, force of stream, intermittency of stream)
  • Bladder function related to the amount and type of fluid intake with or without caffeine
    • Patients should be asked how much fluid and what type they drink each day, how many times they void each day and how many times they void at night
    • If unable to provide accurate intake of fluids, then a diary should be filled out
    • Current medications should reviewed to ensure that voiding symptoms are not adverse effects of the prescribed medications such as anticholinergics or antimuscarinics, antidepressants, antipsychotics, sedatives or hypnotics, diuretics, narcotics, alpha-adrenergic blockers, alpha-adrenergic agonists, beta-adrenergic agonists, and calcium channel blockers
  • Degree of bother from bladder symptoms
    • Can affect daily activities related to work and leisure
    • Patients are advised to avoid certain activities like travel or in situation that will not allow an easy access to a toilet
  • Assess for co-morbid conditions
    • Neurologic diseases (eg, stroke, multiple sclerosis, spinal cord injury)
    • Mobility deficits
    • Medically complicated/uncontrolled diabetes
    • Fecal motility disorders (fecal incontinence or constipation)
    • Chronic pelvic pain
    • History of recurrent urinary tract infections (UTIs) and gross hematuria
    • Prior pelvic surgeries (incontinence/prolapse surgeries)
    • Pelvic cancer (bladder, colon, prostate) and pelvic radiation

Physical Examination

  • Comprehensive physical examination would determine the nature, severity, and impact of the symptoms in patients with overactive bladder (OAB)
  • Pulmonary and cardiovascular evaluation
    • Assess control of cough or the need for medications such as diuretics
  • Abdominal examination
    • Assess and check for presence of diastasis recti, scars, masses, ascites, organomegaly, hernias and areas of tenderness as well as for suprapubic distension that may suggest urinary retention
    • Palpable bladder may imply overflow incontinence or obstructive problem
  • Lower extremities
    • Check if there is edema (potential for fluid shifts during periods of postural changes)
  • Bimanual examination
    • Should include rectal examination to check the anal sphincter tone, fecal impaction, presence of rectal lesions
    • Rectal examination should also be focused on the prostate to rule out benign prostatic hypertrophy (BPH) or prostate cancer
  • Pelvic examination
    • Evaluate for inflammation, infection and atrophy
    • Above-mentioned conditions can increase afferent sensation leading to urinary urgency, frequency, dysuria, and OAB
  • Neurological examination
    • Related to the severity of symptoms and therapeutic implications (Mini-Mental State Examination-MMSE)
    • Assessment of the lumbosacral nerve roots and evaluation of the deep-tendon reflexes, lower-extremity strength and sharp/dull sensation
    • Abnormal findings such as deep tendon hyperreflexia or absent bulbocavernosus reflex are possible underlying neurologic lesions contributing to urinary incontinence

Laboratory Tests

Urinalysis
  • Used to rule out microhematuria, pyuria, urinary tract infection (UTI) and glucosuria
Urine culture
  • Indicated for patients with irritative voiding symptoms in the absence of signs of infection and this may completely exclude the presence of clinically significant bacteriuria
Post-void residual (PVR)
  • Assessed in patients with obstructive symptoms, history of incontinence or prostatic surgery, neurologic diagnoses and when PVR assessment is deemed necessary to optimize care and minimize potential risks
  • Baseline PVRs should be performed in men who have overlap of symptoms between storage, emptying and voiding prior to initiation of antimuscarinic therapy
  • Antimuscarinics should be used with caution in patients with PVR of >250-300 mL
Optional Tests
Cystoscopy
  • Used to look for presence of tumors in the bladder
Urodynamic testing
  • Measures the anatomic and functional status of the bladder and urethra
  • Used when there is suspicion of neurologic etiology
  • Multiple components:
    • Cystometrography (CMG): assesses the storage phase of bladder function and looks at bladder capacity, compliance, detrusor overactivity, sensation of filling
    • Uroflow/electromyelography: assesses the detrusor pressure during voiding, relaxation of pelvic floor muscles during voiding, and nature of the flow pattern
    • Intravesical pressure: determines the detrusor pressure
Bladder diaries
  • Documents the intake, voiding behaviour and baseline symptom levels to assess treatment efficacy

Screening

Symptom questionnaires
    • Used in overactive (OAB) clinical trials to quantitate symptoms and changes with OAB therapies such as Urogenital Distress Inventory (UDI), UDI-6 Short Form, Incontinence Impact Questionnaire (IIQ) and Overactive Bladder Questionnaire (OAB-q)
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