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.

Principles of Therapy

  • To reduce urinary urgency and frequency
  • To increase voided volume (bladder capacity)
  • To decrease urge incontinence (reduce leakage episodes)
  • Before starting overactive bladder (OAB) drugs, the following should be monitored:
    • Coexisting conditions (eg, poor bladder emptying, constipation, glaucoma)
    • Use of other existing medication affecting the total antimuscarinic load
    • Risk of adverse effects
  • Treatment should be individualized; consider the patient’s comorbidities, concomitant medications and pharmacological profiles of different drugs

Pharmacotherapy

Antimuscarinics
  • Anticholinergic agents that specifically block the muscarinic form of the cholinergic receptor
  • Recommended as first-line pharmacologic therapy for patients with overactive bladder (OAB)
  • They decrease the bladder tone and amplification of contractions of the urinary bladder and counteract the relaxation of the trigone and external sphincter responsiveness of the bladder wall muscle to stimulating nerve impulses
  • Should be offered in patients with spinal cord disease, symptoms of OAB, conditions affecting the brain and impaired bladder storage
  • Residual urine volume should be monitored in patients who are not using intermittent or indwelling catheterization after the start of antimuscarinic treatment
  • Extended-release (ER) preparations should be prescribed over intermediate-release (IR) because of lower rates of adverse effects of dry mouth
  • If there is inadequate symptom control or unacceptable adverse drug reaction to antimuscarinic drugs, patient can be shifted to another or different antimuscarinic medication or β3-adrenoreceptor agonists
  • Constipation and dry mouth should be managed before abandoning the antimuscarinic therapy
Darifenacin
  • ER form that elicits competitive muscarinic receptor antagonistic activity
  • Reduces smooth muscle contractions of the bladder
  • Indicated for symptoms of OAB such as urge incontinence, urgency and frequency
Fesoterodine
  • Has similar muscarinic receptor affinity as Tolterodine but was shown to be superior to it
  • Based on the IMPACTA study, patients who were shifted from their previous anticholinergics to Fesoterodine had decreased incidence of dry mouth and constipation
Oxybutynin
  • An M3, M1 specific receptor
  • Inhibits the action of acetylcholine on the smooth muscle with antispasmodic effect
  • Increases bladder capacity and decreases uninhibited contractions
Propiverine
  • Well-established antimuscarinic agent with mixed mechanism of action in the treatment of symptoms associated with OAB
  • Blocks muscarinic receptors in the detrusor muscle and cellular calcium influx thereby diminishing muscle spasm
  • Generally tolerated with a lower incidence of dry mouth than that of Oxybutynin
  • Valuable option for adults with OAB associated with idiopathic and neurogenic detrusor overactivity and in men with storage lower urinary tract symptoms (LUTS)
  • Patients must be willing to return for frequent post-void residual evaluation and perform self-catheterization
Solifenacin
  • Competitive muscarinic receptor antagonist approved for the treatment of OAB symptoms
  • Has been shown to be effective in treating OAB symptoms in multiple sclerosis patients and significantly improved the frequency, urgency, volume voided, and number of pads used per 24 hours
    • Reduces micturition and urgency urinary incontinence episodes for 24 hours
Tolterodine
  • Non-specific competitive inhibitor muscarinic receptor antagonist for OAB
  • Anticholinergic receptor with selectivity to urinary bladder
  • Has high specificity for muscarinic receptors
Trospium
  • Non-specific quarternary ammonium compound that is excreted intact in the urine and is not dependent on cytochrome P450 system for its metabolism
  • Indicated for the treatment of OAB symptoms
β3-Adrenoreceptor agonist
Mirabegron
  • First-in-class β3-adrenoreceptor agonists licensed for OAB treatment
  • Causes relaxation of detrusor smooth muscle by its agonist action at β3 receptors leading to increased storage capacity of bladder
  • Well-tolerated and effective in the treatment of urinary incontinence and frequency micturition
  • Has lower incidence of dry mouth as compared to other antimuscarinics
  • Recommended as an option only for people whom antimuscarinic drugs are contraindicated, clinically ineffective, or have unacceptable side effects
Botulinum toxin type A
  • A Food and Drug Administration (FDA)-approved medication used for the treatment of urinary incontinence due to detrusor overactivity associated with neurologic conditions in adults who have inadequate response to anticholinergic drugs
  • In the study of Hobbs et al, botulinum toxin type A, was a successful treatment in males with idiopathic wet and dry OAB irrespective of detrusor overactivity
  • Intradetrusor onabotulinumtoxin A (100U) may be given for carefully-selected and thoroughly-counseled patient who became refractory to 1st and 2nd-line treatments
  • Based on the study of Khan et al, there was a considerable improvement shown in the mean Urogenital Distress Inventory and Incontinence Impact Questionnaire
  • Patients must be willing to return for frequent post-void residual evaluation and perform self-catheterization
  • Monitor the upper urinary tract of patients who are judged to be at risk of renal complications (eg, with high intravesical pressures on filling cystometry) during treatment with botulinum toxin type A

Non-Pharmacological Therapy

Biofeedback
  • Behavior-modification technique that helps to control bodily functions
  • Electrodes are used to gather and display information on a monitor
  • Re-trains the bladder and pelvic floor muscles to minimize the risk of leakage
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