Overactive Bladder in Clinical Practice

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2 Overactive Bladder in Clinical Practice

4 Alan J. Wein Christopher Chapple Overactive Bladder in Clinical Practice

5 Authors Alan J. Wein Division of Urology University of Pennsylvania Health System Philadelphia USA Christopher Chapple Department of Urology Royal Hallamshire Hospital Sheffield UK ISBN e-isbn DOI / Springer London Dordrecht Heidelberg New York British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Control Number: Springer-Verlag London Limited 2012 Whilst we have made considerable efforts to contact all holders of copyright material contained in this book, we may have failed to locate some of them. Should holders wish to contact the Publisher, we will be happy to come to some arrangement with them. Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licenses issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc., in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Printed on acid-free paper Springer is part of Springer Science+Business Media (

6 Contents 1 Introduction Definition Epidemiology Quality of Life Socioeconomic Impact Who Seeks Treatment and Why? References The Pathophysiology of Overactive Bladder Anatomy and Pathophysiology of the Lower Urinary Tract Urinary Symptoms The Detrusor Muscle Detrusor Overactivity Etiology of Detrusor Overactivity Neurogenic Factors Idiopathic Detrusor Overactivity Nocturia References Diagnosis and Assessment Reasons for Visiting the Primary Care Physician Patient Flow Reasons for Visiting the Specialist Physical Examination Abdomen Prostate Pelvic Floor Muscles v

7 vi Contents Female Genitourinary System Importance of Good Communication Patient Questionnaires Patient Diaries Urinalysis and Other Readily Available Studies References The Role of the Specialist General Assessment Differential Diagnosis Symptoms Additional Investigations Urodynamic Investigations Simple Urodynamic Investigations Pressure/Flow Studies References Management of Overactive Bladder Principles of Management The Role of the Primary Care Physician and the Specialist in Management Follow-Up Strategies Self-care Practices and Lifestyle Changes Smoking Cessation Weight Loss Behavioral Modification Patient Compliance Efficacy Combined Behavior Modification and Drug Therapy Acupuncture References Pharmacological Treatment of Overactive Bladder Choosing a Drug Therapy for Overactive Bladder

8 Contents vii Overview of Key Drugs Darifenacin Fesoterodine (Toviaz) Oxybutynin Propiverine Solifenacin Tolterodine Trospium Current Recommendations Efficacy of Antimuscarinic Drug Therapy Long-Term Tolerability and Compliance with Antimuscarinic Drug Therapy Patient-Perceived Outcomes with Antimuscarinic Drug Therapy Intradetrusor Botulinum Toxin Injection Therapy References Neuromodulation and Surgical Approaches Surgery for Overactive Bladder Augmentation Cystoplasty Autoaugmentation Sacral Neuromodulation Percutaneous Posterior Tibial Nerve stimulation Pudendal Nerve Stimulation References Special Populations Overactive Bladder in the Male Postradical Prostatectomy Prostate Enlargement and Bladder Outlet Obstruction Nocturia Incidence of Urine Retention in the Male Elderly People The Neurogenic Group The Mixed Incontinence Group

9 viii Contents Pregnancy and OAB Children References Comorbid Conditions and Complications Prevalence of Comorbid Conditions Depression Sexual Dysfunction Falls and Fractures Cardiac Disorders Gastrointestinal Disorders References

10 Author Biographies Alan J. Wein, MD, PhD (hon) is Professor and Chief of the Division of Urology in the Perelman School of Medicine of the University of Pennsylvania, Chief of Urology at the Hospital of the University of Pennsylvania and Director of the Residency Program in Urology at the University of Pennsylvania. He is a graduate of Princeton University and received his MD from the University of Pennsylvania School of Medicine. He completed training in surgery and urology at the University of Pennsylvania, including a fellowship at the Harrison Department of Surgical Research. He has been certified and recertified (voluntary) by the American Board of Urology. He was awarded an honorary PhD from the University of Patras, Greece in September Dr Wein s affiliations and professional memberships include the American Association of Genitourinary Surgeons, Clinical Society of Genitourinary Surgeons, American Surgical Association, Society of Surgical Oncology, Society of Urologic Oncology, Society of Pelvic Surgeons, Society for Urodynamics and Female Urology, Société Internationale d Urologie, American Urological Association (AUA) and the Royal Society of Medicine. He has served on the American Board of Urology (Vice President), the Examination Committee of the American Urological Association and the Residency Review Committee for Urology (Chair). He has held editorial positions on journals including the Journal of Urology, Neurourology and Urodynamics, Urology, British Journal of Urology International, International Urogynecology Journal, Current Urology Reports, Current Opinion in Urology and Nature Urology. He has been an editor of the textbook considered to be the gold standard in urology, Campbell-Walsh Urology, since 1992, and is currently the Editor-in-Chief. Dr Wein has authored or co-authored more than 880 articles and chapters and has edited or co-edited 28 books. His fields of interest are the evaluation and management of urologic cancer, the physiology and pharmacology of the lower urinary tract, the evaluation and management of voiding function and dysfunction, including problems related to prostate enlargement, urinary incontinence and neurologic disease. Christopher Chapple, MD, FRCS (Urol) is a Consultant Urological Surgeon at Sheffield Teaching Hospitals and visiting professor at Sheffield Hallam University, Sheffield, UK. He trained at the Middlesex ix

11 x Author Biographies Hospital where he subsequently completed his doctorate thesis on Pharmacological Control Mechanisms in the Lower Urinary Tract. His sub-specialist training was at the Middlesex Hospital and Institute of Urology in London and he provides a tertiary service in lower urinary tract reconstructive surgery. He has a particular interest in functional reconstruction of the lower urinary tract and the underlying pharmacological control mechanisms. He is Past Director of the European School of Urology and an Adjunct Secretary General to the European Association of Urology responsible for education. He is editor of the journal Neurourology and Urodynamics, and is on the editorial board of several other journals. Dr Chapple is a member of a number of urology societies including the American Association of Genitourinary Surgeons. He has co-authored over 300 articles in peer-reviewed journals and has written several books and a number of book chapters. He has chaired a number of guidelines initiatives including the recent UK male lower urinary tract symptoms (LUTS) guidelines report for the National Institute for Clinical Excellence (NICE). He was awarded the St Peter s medal by the British Association of Urological Surgeons in 2011 and is an honorary member of several national urology associations.

12 Chapter 1 Introduction Overactive bladder (OAB) is a prevalent condition that is chronic in its course and may be debilitating to those who have it [ 1 3 ]. Consequently, OAB can have a significant impact on an individual s quality of life (QoL) and has significant costs for society [ 3 ]. It is therefore an important syndrome that has become a focus of research with respect to its basic and clinical science and the alleviation of symptoms [ 3 ]. Definition There remains a degree of debate as to what constitutes OAB, how the symptoms themselves should be defined, and the terminology used to describe patients experiences [ 4, 5 ]. The term overactive bladder was first used in the International Continence Society (ICS) standardization of terminology report in 1988 to describe a chronic condition defined urodynamically as detrusor overactivity and characterized by involuntary bladder contractions during the filling phase of the micturition cycle [ 6 ]. The definition of OAB as a symptom syndrome was later refined by the ICS to serve as a symptomatic diagnosis that includes urinary urgency, with or without urgency incontinence, usually accompanied by urinary frequency (more than eight micturitions/24 hours) and nocturia (Figs. 1.1 and 1.2 ) [ 7 ]. For the diagnosis to be OAB, the symptoms must occur in the A.J. Wein, C. Chapple, Overactive Bladder in Clinical Practice, DOI / _1, Springer-Verlag London Limited

13 2 Chapter 1. Introduction Definitions of symptoms of overactive bladder Symptom Definition Urgency Urgency urinary incontinence Increased daytime frequency Nocturia Complaint of a sudden compelling desire to pass urine that is difficult to defer Complaint of involuntary leakage accompanied by or immediately preceded by urgency Complaint by patients who consider that they void too often by day Complaint that the individual has to wake up at night one or more times to void Figure 1.1 Definitions of symptoms of overactive bladder. Adapted from Abrams et al. [ 7, 8 ] Diagram demonstrating the overlap between the different categories of storage symptoms SUI Mixed symptoms Mixed incontinence OAB symptoms UUI Figure 1.2 Diagram demonstrating the overlap between the different categories of storage symptoms. Mixed symptoms represent overactive bladder (OAB) without urgency urinary incontinence (UUI) (OAB dry ) plus stress urinary incontinence (SUI). Mixed incontinence represents OAB with UUI (OAB wet ) plus SUI. Reproduced with permission from Wein and Rackley [ 2 ]

14 Definition 3 absence of pathological (eg, urinary tract infection, urinary stones, or interstitial cystitis) or metabolic factors (eg, diabetes mellitus) that would explain them. Although the symptoms are suggestive of detrusor overactivity (uro-dynamically demonstrable, involuntary bladder contractions), they can be due to other forms of storage or voiding dysfunction. Although OAB is therefore clearly distinct from urodynamically proven detrusor overactivity, most people with OAB are thought to have this underlying diagnosis. It should be noted that the standardized definition of OAB by the ICS is considered somewhat open to interpretation, particularly regarding whether urgency is a dichotomous or continuous variable and the utility of the word sudden [4, 5, 9 ]. In addition, the ICS definition of frequency as more than eight micturitions/24 hours may not always be accurate. A study of 284 asymptomatic US males aged years indicated that the median void frequency was seven/24 hours, with 38% voiding eight or more times daily [ 10 ]. Convenience voids, when the bladder is emptied for solely social reasons, may also have an impact on voiding frequency, with 72% of 53 healthy volunteers in the UK reporting at least one convenience void per week, at an average of 4.6 and 3.4 convenience voids per week for men and women, respectively [ 11 ]. Moreover, it was found in a study of 1809 individuals aged ³ 18 years attending a tertiary referral center in the UK for urodynamics that OAB symptoms were better correlated with the urodynamic diagnosis of detrusor overactivity in men than in women [ 12 ]. Nevertheless, the ICS definition has facilitated rigorous examination of the prevalence, burden, and clinical management of the disorder. The concept of urgency as a subjective term for patients to describe their experience of OAB has also been called into question, because all individuals with sufficient bladder filling to capacity feel a compelling desire to pass urine, regardless of whether or not they have OAB [ 9 ]. What OAB patients do experience that sets them apart from other individuals is a fear of leakage [ 9 ]. It is helpful to consider urgency on a

4 Chapter 1. Introduction Urgency: yes/no versus degree of sensation ON or or OFF ON OFF Like a dimmer? Is the presence of a sudden, compelling desire to void similar to a light switch?

Always suddenly, or gradual buildup of sensation? Figure 1.3 Urgency: yes/no versus degree of sensation. ICS, International Continence Society scale rather akin to what is seen with a rheostat.

When a threshold level is reached, there is a compelling desire to pass urine that will inevitably lead to voiding.

15 4 Chapter 1. Introduction Urgency: yes/no versus degree of sensation ON or or OFF ON OFF Like a dimmer? Is the presence of a sudden, compelling desire to void similar to a light switch? something (presumably a voiding reflex) gets triggered, then urgency occurs Questioning the ICS definition of urgency Seperation pathological sensation, or extreme form of a normal sensation? Always suddenly, or gradual buildup of sensation? Figure 1.3 Urgency: yes/no versus degree of sensation. ICS, International Continence Society scale rather akin to what is seen with a rheostat. Bear in mind that urgency is a sensation and afferent impulses are transmitted to the central nervous system via the periaqueductal gray matter. When a threshold level is reached, there is a compelling desire to pass urine that will inevitably lead to voiding. This results in incontinence if the patient is unable to reach a toilet in time (urgency incontinence) [ 13 ]. This is illustrated in Fig Epidemiology OAB increases in prevalence with age in both sexes (Fig. 1.4 ). Patients with stress incontinence can usually get to the toilet in time, but they are more likely to leak while taking exercise, coughing, or sneezing than those with OAB. Nocturia is less likely to be a prominent feature in patients with stress incontinence than in those with OAB or bladder outflow obstruction, for example. Nevertheless, nocturia occurs with increasing prevalence with age. Nocturia may occur as a consequence of either a bladder storage disorder (eg, detrusor overactivity) or increased production of urine at night (nocturnal polyuria), or from decreased functional bladder capacity caused by a

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