Overactive Bladder: Diagnosis and Approaches to Treatment

Overactive Bladder: Diagnosis and Approaches to Treatment

A Hidden Condition* Many Many patients self-manage by voiding frequently, reducing fluid intake, and wearing pads Nearly Nearly two-thirds thirds of patients are symptomatic for 2 years before seeking treatment 30% 30% of patients who seek treatment receive no assessment Nearly Nearly 80% are not examined * Survey conducted by Gallup Group (European Study).

Spectrum of OAB SUI =stress urinary incontinence UUI = urge urinary incontinence Wein A. 2004. In Press

Prevalence of Types of Urinary Incontinence Women Under 60 Years Old Women Over 60 Years Old 20% Stress Urge Mixed 30% 35% 55% 25% 35% Adapted from: Thom D. J Am Geriatr Soc. 1998;46(4):473-480.

Prevalence of OAB With/Without Urge Incontinence: NOBLE Study With Urge Incontinence 55% Women with OAB (n=463) Men with OAB (n=394) With Urge Incontinence 16% N=5204. Stewart et al. World J Urol. 2003;20:327-336. Without Urge Incontinence 45% Without Urge Incontinence 84%

Urge-Stress Stress-Mixed Incontinence Mixed = Stress + Urge Urge - Overactive bladder - Increased pressure - Detrusor contraction Stress (effort) - Underactive outlet - Decreased resistance - Increased abdominal pressure Abrams P, et al. Urology. 2003; 61:37-49 Guerrero P, Sinert R. Available at: www.emedicine.com/emerg/topic791.htm

A Practical Approach: Diagnosing OAB Many patients can be evaluated based on history, physical examination, and urinalysis Specialized tests *(urodynamics urodynamics, cystoscopy, imaging) are not normally required as part of the basic evaluation

A Practical Approach: Diagnosing OAB Postvoid residual (PVR) should be considered only for patients with Neurogenic disease Significant hesitancy and strain when voiding Feeling of incomplete emptying Palpable bladder The infirm elderly

Differential Diagnosis Benign prostatic hyperplasia (BPH) Prolapse Atrophic vaginitis Pelvic floor dysfunction Interstitial cystitis

Differential Diagnosis Diabetes Fluid intake - urinary output disorders Genitourinary (GU) malignancy UTI Stress urinary incontinence (SUI)

Addressing Transient Conditions That Mimic OAB Easily reversible conditions urinary tract infection Associated conditions urogenital aging bladder outlet obstruction prolapse stress incontinence voiding difficulties

OAB Screening Can Help Diagnose Other Causes of Bladder Symptoms Local pathology infection bladder stones bladder tumors interstitial cystitis outlet obstruction Metabolic factors diabetes polydipsia Medications diuretics antidepressants 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.

Patient History Focus on GU symptoms, neurologic and medical Intake - output Toileting Bladder/outlet Pelvic pathology Neurology General health Voiding patterns and symptoms Voiding diary Medications Functional and mental status

Medication History is Important Some medications may contribute to lower urinary tract dysfunction Diuretics Antidepressants α-agonist α -antagonist β-antagonist Sedatives Fluid output Bladder contractility Outlet response Anticholinergics Analgesics

Assessment by History Drugs Anti-cholinergic Estrogen use Oral or intravaginal Fluid intake/output 2-3 L per day intake maximum Alling Moller L, et al. Obstet Gynecol. 2000;96(3):446-451. Schleyer-Saunders E. J Am Geriatr Soc. 1976;24(8):337-339. Wein AJ, Rovner ES. Urol Clin North Am. 2002;29(3):537-550.

Assessment by History Caution Pelvic pain Hematuria Genital prolapse symptoms Recurrent UTIs Prior incontinence surgery Prior bladder surgery Postvoid fullness Constipation, impaction Onset after recent hysterectomy Prior pelvic radiation therapy Symptoms of vaginal or pelvic mass Prior radical hysterectomy Continue with physical exam or selected referral

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.

Pelvic Floor Muscle Strength Pelvic Floor Muscle Contraction: 0 unable to isolate, no perceived tightening 1 light contraction, unable to retain examiner s finger 2 light contraction, unable to sustain tightening for one (1) second 3 moderate contraction, able to sustain tightening for three (3) seconds 4 strong contraction, able to sustain tightening for five (5) seconds

Pelvic Floor Muscle Dysfunction Muscle hypertonus: 0 No pressure/pain with exam 1 Comfortable pressure with exam 2 Uncomfortable pressure with exam 3 Moderate pain with exam, intensifies with PFM contraction 4 Severe pain with exam, unable to perform PFM contraction due to pain

Assessment by Physical Examination Sacral neurological exam Abdominal and pelvic exam Bladder exam (stress test) Rectal exam Normal Proceed to laboratory and other testing Lind LR, Bhatia NN. In: Ostergard DR, et al, eds. Ostergard s Urogynecology and Pelvic Floor Dysfunction; 2002:103-114.

Assessment by Physical Examination Sacral neurological exam Abdominal and pelvic exam Bladder exam Rectal exam Upper motor neuron lesion Hypoestrogenism Prolapse to hymen Bladder palpable Mass Fistula, ectopic ureter Pelvic or suburethral mass Stress test positive Impaction Supine loss = intrinsic sphincter deficiency Decision to refer to specialist or proceed to laboratory and other testing

Pelvic Floor Dysfunction Voluntary Guarding: SUI, Prolapse, Anal sphincteric incompetence Guarding Reflex: OAB, IC, vulvodynia, overactive bowel, chronic pelvic pain Anti-dromic dromic pelvic floor dysfunction, voiding dysfunction, constipation

Laboratory Tests Urinalysis To rule out hematuria, pyuria, bacteriuria, glucosuria, proteinuria Blood work as appropriate Glucose Prostate specific antigen (PSA) Others

Overactive Bladder: Other Specialized Training Additional specialized diagnostic testing, if indicated Urodynamic procedures-simple/multichannel simple/multichannel cystometry, uroflometry, urtheral pressure profilometry, electromyography Cystoscopy Imaging procedures-radiographic, radiographic, ultrasound Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.

Urodynamics

Laboratory and Other Testing Optional Fluid intake/ output Urinalysis and/or culture Palpable bladder Q-tip test Cystometrogram Voiding diary Postvoid residual Normal Proceed with therapy for stress incontinence Germain MM. In: Ostergard DR, et al, eds. Ostergard s Urogynecology and Pelvic Floor Dysfunction; 2002:285-292. Swift SE, Bent AE. In: Ostergard DR, et al, eds. Ostergard s Urogynecology and Pelvic Floor Dysfunction; 2002:69-76. Theofrastous JP, Swift SE. In: Ostergard DR, et al, eds. Ostergard s Urogynecology and Pelvic Floor Dysfunction; 2002:115-140.

Laboratory and Other Testing Optional Fluid intake/output Urinalysis and/or culture Palpable bladder Q-tip test Cystometrogram Voiding diary >3000 ml/day Many urge episodes Frequency: 8 or more Nocturia: 2 or more UTI Hematuria Glucosuria Proteinuria Treat Multiple treatments required Postvoid residual >100 ml Repeat >100 ml >30 degrees from horizontal Uninhibited bladder contractions OAB Consider referral to a specialist Germain MM. In: Ostergard DR, et al, eds. Ostergard s Urogynecology and Pelvic Floor Dysfunction; 2002:285-292. Swift SE, Bent AE. In: Ostergard DR, et al, eds. Ostergard s Urogynecology and Pelvic Floor Dysfunction; 2002:69-76. Theofrastous JP, Swift SE. In: Ostergard DR, et al, eds. Ostergard s Urogynecology and Pelvic Floor Dysfunction; 2002:115-140.

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. 1989.

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 surgery Radical pelvic surgery Symptomatic prolapse Prostate problems Surgery planned (2 nd opinion) Abrams P, Wein AJ. The Overactive Bladder A Widespread and Treatable Condition. 1998.

Red Flags - Consider Referral Pelvic organ prolapse beyond hymen Long term catheterization Difficulty passing a 14 French catheter Diagnostic uncertainty or poor improvement w/ Rx Dominant symptom suprapubic pelvic pain