Overactive Bladder Syndrome behavioural modifications to pharmacological and surgical treatments Dr Jos Jayarajan Urologist Austin Health, Eastern Health Warringal Private, Northpark Private, Epworth
Overactive Bladder Definition +/- URGE INCONTINENCE URGENCY +/- FREQUENCY (> 8 x daily) +/- NOCTURIA (> 1 x night)
How Common is OAB? Incidence (population based studies): Male: 7-27% Female: 9-35%
Impact of OAB Quality of life Social isolation (family, partner, friends) Sexual health Reduced participation in sport Sleep disturbance Financial Health Mental health (depression) Skin integrity Falls and fracture
Approach to Treatment Exclude pathology Urinary tract infection Red flags (haematuria, dysuria, elevated post void residual) Lifestyle and Behavioural modification Optimise associated medical conditions Pharmacotherapy
Investigations MSU Exclude UTI Exclude microhaematuria Renal tract ultrasound (PVR) Bladder diary
PATIENTS with RED FLAG sx Special Tests / Referral Haematuria Elevated PVR / obstructive voiding Neurological symptoms Prior history of pelvic pathology Radiation Continence or prolapse surgery Cystoscopy Urodynamics CT / MRI
Red flags: Haematuria
Red flags: Previous Mesh Surgery
Behavioural Therapy Patient education Bladder retraining and Pelvic Floor Muscle Therapy Timed or deferred voiding Urge Suppression Biofeedback
Behavioural Therapy Bladder retraining and Pelvic Floor Muscle Therapy Level 1 evidence Improvement in QoL, urinary frequency and incontinence episodes Some studies show equivalence to medical therapy Pharmacotherapy in combination with Behavioural Therapy is superior to either alone
Fluid and caffeine management Level 1 evidence Weight management Lifestyle Modification BMI > 30 increases OAB symptoms Weight loss may improve OAB symptoms in women by upto 47% (Subak et al) Bowel management Optimise associated medical conditions Diabetes, Obstructive Sleep Apnoea, CHF
Normal Bladder Storage Inhibitory sympathetic and somatic pathways 1 1 Suppression of excitatory parasympathetic outflow 1. Arnold J, et al. AustFam Phys2012;41(11):878-83.
First line pharmacotherapy
Anticholinergics Target muscarinic receptors on detrusor muscle Action on muscarinic receptors at other sites causes unwanted effects Dry mouth Constipation Blurred vision GOR Precaution Untreated narrow angle glaucoma GIT motility disorders Urinary retention Elderly
OXYBUTYNIN Anticholinergics Immediate release and non-selective Short half-life Dosing: 2.5-5mg tds PBS Side effects Dry mouth (71%) Constipation (17%) Somnolence (14%) Cognition
Anticholinergics OXYBUTYNIN PATCH Controlled release Dosing: Twice weekly application Avoids first pass hepatic metabolism Side effects Patch site pruritis Dry mouth, constipation
Anticholinergics SOLIFENACIN M3 receptor selective Long half-life Dosing: 5-10mg daily * Side effects (10mg > 5mg) Dry mouth Contipation cognitive
Anticholinergics DARIFENACIN M3 receptor selective Long half-life Dosing: 7.5-15mg daily Similar efficacy to Solifenacin Solifenacin superior QOL / tolerance
Mirabegron B3 adrenergic agonist Dosing: 25 50 mg daily Avoids anticholinergic side effects No change to residual volume Avoid in uncontrolled hypertension
Topical Oestrogen Some evidence of improving OAB symptoms in post-menopausal women * Not systemic HRT
Other medications Tricyclic antidepressant Not FDA approved for OAB Reduces bladder contraction Useful for patients with combined storage and painful bladder conditions
Nocturia > 30% total urine output
NOCDURNA Desmopressin Sublingual wafer Dosing Women: 25mcg Men: 50mcg 1 hour before bed Limit fluid 1 hour prior to admin, and 8 hrs post Monitor serum Na +
Overactive Bladder in Men
Exclude Bladder Outlet Obstruction > 50% have BPH related obstruction High PVR / reduction in flow Consider concurrent use of BPH therapy and OAB medication
Urodynamics In Male OAB
Combination alpha blocker and anticholinergic Combination therapy tamsulosin (0.4mg) and solifenacin (9mg) No stat sign increase in retention Improved storage symptoms and QoL
OAB: Failure of Medical Management.What next?
Urodynamics
BOTOX PBS approval for 1. Idiopathic OAB * 2. Neuropathic OAB * Administration by a Botox registered urologist or urogynae
Botulinum toxin-a PBS reimbursement criteria 1 Clinical criteria: Urinary incontinence due to idiopathic OAB AND Must be inadequately controlled by therapy involving at least two alternative anticholinergic therapies Must experience at least 14 episodes of urinary incontinence per week prior to commencement of treatment with botulinum toxin-a Must be willing and able to self-catheterise Must not continue if the patient does not achieve a 50% or greater reduction from baseline in urinary incontinence episodes 6 12 weeks after the first treatment Patient criteria: Must be 18 years or older. Treatment criteria: Must be treated by a urologist; OR urogynaecologist. 1. Botulinum toxin-a. PBS schedule. Available from http://www.pbs.gov.au/medicine/item/6103f. Accessed September 2015.
Botox: Long-term Efficacy Durable response at 3.5 years Median duration 7.9 months Main complication UTI Retention rate 4% after first injection, 0.6% 1.7% with repeat rx
78yoM Previous TURP Cystoscopy normal urethra, wide open fossa Urinary symptoms Poor flow Urgency / frequency / large volume urge incontinence
Sacral Neuromodulation INDICATIONS Detrusor overactivity Non-obstructive Urinary Retention Faecal incontinence
Sacral Neuromodulation Modifies voiding reflex using direct electrical stimulation of S3 afferent nerve Indications: refractory OAB, non-obstructive urinary retention Contraindications: need for spinal MRI 2 stage procedure Average 75% response rate
Stage 1 S3 lead placement under fluoroscopy in theatre Testing phase 2-3 weeks
Stage 2 Second Stage if >50% reduction in symptoms Otherwise removal of lead 3-5 year battery life
Conclusion Approach to OAB 1. Exclude other conditions that can mimic OAB 2. Multi-disciplinary and holistic Patient specific treatments 3. Caution in the elderly Falls risk / Side effects of medication (anticholinergics) 4. Men with OAB Treat the prostate when required 5. Third line treatments (Botox / SNS) highly effective