OVERACTIVE BLADDER

GENERAL INFORMATION

Overactive bladder (OAB) is a syndrome of lower urinary tract symptoms, characterised by urgency with or without urge incontinence, usually with increased frequency and nocturia (Internatinal Continence Society). OAB affects women, men and children, with a reported prevalence of 15%.

The symptoms are usually chronic and interfere significantly with a person’s daily activities. OAB sufferers are often too embarrassed to seek help, or think that it is a ‘normal’ part of growing up or ageing. They will make lifestyle adjustments and put up with the symptoms for many months or years.

As a general practitioner, it is important to screen for OAB as most patients will not volunteer the information and you can greatly improve a patient’s quality of life by diagnosing the condition and recommending simple conservative measures.

DIAGNOSIS

Screening questions:

Use of incontinence products
Restriction of fluid intake, social activities, intimate relationships
Toilet mapping or seeking
Urine-stained underwear and clothes

Initial assessment:

History
Abdominal and vaginal examination
Urine MCS
Bladder diary 3 days +/- ICIQ symptom and QOL questionnaire

Exclude:

Bladder infections (cystitis), cancer, stones
Vaginal prolapse
Obstructed voiding
Neurological conditions
- Parkinson’s disease
- Multiple sclerosis
- Spinal cord injury
- Spina bifida
- Stroke
- Brain or spinal tumours
Diabetes mellitus/insipidus
Congestive cardiac failure

Further assessment as indicated:

Uroflowmetry
US renal tract and pelvis
MRI brain and spine
Cystoscopy
Urodynamic studies

MANAGEMENT

Lifestyle interventions

Trial of supervised pelvic floor muscle training for at least 3 months for mixed UI
Regulation of fluid intake
Restriction of caffeine, alcohol, carbonated drinks, spicy food
Weight loss if BMI>30
Behavioural therapy
- First-line for urge or mixed UI
- Minimum of 6 weeks
- Bladder retraining and diary
- Prompted and timed voiding if cognitively impaired
Pharmacotherapy
- Anticholinergic
  - Oxybutynin tablet (Ditropan) 2.5-5mg bd, tds or qid
  - Oxybutynin patch (Oxytrol) 3.7mg twice weekly
- Selective antimuscarinic
  - Tolteridine (Detrusitol)
  - Solifenacin (Vesicare) 5-10mg daily
  - Darifenacin
- Intravaginal oestrogen (postmenopausal women with vaginal atrophy)
  - Vagifem

WHEN TO REFER

Urgent referrals should be made to a UROLOGIST in patients with:

Asymptomatic microscopic haematuria aged >50 years
Macroscopic haematuria
Recurrent or persistent UTI aged >40 years
Bladder mass
Cancer risk factors – previous or current smoker, age >40 years, chemical or pesticide exposure, pelvic radiotherapy, cyclophosphamide, schistosomiasis, previous urinary tract malignancy

Referrals to the following specialities should be considered when patients have:

UROLOGIST
- Persistent bladder or urethral pain
- Voiding dysfunction
- Previous continence surgery
UROGYNAECOLOGIST
- Benign pelvic masses
- Significant prolapse (at or below introitus)
- Suspected urogenital fistula
NEUROSURGEON or NEUROLOGIST
- Neurological disease
COLORECTAL SURGEON
- Associated faecal incontinence
- Suspected colovesical fistula

Surgical management after a failed trial of conservative therapy include:

Sacral Neuromodulation
Intravesical Botulinum Toxin A
Augmentation cystoplasty
Urinary diversion
Suprapubic catheter

RESOURCES

http://www.nice.org.uk/nicemedia/live/10996/30282/30282.pdf - National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 40. Urinary incontinence: The management of urinary incontinence in women. Oct 2006.

http://www.gponline.com/Clinical/article/978672/Clinical-Review-Overactive-bladder-syndrome/ - GPonline.com is the official website for GP magazine, dedicated to supporting UK GPs in all aspects of their working lives.

Continence Foundation of Australia

National Continence Helpline (free call) 1800 33 00 66

Find a physiotherapist or continence advisor

Free resources for download or order with free delivery - continence.org.au is the official Web site of the Continence Foundation of Australia, the peak body for continence promotion, management and advocacy.

Australian Government Web Site for Bladder and Bowel Problems

Continence Aids Payment Scheme (CAPS) Application form - bladderbowel.gov.au is the official Web site of the Department of Health and Ageing, Australian Government, Commonwealth of Australia.

Pelvic Floor Exercises Fact Sheet in English, Greek, Italian, Turkish, Vietnamese - thewomens.org.au is the official Web site of the Royal Women’s Hospital, Victoria, Australia.