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Information

Editors

BeataStach-Lempinen
Veli-MattiPuolakka

Overactive Bladder

Essentials

  • An overactive bladder (OAB) is an idiopathic syndrome complex of
    • urinary urgency
    • with or without frequency (need to urinate more than 8 times/24 hours) and/or nocturia (more than 2 times/night).
  • One third of patients also suffer from urge incontinence, which is an OAB symptom that has the most impact on the quality of life.
  • The criteria are not standardised.
  • The detrusor muscle shows hyperactivity and hypersensitivity.
  • Urinary tract infection, prostatic hyperplasia and other obvious cause must be excluded.
  • Mild symptoms may often be corrected by lifestyle changes, bladder training and pelvic floor exercises.

Prevalence

  • The prevalence increases with advancing age.
  • Among patients with overactive bladder syndrome, urge incontinence is more prevalent in women (27%) than in men (11%).

Investigations

  • The patient's medical history should be explored as regards illnesses and medication (particularly diuretics) that may affect the bladder function.
  • Palpation of the abdomen is to be carried out in all patients and a gynaecological examination in women. In men, palpation of the prostate is carried out in order to estimate the size of the prostate and the presence of possible masses, and the urethral orifice and foreskin should also be examined.
  • If indicated, the measurement of residual urine should be carried out.
  • Chemical screening of urine should also be performed and, if indicated, microscopic examinations and culture. In men, plasma PSA and, if indicated, free/total PSA ratio are determined.
  • A bladder diary, over 2-3 days, is essential. It will clarify the nature and severity of the symptoms and the patient's drinking habits.
    • The normal frequency of micturition is less than 8 times/24 hours.
    • Night time urine volume that is > 33% of the total 24-hour urine volume is abnormal.
    • Polyuria: urine volume > 30 ml/kg/24 hours Polyuria
    • If the largest amount of urine from a single voiding (i.e. the functional capacity of the bladder) is less than 100-150 ml, an organic pathology must be excluded with cystoscopy.

Differential diagnosis

Treatment

  • Excessive pharmacotherapy should be avoided; mild symptoms do not always need treatment.
  • Treatment should be aimed towards the most troublesome symptom and the cause.

Women

Men

  • The principles are the same as for women. Bladder outflow obstruction is common in elderly men. An anticholinergic drug alone may worsen the outflow in these patients and may even cause urinary retention.
  • If the patient has prostatic hyperplasia, an alpha-blocker combined with an anticholinergic drug alleviates the symptoms better than either drug used alone. Moreover, the risk of urinary retention is small.
  • Poor treatment resistance warrants more detailed urodynamic studies (urologist).

Elderly

Other treatment

  • In severe cases refractory to other therapies, injecting botulinum toxinin the bladder wall has yielded promising results.
    • The treatment can be carried out in an outpatient setting, starting with local anaesthesia using lidocaine solution administered into the bladder and then injecting the drug with an endoscopic needle through a cystoscope.

References

  • Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Am J Obstet Gynecol 2002 Jul;187(1):116-26 [PubMed]
  • Tikkinen KA, Tammela TL, Rissanen AM, Valpas A, Huhtala H, Auvinen A. Tikkinen KA, Tammela TL, Rissanen AM, Valpas A, Huhtala H, Auvinen A. Is the prevalence of overactive bladder overestimated? A population-based study in Finland. PLoS ONE 2007 Feb 7;2(2):e195 [PubMed]
  • Madersbacher H. Overactive bladder: a clinical entity or a marketing hype? Eur Urol 2005 Mar;47(3):273-6 [PubMed]
  • Kaplan SA, Roehrborn CG, Rovner ES, Carlsson M, Bavendam T, Guan Z. Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: a randomized controlled trial. JAMA 2006 Nov 15;296(19):2319-28 [PubMed]
  • Maman K, Aballea S, Nazir J et al. Comparative efficacy and safety of medical treatments for the management of overactive bladder: a systematic literature review and mixed treatment comparison. Eur Urol 2014;65(4):755-65. [PubMed]
  • Apostolidis A, Dasgupta P, Denys P et al. Recommendations on the use of botulinum toxin in the treatment of lower urinary tract disorders and pelvic floor dysfunctions: a European consensus report. Eur Urol 2009;55(1):100-19. [PubMed]