Overactive_Bladder management plane.

1. The Overactive Bladder

2. Overactive Bladder
OAB defined as
 Urgency, with or without urge incontinence,
usually with frequency and nocturia
 In the absence of pathologic or
metabolic conditions that might
explain these symptoms
ICS = International Continence Society (www.icsoffice.org)

3. Estimated Prevalence of OAB in Comparison
With Other Selected Chronic Conditions: 1990s
Data
Payne CK. Campbell’s Urology Updates. 1999;1:1-20.
Evans DA et al. Milbank Q. 1990;68:267-289.
Bureau of the Census, Population Estimate Data, 1995.
National Institutes of Health. Osteoporosis and Related Bone Diseases
National Resource Center. Osteoporosis Overview.
National Center for Health Statistics. Vital Health Stat. 10(199):1998.
Alzheimer’s Disease
Diabetes
Osteoporosis
Asthma
OAB
Heart Conditions*
Arthritis
Chronic Sinusitis
Condition Millions of Americans
5
9
10
15
17
21
33
37
Excludes hypertension
*

4. Prevalence of OAB in the US
Age (years)
0
5
10
15
20
25
30
35
40
18–24 25–34 35–44 45–54 55–64 65–74 75+
Prevalence
(%)
Men
Women
• Overall, 16.6%
had symptoms
of OAB
• Prevalence of
OAB increased
with age
Adapted from Stewart W et al. WHO/ICI 2001. Poster.

5. Prevalence of OAB in Egypt
(Qalubia governorate)2010
 Stress urinary incontinence was the most common
feature of voiding dysfunction in the age group
ranging from 40 to 50 years old (17.2%), and its
prevalence gradually increases with age.
 Urge incontinence prevalence increases with age
as it reaches 7.9% in the age group more than 40
years old.
 Frequency of urination prevalence increases
gradually with age from 4.7% in the age group
from 20 to 30 years old to 6.4% in the age group
from 41 to 50 years old.

6. Prevalence of OAB:
Wet versus Dry
Wet
(37% of OAB)
Dry
(63% of OAB)
12.2 million (6.1% of the population)
21.2 million (10.5% of the population)
OAB
Adapted from Stewart W et al. WHO/ICI 2001. Poster.

7. Urge Incontinence
• Sudden & involuntary
loss of urine
Frequency
• 8 or more visits to the toilet per 24 hours
Urination at night
• 2 or more visits to toilet
during sleeping hours
OAB
OAB Symptoms
Urgency
• Sudden, strong
desire to urinate

8. Types of Urinary Incontinence
 Mixed symptoms
– combination of stress
and urge
incontinence
Urge
urine loss
accompanied by
urgency resulting
from abnormal
bladder contractions
Stress
urine loss resulting from
sudden
increased intra-abdominal
pressure (eg, laugh, cough,
sneeze)
Sudden increase
in intra-abdominal
pressure
Uninhibited
detrusor
contractions
Urethral pressure

10. Differential Diagnosis:
OAB and Stress Incontinence
Symptom Assessment
Medical History and Physical Examination
Abrams P, Wein AJ. The Overactive Bladder:
A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.
Symptoms Overactive
bladder
Stress incontinence
Urgency (strong, sudden desire to
void)
Yes No
Frequency with urgency
(>8 times/24 h)
Yes No
Leaking during physical activity;
eg, coughing, sneezing, lifting
No Yes
Amount of urinary leakage with
each episode of incontinence
Large
(if present)
Small
Ability to reach the toilet in time
following an urge to void
Often no Yes
Waking to pass urine at night Usually Seldom

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

13. Barriers to Treatment
 Patient misconceptions and fears:
“Part of normal aging or everyday life”
“Not severe or frequent enough to treat”
“Too embarrassing to discuss”
“Treatment won't help”

14. Screening and
Diagnosing OAB
 Assess history, symptoms, and test results
 Establish a diagnosis
“Do you have bladder problems that are
troublesome, or do you ever leak urine?”
YES

15. 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.

16. Diagnosis
 History
.symptoms assessment (clinical diagnosis)
.past history (risk factors)
 Physical examination
.General examination (gait ,speech ,neurological deficit.)
.Abd. Examination (masses ,ascitis ,organomegaly ,urine
retention….)
.neurological examination
. DRE
.Vaginal examination (POP ,vaginitis ….)
.External genetalia (abnormalities, inflamatory conditions…)
.Back examination(dimple ,scar ,trauma….)

17.  Special tests
.Cough stress test (SUI)
.Pad test (pad weight gain in 1h “short test”or 24h “long
test”)
.A cotton swab “Q-tip”test (uretheral hypermobility)
 Lab. investigations
. Urine analysis to rule out hematuria, pyuria, bacteriuria,
glucosuria, proteinuria
.Blood work

18.  Radiological investigations
.US (detect PVRU ,upper UT )
.Cystogram ,VCUG (detect VUR ,bladder abnormalities..)
 Endoscopic investigations
. Cystoscopy (cases of persistent irritative symptoms,
heamaturia.)
.Dynamic retrograde urethroscopy
 Urodynamic investigations (cystometry is very
important)

19. Urodynamics
Indications
 Incontinence:
-recurrent incontinence in whome surgery is planned.
-mixed urge and stress symptoms.
-associated voiding problems
-pt with neurologic disorders
-pt with mismatch between signs and symptoms.
 Neurogenic bladder:
-all neurologically impaired patients with neurogenic
bladder dysfunction.

20. Cystometry
 Measurement of intravesical bladder pressure
during bladder filling.
 bladder access by transurethral catheter, or rarely
by percutaneous s/p tube.
 filling medium either gas (CO2) or liquid (water,
saline, or contrast material at body temp).
 liquid cystometry is more physiologic.

21. Cystometry
 Bladder filling either by diuresis or filling through
a catheter.
 filling
– slow (up to 10 ml/min), physiologic
– medium (10 to 100 ml/min)
– fast ( > 100 ml/min)
 children and pts with known bladder hyperactivity
require slow fill rates.
 The reference point is the superior edge of the
symphysis pubis.
 All systems should be zeroed to atmospheric
pressure.
 No air bubbles.

22. Cystometry
 Single Vs multi-channel UDS:
-single: Pves only
-multi: Pves, Pdet, Pabd
 Provocative maneuvers:
- to unmask abnormalities of detrusor function(UC)
- fast fill cystometry, posture change(erect),
coughing, jumping.

23. Phases of cystometrogram

24. Cystometry
 Measurements via cystometry:
- bladder capacity
- Sensation
- Compliance
- Detrusor stability

25. Cystometry
 Measurements via cystometry
– bladder capacity, volume at which a patient
with normal sensation feels that micturition can
no longer be delayed.
-normal=400-500ml. Can’t be determined in pts
with impaired sensation.
- maximal bladder capacity,functional bladder
capacity,anesthetic bladder capacity.
– sensation, first ,normal,strong desire to
void,urgency,pain.
– bladder compliance, change in detrusor
pressure over a given change in volume.

26. Cystometry
 Compliance:
- normal bladder is highly compliant,and can hold
large volumes at low pressure.
- Normal pressure rise during the course of CMG in
normal bladder will be only 6-10 cmH2o.
- Decrease compliance = > 20 ml/cmH2o, poorly
distensible bladder.

27. Cystometry(cont.)
- Leak point pressures:
*Detrusor LPP, the lowest bladder pressure
where urethral leak of urine is first identified
(risk with > 40cm H2O).
*Valsalva LPP,the pressure that causes leakage of
urine in the absence of bladder
contraction.(using valsalva maneuver,cough. If
there is no leakage at high
pressures(<150cmH2O) then the urethera is
unlikely to be the cause of the pt’s
incontinence,and rather the bladder is the more
likely cause.
VLLP>60 cm H2O: significant ISD
VLLP 60-90 cm H2O :equivocal

28. Cystometry
 Involuntary contractions:
- detrusor stability, reflects the integrity of central
nervous system control over bladder function.
- Unstable bladder,contract either spontaneously or
with provocative maneuvers during filling
cystometry, while pt is trying to inhibit
micturation.it is any involuntary pressure rise that
is associated with urgency.
- Detrusor hyperreflexia: in pt with neurologic
disease.
- Detrusor instability: in absence of neurologic
disease.

29. Cystometry
Involuntary contractions:
– hyperactive bladder is one that demonstrates
instability, hyperreflexia, or low compliance.
– motor urge incontinence, pts with urgency and
urge incontinence in whom unstable detrusor
contractions can be demonstrated on UDS
– sensory urgency, pts in whom the same
symptoms are present but have a stable bladder
on UDS.
*ambulatory monitoring has confirmed the
presence of unstable bladder contractions in up
to 69% of normal volunteers.

30. Cystometry
– factors that may alter the CMG include an
incompetent outlet, massive reflux, rapid fill,
lack of pt cooperation, and substances irritative
to bladder.

31. Cystometry
 Normal CMG:
- capacity 400-500ml
- Constant low pressure that does not reach
more than 6-10 cmH2o above baseline at
the end of filling.
- Provocative maneuvers should not provoke
a bladder contraction normally.

32. Treatment Options
 Behavioral therapy
 Medication
 Combined therapy: behavioral and
pharmacologic therapy
 Minimally invasive therapies
– Botulinum A-toxin
– Neuromodulation
 Surgery

33. So when the Drug Rep. visits,
which drug do I use?

35. Pharmacotherapy
 Anticholinergic Agents
– Oxybutynin
– Oxybutynin transdermal
– Tolterodine
– Solifenacin
– Trospium chloride
– Darifenacin

36. Oxybutynin
 Immediate and long acting form
 Immediate – TID dosing
 Long acting XL – once a day, 5 or 10 mg.
 Side effects – dry mouth, constipation,
headache
 Approved for pediatric use (age 6 or older)

37. Oxybutynin Transdermal
 3.9 mg patch, twice weekly
 Similar in effects to po
 Side effects – less dry mouth but
erythema/pruitis

38. Tolterodine
 Immediate 2 mg. and long acting LA 4 mg
dosing
 Side effects profile similar to oxybutynin

39. Solifenacin
 5 – 10 mg daily dose
 Side effects – dry mouth, constipation

40. Trospium Chloride
 Quaternary amine as opposed to tertiary
amine
 20 mg BID dose
 Theoretically harder to pass through
blood/brain barrier with less side effects
 Not metabolized by liver
 60% excreted in the urine unchanged

41. Darifenacin
 M3 selective anticholinergic
 7.5 mg or 15 mg once a day
 Side effects – constipation and dry mouth