Overactive_Bladder management plane.

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. VOIDING DYSFUNCTION
SHERIF MOURAD, MD

3. BPH / OAB
• Of the most common diseases to affect men.
• Histological disease is present in > 60% of men in
their 60s.
• Over 40% of men beyond 60s have Symptoms.
• About half of whom have an impaired Qol.
• The prevalence increases with age (patients
affected are rising worldwide)

4. Incidence
20%
50%
70%
75%
80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
41-50 51-60 61-70 71-80 >80
prevelence of symptomatic BPH increase with age
Kirby & McConell, BPH, 1996

5. BPH / OAB
Erodes Quality of Life
• About 50 % of men with BPH reported that urinary
dysfunction interferes with at least one aspect of
daily living
• One in five with BPH reported that urinary
dysfunction interferes with daily activities most or
all of the time
• Men with BPH are not the only one affected, family
members may also be forced to make compromises

6. LUTS Can Be Associated With the Bladder,
the Prostate, or Both
Prostate
Male
Lower Urinary
Tract System
Benign Prostatic Obstruction (BPO)
Obstruction due to size
Benign Prostatic Hyperplasia (BPH)
Histology
Bladder Condition Prostate Condition
Detrusor Overactivity (DO)
Urodynamic observation
characterized by involuntary
detrusor contractions during the
filling phase, which may be
spontaneous or provoked
Overactive Bladder (OAB)
Urgency, with or without urgency
incontinence, usually with
frequency and nocturia
Bladder Outlet Obstruction (BOO)
Urodynamic pressure flow
Abrams P et al. Neuro Urodyn. 2002;21:167-178.
Benign Prostatic Enlargement (BPE)
Size
LUTS = lower urinary tract symptoms.

7. Evolving Terminology:
Prostatic Conditions
• Terms for prostatic conditions
– Prostatism implies prostatic disease
– BPH means histopathologically confirmed hyperplastic changes in the
prostate
– BPE is prostatic enlargement caused by BPH that has not been
histologically confirmed
– BOO may be caused by BPE and is diagnosed by urodynamic pressure-
flow studies
– LUTS suggestive of BOO implies that BOO has not been confirmed with
pressure-flow studies
• Terms should be used only after confirmation of the
condition using the appropriate diagnostic procedures
Chapple CR et al. Eur Urol. 2006;49:651-659.

8. Pathophysiology

9. Sympathetic Activity Increases
With Age
• Plasma norepinephrine levels increase more in
older patients than in younger patients.
• Aging is associated with an increase in muscle
sympathetic nerve activity.
• The highest levels of muscle sympathetic
nerve activity have been observed in the older
hypertensives.
• Sympathetic activity increases with age
contributing to the development of LUTS.

10. Development of BPH : Early
Slide 1 of 3

11. Development of BPH : Intermediate
Slide 2 of 3

12. Development of BPH : Late
Slide 3 of 3

13. Neurotransmitter Receptors

14. Distribution of Cholinergic and
Adrenergic Receptors in the LUT
Urethra (a)

15. Sympathetic and Somatic Innervation
and Receptors

16. Parasympathetic Innervation
and Receptors

17. Regulation of Urinary Function
Autonomic nervous system Somatic nervous system
• Controls involuntary functions
of the urinary tract
• Controls voluntary functions
of the urinary tract
• Some voluntary control
(eg, micturition)
• Fully under voluntary control
• Innervates smooth muscle • Innervates striated muscle

18. LUTS / OAB
A substantial proportion of men with “LUTS”
have a combination of both
“storage” & “voiding” symptoms,
suggesting possible coexisting
BOO and OAB

19. Clinical Presentation
BPH comprises;
Obstructive symptoms:
(Voiding)
Hesitancy
Weak stream
Straining to pass urine
Prolonged micturition
Feeling of incomplete
bladder emptying
Irritative symptoms:
(Storage)
Urgency
Frequency
Nocturia
Urge incontinence
a Static Component (mechanical compression of the
urethra by the enlarged prostate gland)
a Dynamic Component (increased tone of smooth
muscle fibres in the bladder neck and prostate gland)
together, the two components can give rise to a
variety of lower urinary tract symptoms (LUTS)

20. Clinical Presentation
• Storage symptoms (irritative symptoms):
– which tend to have a greater influence in provoking
patients to seek medical advice
– symptoms …… detrusor overactivity
– 40% to 60% of patients
– BPH or BOO
• Voiding symptoms (obstructive symptoms):
– Physicians tend to be more concerned about these
symptoms which are more likely to result in serious
sequelae
Rosier et al, Neurourol Urodyn, 1995

21. Definition of OAB
• Overactive Bladder Syndrome (OAB): urgency,
with or without urgency incontinence, usually
with frequency and nocturia, if there is no
proven infection or other obvious pathology.
• Detrusor Overactivity (DO):
involuntary detrusor contractions during the
filling phase of cystometry which may be
spontaneous or provoked. Previously known
as detrusor instability.
Abrams P et al. Neurourol Urodyn; 25(3):293 (2006)

22. How Does OAB Occur?
Wein AJ, Rovner ES. Int J Fertil. 1999;44:56-66.

23. Standardisation of Terminology of LUT
Function: ICS 2002
• Detrusor function during filling cystometry:
–Normal detrusor function:
–Detrusor overactivity:
• A urodynamic observation chch by involuntary
detrusor contractions during the filling phase
which may be spontaneous or provoked.
(CHANGED)

24. Standardisation of Terminology of LUT
Function: ICS 2002
• Detrusor function during filling cystometry:
–Detrusor overactivity (patterns):
• Phasic detrusor overactivity (NEW)
• Terminal detrusor overactivity (NEW)
• Detrusor overactivity incontinence (NEW)
–Detrusor overactivity (causes):
• Neurogenic detrusor overactivity (NEW)
• Idiopathic detrusor overactivity (NEW)

25. OAB vs DO
• OAB: Clinical symptomatic diagnosis
• DO: Urodynamic diagnosis
• 82% of men with OAB have DO
• 58% of women with OAB have DO
Hashim H et al. J Urol; 175 (1): 191-4 (2006)

26. The Symptoms of OAB
• Urgency: the complaint of a sudden compelling
desire to pass urine which is difficult to defer
• Urge(ncy) urinary incontinence: the complaint of
involuntary leakage accompanied by or immediately
preceded by urgency
• (Increased daytime) frequency: the complaint by the
patient who considers that he/she voids too often by
day
• Nocturia: the complaint that the individual has to
wake at night one or more times to void
Abrams P et al. Neurourol Urodyn; 21:167-178 (2002)

27. 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
Milsom I, et al. Am J Manag Care. 2000;6(suppl):S565-S573.

28. Definition of OAB
•OABdry
•OAB wet

29. Definition of OAB
To be qualified as OAB, the following symptom
combinations had to be present:
• OAB dry:
– Urgency + Frequency
– Urgency + Nocturia
– Urgency + Frequency + Nocturia

30. Definition of OAB
To be qualified as OABw, the following symptom
combinations had to be present:
• OAB wet:
– Urgency + Urge Incontinence
– Urgency + Frequency + Nocturia + Urge Incontinence
– Urgency + Frequency + Urge Incontinence
– Urgency + Nocturia + Urge Incontinence
– Urgency + Mixed Incontinence
– Urgency + Frequency + Nocturia + Mixed Incontinence
– Urgency + Frequency + Mixed Incontinence
– Urgency + Nocturia + Mixed Incontinence

31. Pathophysiology of Stress
Urinary Incontinence
• 2 Main Components:
– Intrinsic Sphincteric deficiency
– Urethral Hypermobility

32. •Urethral hypermobility
–Displacement of
urethra during sudden
increase in abdominal
pressure
–Decreases pressure
transmission
Pathophysiology of Stress
Urinary Incontinence

33. •Intrinsic sphincter
deficiency (ISD)
–Urethra is unable to
generate enough
outlet resistance to
keep the urethra
closed at rest or with
minimal physical
activity
Normal
Closure
Abnormal
Closure
Pathophysiology of Stress
Urinary Incontinence

34. •Any factor that
pushes the equation
towards
a positive urethral
pressure gradient
has the potential to
be effective
Surgery
Exercises,
medication
Cough
control,
weight loss
.
SUI Occurs When;
Bladder Pressure > Urethral Pressure