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Current Approach to Overactive Bladder, Issues & Management by Prof. Haleema A. Hashmi

Current Approach to Overactive Bladder, Issues & Management by Prof. Haleema A. Hashmi, Obstetrician & Gynaecology, Liaquat National Hospital & Medical College, Karachi, Pakistan.

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Current Approach to Overactive Bladder, Issues & Management by Prof. Haleema A. Hashmi

  1. 1. Prof. Haleema A. Hashmi Department of Obstetrics & Gynaecology Liaquat National Hospital & Medical College Karachi - PAKISTAN
  2. 2. Storage phase Emptying phase Bladder pressure Storage phase Detrusor relaxes + Urethra contracts + Pelvic floor contracts Bladder filling Normal desire to void Detrusor contracts + Urethra relaxes + Pelvic floor relaxes MICTURITION First sensation to void Detrusor relaxes + Urethra contraction increases + Pelvic floor contracts First sensation to void Detrusor relaxes + Urethra contraction increases + Pelvic floor contracts Bladder filling Detrusor relaxes + Urethra contracts + Pelvic floor contracts Bladder filling Detrusor relaxes + Urethra contracts + Pelvic floor contracts Normal desire to void Detrusor contracts + Urethra relaxes + Pelvic floor relaxes MICTURITION
  3. 3. Frequency, including nocturia Urgency Urge incontinence OAB “OAB is defined as urgency, with or without urge incontinence, and usually with frequency and nocturia” OAB = overactive bladder; ICS = International Continence Society.Abrams P. Urology. 2003;62(Suppl 5B):28-37.
  4. 4. l Urgency: The complaint of a sudden, compelling desire to pass urine that is difficult to defer l Urge incontinence: The complaint of involuntary leakage of urine accompanied or immediately preceded by urgency l Frequency: Usually accompanies urgency with or without urge incontinence and is the complaint by the patient who considers that he/she voids too often by day l Nocturia: Usually accompanies urgency with or without urge incontinence and is the complaint that the individual has to wake at night one or more times to void Abrams P, et al. Urology. 2003;61:37-49.
  5. 5. Increased Frequency and Reduced Intervoid Interval Nocturia Urgency 1 Incontinence Reduced Volume Voided per Micturition 1 2 2 1. Proven direct effect 2. Effect correlated with urgency but inconsistent due to multifactorial etiology of the symptom Reference: Chapple CR et al. Br J Urol (2005) 95: 335-340
  6. 6.  Symptoms of OAB are due to involuntary contractions of the detrusor muscles during the filling phase of the micturation cycle.  Mediated by acetylcholine induced stimulation of bladder muscarinic receptors  Muscarinic receptors M2 – M3 are demonstrated to cause direct smooth muscle contraction  M3 receptor is responsible for the normal micturition contraction.
  7. 7. +M3 Pelvic Nerve (Parasympathetic) ACh +N Pudendal Nerve (Somatic) ACh - 3 +1Hypogastric Nerve (Sympathetic) NE
  8. 8. 0 5 10 15 20 25 30 35 40 45 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75+ Age (years) Prevalence(%) EU SIFO Study Men Women l 17% of the adult population have symptoms of OAB l Prevalence of OAB increases with age l Similar prevalence among men and women (women may present more) Source: Milsom et al. 2001
  9. 9.  Prevalence of OAB in women of reproductive age is 16.9%, 30.9% women over 65 years.  Frequency 8.5%  Urgency 65%  Urinary Incontinence 36%
  10. 10. Outflow obstruction Hypothesis:  Outflow obstruction lead to partial denervation  Reduction in acetyl cholinesterase staining nerves in obstructed human bladder.  Muscle strips from patient, with detrusor over activity exhibit super-sensitivity to acetylcholine  It causes alteration of the contraction properties of the detrusor muscle.  Individual cells are more irritable when synchronus activation is damaged.
  11. 11.  The patho-physiology of idiopathic and obstructive overactive bladder is different  Neurogenic hypothesis is controversial  Detrusor develops post junctional super sensitivity due to partial denervation, with reduced sensitivity to stimulation to electrical stimulation of its nerve supply, but a greater sensitivity to stimulation with Ach.  If obstruction is relieved the detrusor can return to normal behaviour, renervation may also occur.
  12. 12.  Relaxation of urethra is known to precede contraction of the detrusor in women with detrusor over-activity  Not proved by experiments done by southerst & Brown. Ref: Sutherst JR etal, The effect on the bladder pressure of sudden entry of fluid into the posterior urethra. Br J Urol 1978; 50: 406-9.
  13. 13.  Brading & Turner Suggested that common feature in all cases of detrusor over-activity is partial denervation of detrusor which alters the properties of smooth muscle resulting in coordinated myogenic contraction of the whole detrusor.  Charton etal suggested that primary defect in the Idiopathic and neuropathic bladder is a loss of nerves accompanied by hypertrophy of the cells and increased production of elastin and collagen within the muscle fascicles. Ref: 1. Brading AF, Turner WH. The unstable bladder: towards a common mechanism. Br. J Urol 1994; 73: 3-8. 2. Charlton RG, Morley AR, etal, Focal changes in nerve, muscle and connective tissue in normal and unstale human bladder. BJU Int 1999; 84 953-60.
  14. 14.  The role of the afferent activation in the urothelium and sub-urothelial myofibroblasts has been investigated as a factor in pathophysiology of detrusor over-activity.  Studies revealed that ATP is released from the urothelium by bladder distension evoking neuronal discharge leading to bladder contraction.  In addition prostanoids and nitric oxide are synthesised locally in urothelium and also released by bladder distension.
  15. 15.  Multiplicity of symptoms  Urgency  Daytime frequency  Nocturia  Urgency incontinence  Exclude other causes of frequency & urgency
  16. 16.  History  Abdominal examination  abdominal mass  full bladder  Pelvic examination  demonstrable stress incontinence  oestrogen status, vulval excoriation  associated pathology  Rule out neurological lesion  Examine cranial nerves and S2, S3 & S4 outflow to rule out multiple sclerosis
  17. 17.  Idiopathic detrusor overactivity  Urinary tract infection  Stress urinary incontinence  Interstitial cystitis  Renal stone  Bladder tumours  Overflow incontinence with retention  External pressure (pregnancy, fibroids, pelvic mass)  Secondary to medical conditions (diabetes, myeloma)  Iatrogenic (diuretics and other drugs, post hysterectomy)  Psychosocial (dementia, physical disability)
  18. 18.  Urine analysis  Micturition diary  Symptoms questionnaire  QOL Questionnaire  Uroflowmetry  Pad test  Urodynamics
  19. 19.  Recurrent urinary tract infections  Haematuria – calculus, tumour  Painful symptoms  Short duration of symptoms  Symptoms persist inspite of treatment e.g. recurrent UTI
  20. 20.  The International Continence Society (ICS) has defined the following three types of urinary diary on the basis of the recorded parameters:  Micturition charts record only the times of micturition, day and night, for at least 24 h.  Frequency-volume charts record the volumes voided and the time of each micturition, day and night, for at least 24 h.  Bladder diaries record the times of micturition and voided volumes, as well as other information, such as incontinence episodes, pad usage, fluid intake, degree of urgency, and the degree of incontinence.
  21. 21.  Frequency  Nocturia  Total Voided Volume  Nocturnal Voided Volume  Total Intake  Functional Bladder Capacity  Mean Voided Volume  Type of fluid ingested
  22. 22.  Modified bladder diary De Wachter and Wyndaele  No desire to void  Normal desire to void  Strong desire to void  Urgent desire to void
  23. 23. In order to measure urgency severity urgency scoring systems can be used such as:  Patient perception of intensity of urgency score (PPIUS)  Urgency perception score (UPS)  Indevus Urgency Severity Scale (IUSS)
  24. 24.  Uroflowmetry  Filling cystometry  Pressure / flow voiding studies
  25. 25. Unobstructed Equivocal Obstructed
  26. 26. Therapeutic Agents Side-effects Diuretics urgency, frequency and UI Some calcium antagonists urgency Benzodiazepines sedation and confusion causing secondary incontinence Alcohol diuresis, impaired perception of bladder filling, OAB Anticholinergics including Antidepressants Opiates & Antiparkinson drugs urinary retention with overflow
  27. 27.  Bladder Retraining – first line treatment recommended by AUA. First described by Jeffcoate & Francis  Pelvic Floor Muscle Retraining Detrusor muscle contraction can be inhibited by pelvic floor muscle contraction  A meta analysis has concluded that bladder retraining is more useful than placebo.  Too few studies to evaluate PFMT.  NICE and ICI (International consultation on Incontinence) recommend that bladder retraining should be considered as first line treatment in all women with OAB.
  28. 28.  Botulinium Toxin Botox A  In 2011 FDA approved Botox A injections use on bladder.  In 2013 approved for treatment of OAB.  100 units injected into bladder wall muscle at 30 sites for OAB & 200 units for neurogenic bladder.  Acts by inhibiting the parasympathetic response of Ach from the motor neurons and inhibits detrusor contraction.
  29. 29.  Stop Aspirin 7 days before therapy  Antiplatelet therapy should be stopped  Do not give if nitrite +ve in dipstick of morning urine.  UTI should be excluded at the site of injection  No acute urinary retention at the time of treatment  Patient willing to initiate self catheterization as there is significant risk of voiding diffeculties.
  30. 30.  Minimally invasive  A small electrode is placed in both legs near medial malleolus  Electrode connected to stimulator which generates electric current  Every 12th week 30 minutes session is required.
  31. 31.  Acts by activation of affarent sacral nerve that inhibit para sympathetic motor neuros there by prevents detrusor contractions.  More invasive  Requires O.T. fascilities
  32. 32.  OAB, distressing condition affect QOL  The clinical diagnosis is of exclusion  Urodynamic investigations needed to demonstrate detrusor over activity  Majority will benefit from conservative treatment eventually requires drug therapy.  Refractory OAB treated with Botulinum Toxin, neuro modulation  Reconstructive surgery for refractory patients – may require ileal diversion, clam cystoplasty or detrusor myectomy. A every small number will need with severe morbidity.