Management of Overactive BladderFor Gynecologist

1. Management of Overactive Bladder
For Gynecologist
Prof Aboubakr Elnashar
Benha university Hospital, EgyptAboubakr Elnashar

2. Definition
2002 ICS
OAB defined based on symptoms
 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)
Aboubakr Elnashar

3. Urge IncontinenceUrge Incontinence
• Sudden & involuntarySudden & involuntary
loss of urineloss of urine
Urge IncontinenceUrge Incontinence
• Sudden & involuntarySudden & involuntary
loss of urineloss of urine
FrequencyFrequency
• 8 or more visits to the toilet/24 h8 or more visits to the toilet/24 h
Nocturia Urination at nightUrination at night
•• 2 or more visits to toilet2 or more visits to toilet
during sleeping hoursduring sleeping hours
FrequencyFrequency
• 8 or more visits to the toilet/24 h8 or more visits to the toilet/24 h
Nocturia Urination at nightUrination at night
•• 2 or more visits to toilet2 or more visits to toilet
during sleeping hoursduring sleeping hours
OABOABOABOAB
SymptomsSymptoms
UrgencyUrgency
• Sudden, strongSudden, strong
desire to urinatedesire to urinate
UrgencyUrgency
• Sudden, strongSudden, strong
desire to urinatedesire to urinate
Aboubakr Elnashar

4. Epidemiology
 Adult:
1 out of 11
i.e. >osteoporosis or Alzheimer’s disease
 All ages
Aboubakr Elnashar

5. Impact on HRQoLImpact on HRQoL
significantly impairedsignificantly impaired
 SocialSocial
– Reduction in social interaction/increased socialReduction in social interaction/increased social
isolationisolation
– Cessation of some hobbiesCessation of some hobbies
 PhysicalPhysical
– Limitations or cessation of physical activitiesLimitations or cessation of physical activities
 SexualSexual
– Avoidance of sexual contactAvoidance of sexual contact
 PsychologicalPsychological
– Guilt/depressionGuilt/depression
– Fear of:Fear of:
» Being a burden Or Having urine odorBeing a burden Or Having urine odor
 OccupationalOccupationalAboubakr Elnashar

6. Physical ProblemsPhysical Problems
Limitations or cessation of
physical activities
Aboubakr Elnashar

7. Psychological ProblemsPsychological Problems
Guilt/depression
Fear of:
Being a burden Or Having
urine odor
Aboubakr Elnashar

8. Social ProblemsSocial Problems
Reduction in social
interaction/increased
social isolation
Cessation of some
hobbies
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9. Sexual ProblemsSexual Problems
• Avoidance of
sexual contact
Aboubakr Elnashar

10. Occupational/FinancialOccupational/Financial
ProblemsProblems
• Absence from work
• Job loss
• Change of job
• Poor relationship with
employers/ employee
• Financial loss
Aboubakr Elnashar

11. Vicious Circle ofVicious Circle of
Bladder Control ProblemsBladder Control Problems
Isolation Guilt
Social, domestic,
physical, sexual
and psychological
problems
Absence
from work
DepressionAboubakr Elnashar

12. Causes
• Majority: Idiopathic unknownunknown.
• Some: ±neurologicalneurological deficit.
• Multiple sclerosis
• Stroke
• Parkinson’s Disease
• Spina Bifida
• Spinal cord damageAboubakr Elnashar

13. Screening and DiagnosisScreening and Diagnosis
Aboubakr Elnashar

14. * Survey conducted by Gallup Group (European Study).
A Hidden Condition*A Hidden Condition*
 Many:Many:
Self-manage:Self-manage:
voiding frequently, reducing fluid intake, wearingvoiding frequently, reducing fluid intake, wearing
padspads
 Two-thirds:Two-thirds:
symptomatic for 2 ys before seeking treatmentsymptomatic for 2 ys before seeking treatment
 30% who seek treatment:30% who seek treatment:
receive no assessmentreceive no assessment
 80%80%
not examinednot examined
Aboubakr Elnashar

15. ScreeningScreening
 Assess history, symptoms, and test resultsAssess history, symptoms, and test results
 Establish a diagnosisEstablish a diagnosis
“Do you have bladder problems that are
troublesome, or do you ever leak urine?”
YES
Aboubakr Elnashar

16. DiagnosisDiagnosis
 A presumptive diagnosis based onA presumptive diagnosis based on
– HistoryHistory
– Physical examinationPhysical examination
– UrinalysisUrinalysis
 Initiation of noninvasive treatment mayInitiation of noninvasive treatment may
not require an extensive further workupnot require an extensive further workup
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.Aboubakr Elnashar

17. Medications That MayMedications That May
Cause IncontinenceCause Incontinence
 DiureticsDiuretics
 AntidepressantsAntidepressants
 AntihypertensivesAntihypertensives
 AnalgesicsAnalgesics
 Narcotics
 Sedatives
 Hypnotics
Aboubakr Elnashar

18. Differential Diagnosis:Differential Diagnosis:
OAB and Stress IncontinenceOAB 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
Aboubakr Elnashar

19. ManagementManagement
Aboubakr Elnashar

20. Who Manages Patients?Who Manages Patients?
• General practitioners
• Gynecologists
•Geriatricians
• Urologists
• Others E.g.
•pediatricians, neurologists, physiotherapists and
psychologists
Aboubakr Elnashar

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

22. Care PathwayCare Pathway
Screening OAB? Yes
Treat if:
Urgency and Frequency, with or
without urge incontinence, and
normal urinalysis
>8-12 w
TT Failed
Referral to
specialist
Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition.
Aboubakr Elnashar

23. ReferralReferral
 Symptoms do not respondSymptoms do not respond
to initial TT within 2 to 3to initial TT within 2 to 3
monthsmonths
 Hematuria without infectionHematuria without infection
on urinalysison urinalysis
 Symptoms suggestive ofSymptoms suggestive of
poor bladder emptyingpoor bladder emptying
 Pelvic, bladder, vaginal, orPelvic, bladder, vaginal, or
urethral painurethral pain
 Evidence of complicatedEvidence of complicated
neurologic or metabolicneurologic or metabolic
diseasedisease
 Failed previousFailed previous
incontinence surgeryincontinence surgery
 Elevated PVR volumeElevated PVR volume
 Radical pelvic surgeryRadical pelvic surgery
 Symptomatic prolapseSymptomatic prolapse
Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition.
1998.
Aboubakr Elnashar

24. Treatment OptionsTreatment Options
I.I. Life style changesLife style changes
II.II. Behavioral therapyBehavioral therapy
III.III. MedicationMedication
IV.IV. Minimally invasive therapiesMinimally invasive therapies
Botulinum A-toxinBotulinum A-toxin
NeuromodulationNeuromodulation
I.I. SurgerySurgery
Aboubakr Elnashar

25. I. Lifestyle changesI. Lifestyle changes
Moderate fluid intake
Reduce or eliminate caffeine
Avoid fluids before bed
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26. II. Behavioral Therapy
 Bladder education/retraining
 Pelvic floor muscle exercises
Aboubakr Elnashar

27. Bladder Training:Bladder Training:
• Helps patients regain control of their bladder byHelps patients regain control of their bladder by
teaching them to resist the urge to pass urineteaching them to resist the urge to pass urine
• Helps to increase bladder capacity and reduceHelps to increase bladder capacity and reduce
the number of episodes of incontinence.the number of episodes of incontinence.
- delayed/timed voidingdelayed/timed voiding
- urge suppression exercisesurge suppression exercises
• Effective but requires a high degree ofEffective but requires a high degree of
motivation and commitment from patients.motivation and commitment from patients.
Aboubakr Elnashar

28. Pelvic Floor ExercisesPelvic Floor Exercises
Repeat, as
recommended
by physician
1. Locate pelvic floor
muscles
Squeeze pelvic floor
muscles as tightly
as possible for a few
seconds (maximum
of 10 sec)
Relax completely for
at least 10 seconds
Aboubakr Elnashar

29. III. MedicationsIII. Medications
 Anticholinergic AgentsAnticholinergic Agents
1.1. Trospium chloride (Spasmex)Trospium chloride (Spasmex)
2.2. Oxybutynin (Ditropan)Oxybutynin (Ditropan)
Oxybutynin transdermal (Oxytrol)Oxybutynin transdermal (Oxytrol)
3. Tolterodine (Detrol)3. Tolterodine (Detrol)
4. Solifenacin (Vesicare)4. Solifenacin (Vesicare)
5. Darifenacin (Enablex)5. Darifenacin (Enablex)
Aboubakr Elnashar

30. Spasmex
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31. Aboubakr Elnashar

32. Onset of actionOnset of action
Trospium chlpride has looked to onset of action in the firstTrospium chlpride has looked to onset of action in the first
weekweek
Rudy D. BJU International. 2006;97:540-546.
Week 2 Week 4 Week 6 Week 8 Week 10 Week 12Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
TROSPIUMTROSPIUM
OXYBUTININ VS. TOLTERODINEOXYBUTININ VS. TOLTERODINE
SOLIFENACIN
TOLDERODINE
DARIFENACIN
TROSPIUM
Aboubakr Elnashar

33. Aboubakr Elnashar

34. Side EffectsSide Effects
Aboubakr Elnashar

35. 1. Trospium Chloride1. Trospium Chloride
((SpasmexSpasmex))
 Quaternary amine as opposed toQuaternary amine as opposed to
tertiary aminetertiary amine
 20 mg BID dose20 mg BID dose
 No pass through blood/brain barrierNo pass through blood/brain barrier
with less side effectswith less side effects
 Rapid onsetRapid onset
 Not metabolized by liverNot metabolized by liver
 60% excreted in the urine unchanged60% excreted in the urine unchanged
Aboubakr Elnashar

36. 2. Oxybutynin (Ditropan)2. Oxybutynin (Ditropan)
 Previous standard of treatment for urgePrevious standard of treatment for urge
incontinenceincontinence
 Effectively reduces symptomsEffectively reduces symptoms
 High incidence of dry mouth severe enough toHigh incidence of dry mouth severe enough to
cause discontinuationcause discontinuation
 Reported to cause CNS adverse events andReported to cause CNS adverse events and
cognitive dysfunctioncognitive dysfunction
Katz IR et al. Am J Geriatr Soc. 1998;46:8-13.
Donnellon CA et al. BMJ. 1997;315:1363-1364.
Yarker YE et al. Drugs and Aging. 1995;6:243-262.
Aboubakr Elnashar

37. Oxybutynin TransdermalOxybutynin Transdermal
(Oxytrol)(Oxytrol)
 3.9 mg patch, twice weekly3.9 mg patch, twice weekly
 Similar in effects to poSimilar in effects to po
 Side effects – less dry mouth butSide effects – less dry mouth but
erythema/pruitiserythema/pruitis
Aboubakr Elnashar

38. 3. Tolterodine (Detrol. Detrusitol)3. Tolterodine (Detrol. Detrusitol)
 Immediate: 2 mg.Immediate: 2 mg.
long acting LA 4 mg dosinglong acting LA 4 mg dosing
 Side effects: similar to oxybutyninSide effects: similar to oxybutynin
 Develop a potent and pure muscarinicDevelop a potent and pure muscarinic
receptor antagonistreceptor antagonist
 Equipotent to oxybutynin on the bladderEquipotent to oxybutynin on the bladder
 Less potent than oxybutynin onLess potent than oxybutynin on
glands/salivationglands/salivation
Aboubakr Elnashar

39. 4. Solifenacin (Vesicare)4. Solifenacin (Vesicare)
 5 – 10 mg daily dose5 – 10 mg daily dose
 Side effects: dry mouth, constipationSide effects: dry mouth, constipation
Aboubakr Elnashar

40. 5. Darifenacin (Enablex)5. Darifenacin (Enablex)
 MM33 selective anticholinergicselective anticholinergic
 7.5 mg or 15 mg once a day7.5 mg or 15 mg once a day
Aboubakr Elnashar

41. IV. Minimally invasive therapies
1. Botox®
injection
• 100 units diluted in 10ml saline in 30 injection sites,
sparing the trigone
• Under local anesthesia (xylocaine 2% in 20ml, 20
minutes)
Aboubakr Elnashar

42. 2. Sacral
Neuromodulation
Implantation of programmable
stimulator SC which delivers
low amplitude electrical
stimulation via a lead to the
sacral nerve, usually accessed
via the S3 foramen.
FDA has approved InterStim
Therapy, by Medtronic, as a
safe sacral nerve stimulator for
treatment of Urinary Urge
Incontinence, Urinary
Frequency, and Urinary
Retention.
Aboubakr Elnashar

43. V. SurgeryV. Surgery
 All measures: failedfailed.
 CystoplastyCystoplasty
a portion of the bowel is attached to the
bladder to increase its capacity
Aboubakr Elnashar

44. Conclusion
1. Definition
• Urgency
• Frequency ± Urge incontinence
1. Screening and Assessment
• History, Physical
1. Management Approach
• Lifestyle, Behavioural, Pharmacological
1. Safety of Pharmacologic agents in the
Elderly
• Use agents which don’t cross the BBB
Aboubakr Elnashar

45. Thank YouThank You
Aboubakr ElnasharAboubakr Elnashar
Aboubakr Elnashar