Over Active Bladder ‘an enigma’Simplified for the Dignified Audience

1. Over Active Bladder
‘an enigma’
Dr. Jyoti Agarwal
Dr Sharda Jain
Simplified for the Dignified
Audience
…Caring hearts, healing hands

2. “ Every life matters ”
“Every quality of life matters”

3. OVER ACTIVE BLADDER
Disabling condition
Significantly affects QOL

4. OAB affects all aspects of QOL
PHYSICAL
Occupational
/ Financial
Psychological
SEXUAL SOCIAL

5. OAB is an idiopathic situation where bladder
contracts erratically & is out of control
Bladder becomes
the master
sufferer becomes
the slave of bladder
Forced to map the restrooms in public places on
priority basis so as to avoid any embarresment

6. … It is a Huge Topic
Undergoing revolution
every year in terms of
definition, guidelines &
therapy

7. DefinitionInternational Continence Society meeting
Seoul, South Korea
September 2001

8. ICS defines OAB
Totally Based On Symptoms
It is a clinical syndrome :
The presence of “urinary urgency, usually
accompanied by frequency and nocturia,
with or without urge incontinence, in the
absence of UTI or other pathology.”
Widely accepted across the world

9. OAB translates into
Agony , Anxiety & Expectation
Urinate frequently ,
8 or more times in
24 hrs
Sudden, strong
desire to urinate
difficultto postpone
Sudden &
involuntary
loss of urine
Awakens
2 or more
times in night
to urinate
Urgency is the key symptom

10. OAB Burden is
Very Huge in the Society
Significantly affects QOL

11. In 2014 a large Pan Asian study :
53% of Asian women have symptoms of OAB
In India, OAB have been reported to occur as many as
1 in 6 women over 40 yrs of age

12. OAB– Underreported & Undertreated
“Tip of the iceberg”
• Less than half with bladder control problems
see a doctor
WHY?
• Embarrassment
• Low expectation from therapy
• “Normal” part of aging
• Women continue to live with it

13. Why we Gynaecologists
should burden ourselves ??

14. Simple reason is……
• Women prefers going to
women
• Women are more
comfortable with a
Gynaecologist ,
Who are masters of
pelvis and perineum &
can understand & treat
pt’s with much more
clarity

15. Important to bring the subject back to
gynaecologist to whom it belongs
To help patients of OAB
who have a physical
problem and are very
low on self - esteem

16. Our recent understanding of OAB
Moved from unknown to known

17. OAB
Facts
TricksTips

18. Bladder
Physiology

19. Micturition Cycle : Two Phases
Overactive bladder – filling phase defect

20. Bladder is Governed By Two Functions
Contraction
Relaxation

21. Inappropriate , involuntary , unpredictable detrusor
contraction during filling phase of micturition
Normal Bladder
Detrusor muscle contracting
when bladder is Full
Overactive Bladder
Detrusor muscle contracting
when bladder isn’t Full

22. Spectrum of OAB
z
• Urgency
• Frequency
• Nocturia
SUI Mixed
(UUI+SUI)
UUI
Overactive BladderOveractive Bladder
Treat the most bothersome symptom first
in pt’s with mixed urinary incontinence

23. Over activity of bladder is mostly idiopathic
but at times can have causative mechanism
• UTI
• Bladder outflow obstruction
• Interstitial / pan cystitis bladder pain
syndrome
• Honey moon cystitis
• Peri /post menopausal
• Brain & spinal cord disorders
• Drug induced
• ………

24. Risk of OAB : Strongly associated with age

25. Int Neurourol J. 2018 Jun
Published online 2018
• 50% of pt’s with cardiovascular
problem have an associated
urinary problem
• Association between cvs and
urinary symptoms may be
directly attributable to
worsening cvs
pathophysiology
• Age related heart problems
are increasing
• Drugs used to treat heart
problems : diuretics , B
blockers ,increase urinary
problems
• Drugs used to manage OAB
have documented
cardiovascular side effects

26. Urgent
Need of the hour is to have
Newer drugs which can
treat Urinary symptoms
without Worsening
cardiovascular symptoms

27. Diagnosis …..Investigations
• Diagnosis is telling you on
face
• No major test required
• Can be diagnosed easily
by taking a good history
• Listen patiently & let the
patient speak

28. Initiation of treatment does not
require an extensive workup
• Urine routine & C/S
• USG :
(renal causes, bladder wall thickness & pre
and post void urine )
• Uroflowmetry
• Urodynamics / Cystoscopy : only in refractory
cases

29. Treatment of OAB

30. Goals of Rx are
• Decrease episodes of
urgency & frequency
• Eliminate or decrease in
urinary urge
incontinence
• Ensure treatment
compliance to achieve
long term benefits
• Meet patient’s
expectation

31. Pharmacotherapy

33. Huge Amount of Behavioral
Modification
Behavioral
Modification
Education
Delayed
voiding
Timed
voiding
Diet & fluid
intake
Pelvic floor
exercises

34. Always involve the patient in therapy
Confidence Building
Both Subjective And Objective Proof

35. Bladder Training
Bladder is an organ needs to be taught
Gradually Increase Void Interval Teach Coping Strategies

36. Strengthen pelvic floor muscles
to improve bladder stability

37. Fluid & Dietary Modifications
• Avoid food/beverages which irritates the bladder
(coffee, caffeine,chocolates ,spices, tomato based food)
• Avoid fluid intake from 4 hours before sleep
• Empty bladder before sleep
or going out
• Drink small amounts often
• Avoid constipation
Weight reduction , quit smoking & alcohol

38. Since 1975 Host of drugs
available to treat OAB
Oxybutynin
Tolterodine
Solifenacin
Darifenacin
• All these drugs are good
• They all belong to the same family so
similar side effects
• Results : 50-60% with best of therapy

39. Antimuscarinics burden is huge
Causes bothersome adverse effects
Blurred Vision Constipation Dry MouthDry Eyes
80% of patients discontinue treatment at 3 months
Reduced cognitive function
Dementia in the long term
Unacceptable cardiovascular S/E limits their use

40. So…need for a newer drug
Which would be
– Efficacious
– Organ selective
– Tolerable with good
compliance
– Fewer adverse
effects

41. We were improving ourselves with one
more drug in the same family
“Ideal not obtained”
so…..Changed the Goal Post

42. • Is a wonderful drug
• Low side effect profile
• Good efficacy
• Low discontinuation
rate
Mirabegron
approved as first
line of therapy for
OAB
adrenoreceptor

43. Dawn of New Era
• Japan approved in 2011
• USA FDA approved in 2012 June
India since 2017

44. Mirabegron :
Globally Accepted Molecule and Only β3 agonist for OAB

45. For the treatment of Overactive Bladder
with Symptoms ofUrgency
Leakage
Nocturia
Overflow

46. Activates Beta-3
receptor on
Bladder wall
Inhibit afferent
signals during
filling process
Relaxes Detrusor Muscle
Increases Bladder Storage Capacity
Suppresses involuntary detrusor activity
• Reduction in Micturition Frequency
• Decreases Incontinence Episodes
• Increases Volume Voided per Micturition
Unique Mechanism of Action of
Mirabegron

47. Mirabegron
Dosage forms and strength
• Extended – release tablets
• 25 mg and 50 mg
• Once daily
• With or without food
Results are seen as early as 48 hrs

48. • Start with 25 mg Mirabegron once daily
• Assess after 2 weeks (symptons, FV chart )
• If required increase to 50 mg
• Or
• Can add a second drug as a combination
therapy – solifenacin 5 mg

49. For young patients with no comorbidity &
previous failed therapy
• Start with 50 mg once
daily
• Assess after 2 to 4 weeks
1.Frequency volume chart
2. Post void urine
• Follow up monthly
• Decrease over 8 – 12 wks
• Therapy may last for 6 to
12 months

50. • Mirabegron causes less dry mouth, constipation,
urinary retention, or blurred vision than
antimuscarinics
• Incidence of dry mouth is same as that of placebo
• Pregnancy it is category C drug
Side effects are few
& transient

52. • This prospective, non-interventional study (BELIEVE) is the largest
real-world European study to date to assess quality-of-life,
treatment satisfaction, resource utilization, and persistence in
patients with overactive bladder (OAB) who were prescribed
mirabegron as part of routine clinical practice.
• Follow-up was for 12 months with visit windows at 2-4 and 10-12
months No unexpected safety issues were observed
Curr Med Res Opin. 2017 Dec 18:1-9.
doi:10.1080/03007995.2017.1419170
862 patients were enrolled from eight European countries

53. Persistence with anti-muscarinic and mirabegron
treatment for OAB
Single-centre, retrospective study in N=701 pts with OAB treated with anti-
muscarinic agent (N=356) or mirabegron (N=345) according to physician’s preference
OAB pts seem to stay longer on mirabegron treatment
than on anti-muscarinic treatment
27% 21%
14%
63%
56% 52%
0%
20%
40%
60%
80%
1 yr 2 yr 3 yr
%ofptson
therapy
Anti-muscarinic
Mirabegron
% pts Anti-muscarinic (N=356) Mirabegron (N=345)
Symptom improvement 41.2% 68.5%

54. Bladder has a mind of its own
Very careful & delicate
balance between
Behavioral therapy &
Pharmacotherapy helps
patient’ mind to win
over bladder
Behavioral therapy continues while
Pharmacotherapy stabilises !!

56. All measures: failed
• Cystoscopic Botox injection
• Sacral Neuromodulation
• Augmentation Cystoplasty
portion of the bowel is
attached to the bladder to
increase its capacity

57. OAB is Truly A Jigsaw Puzzle
As the pieces of the puzzle are getting organised ……

58. Next time……
• If you think of urgency
• If you think of urge incontinence
• If you think of increased frequency
• If you think of nocturia – post void dribble
• Think OVER ACTIVE BLADDER
Think about all those women
whom you can empower more with Mirabegron !!

59. In my end is my begining
OAB ! Truly a challenge
Awareness ..A Dream…
Management ! A satisfying journey
Thank you

60. ADDRESS
11 Gagan Vihar, Near
Karkari Morh Flyover,
Delhi - 51
CONTACT US
9650588339
9599044257
011-22414049
WEBSITE :
www.lifecareivf.in
www.lifecarecentre.in
www.lifecareabs.in
…..Caring hearts, healing hands
ISO 9001:2008
Helpline : 9599044257
Web.www.lifecareivf.in
Helpline : 9910081484
29
Year
In
your
service