This document discusses Dr. Santosh Agrawal's background and credentials as a urologist and kidney transplant surgeon. It then provides information on overactive bladder (OAB), including definitions, prevalence statistics, quality of life impacts, incidence being underreported, and OAB classification systems. Diagnosis of OAB is discussed, covering patient history, physical exam, lab tests, bladder diaries, and urodynamics. Conservative management options like behavioral modification, bladder training, pelvic floor muscle therapy, and pharmacologic therapies are summarized. Specific drugs for treating detrusor overactivity like tolterodine are also mentioned.

1. DR SANTOSH AGRAWALDR SANTOSH AGRAWAL
Chief Urologist and Kidney Transplant SurgeonChief Urologist and Kidney Transplant Surgeon
Bansal Hospital , Bhopal, MPBansal Hospital , Bhopal, MP
MBBS, MS, MCh (PGI, Chandigarh), FIAGES, FALSMBBS, MS, MCh (PGI, Chandigarh), FIAGES, FALS
Fellow in Robotic Surgery, Roswell Park Cancer Institute, Buffalo ,Fellow in Robotic Surgery, Roswell Park Cancer Institute, Buffalo ,
USAUSA

2. 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)
OAB16.6%

3. Impact of Urinary Incontinence on
Quality of Life
Quality of Life
Physical
• Limitations or cessation
of physical activities
Sexual
• Avoidance of sexual
contact and intimacy
Occupational
• Absence from work
• Decreased productivity Social
• Reduction in social interaction
• Alteration of travel plans
• Increased risk of institutionalization
of frail older persons
Domestic
• Requirements for specialized
underwear, bedding
• Special precautions with clothing
Psychological
• Guilt/depression
• Loss of self-respect and
dignity
• Fear of:
− being a burden
− lack of bladder control
− urine odor
• Apathy/denial

4. Incidence
underreported
• Tip of the iceberg
• Increasing incidence
in an aging
population
Tip of Iceberg

5. OAB - Definition
“Urgency, with or without urge
incontinenence , usually with frequency and
nocturia… if there is no infection or proven
pathology.
Abrams et al . Neurourol Urodyn 2002:21; 167- 78

6.  Nocturia is the complaint that the individual has to wake at
night one or more times to void. (NEW)
 Urgency is the complaint of a sudden compelling desire to
pass urine which is difficult to defer. (CHANGED)
 Increased daytime frequency is the complaint by the patient
who considers that he/she voids too often by day. (NEW)
 Urinary incontinence is the complaint of any involuntary
leakage of urine. (NEW)
 Urge urinary incontinence is the complaint of involuntary
leakage accompanied by orimmediately preceded by
urgency. (CHANGED)

7. Confusing terminologies
 Unstable bladder- english term for
involuntary detrusor contraction
 Detrusor hyperreflexia – scandinavian
term
Sensory urgency/motor urgency
 Overactive bladder
First ICS standardistion , 1980( tage Hald)
1.Unstable bladder – idiopathic
2.- detrusor hyperreflexia – neurogenic

8. Diagnosis of OAB

9. Diagnosis of Overactive Bladder
 Most cases of overactive bladder can be diagnosed
based on:
patient history, symptom assessment
physical examination
urinalysis
 Initiation of noninvasive treatment does not require an
extensive further workup
 Bladder diary

10. History
 How long? How old when started?
 How much (volume)? Degree of bother?
 Characteristics of leakage?
Activity related?
Day and night, wet pads at night = instability
Urgency?
○ Suppressible = probably SUI
○ not suppressible (urge incontinence) = instability
 Other: fluid intake, UTI’s, pain, hematuria, LE swelling,
medications

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

12. Bladder diary
 The ICS describes three types of charts (ICS 2002)
1. Micturition time chart: This records only the times of micturition,
day and night, for at least 24 hours.
2. Frequency-volume chart: This records the volumes voided as well
as the time of each micturition, day and night, for at least 24
hours.
3. Bladder diary: This records the times of micturition, voided
volumes, incontinence episodes, pad usage, and other
information, such as fluid intake, the degree of urgency,and the
degree of incontinence.

13. Bladder diary
 Importance -
1. Substitute for cystometry (largest VV correlate
with cystometric capacity.
2. Helps determining safe voiding interval to begin
bladder training.
3. Helps in objectively measuring the change during
treatment.
4. Involves the patients in treatment program which
is essential to behavioral therapy.
5. Fluid intake may be assessed.
Patient is asked to void at longest consistently dry
interval, increased 15 – 30 minutes per week

14. Physical Examination
• Abdomen
– Masses: palpable bladder, etc.
• Pelvis/perineum
– External genitalia: atrophic vaginitis
• vaginal
• Strenght of PFM
• Prolapse (assoc. 50% of SUI patients)
• GYN malignancy, fistula
• Rectal:
– tone, masses, teach Kegels during exam
– prostate
• Neurological (reflexes, LE’s, sensory, motor)

15. Physical Examination
 Rule out possible causes of LUTS
 Atrophic vaginitis
 Estrogen deficiency
 Pelvic floor dysfunction
 Pelvic organ prolapse
 Potentially serious pathologic conditions
• Cystocele
• Rectocele
• Enterocele
• Uterine prolapse
Signs of HypoestrogenationSigns of Hypoestrogenation
Prominent
caruncle

16. OAB Vs PBS/IC

17. OAB Vs PBS/IC

18. The differences in the development of bladder
sensation in OAB and PBS.

19. Fantl JA, et al. Agency for Healthcare Policy and Research;
1996. AHCPR publication 96-0686.
Laboratory Tests
 Urinalysis
Routine & microscopy
 Culture
 Look for hematuria, pyuria, bacteriuria, glucosuria,
proteinuria
 Appropriate blood work up
Glucose
Electrolytes
Prostate specific antigen (PSA) in men

20. Laboratory Tests
 Rule out possible causes of LUTS
Urinary tract infection (UTI) or sexually transmitted
disease (STD)
Diabetes mellitus
LUT tumor or kidney stones
Potentially serious pathologic conditions

22. Urodynamics
• Urodynamic evaluation is recommended:
prior to invasive treatments
after treatment failure
 Urodynamic studies should only be performed after a full
basic urological assessment

23. ‘A Urodyanamic observation characterized by
involuntary detrusor contractions during the
filling phase which may be spontaneous or
provoked’
Abrams et al, 2002
Neurogenic Idiopathic
Non neurogenic Terminal Phasic

24. Cough induced DOPhasic DO

25. Urodynamic classification of OAB
(Flisser et al)
 Based on-
Presence of DO
Patients awareness
Ability to abort
 Type 1 -4

26. OAB – 1: The patient complains of OAB
symptoms, but no involuntary detrusor contractions
are demonstrated.

27. OAB - 2
There are involuntary
detrusor contractions,
but the patient is aware
of them and can
voluntarily
contract the sphincter,
prevent incontinence,
and abort the detrusor
contraction.

28. OAB - 3
•Involuntary detrusor
contractionspresent , the
patient is aware of them and
can voluntarily contract the
sphincter and momentarily
prevent incontinence, but the
patient is unable
to abort the detrusor
contraction and when the
sphincter fatigues,
incontinence ensues .

29. OAB- 4
Involuntary detrusor
contractions present , but
the patient is not able to
contract the
sphincter voluntarily or
abort the detrusor
contraction and simply
voids involuntarily

30. Overactive bladder and detrusor
over activity

31.  Maneuvers to do if no DO demonstrated –
Sitting position
Fast fill rate
Coughing

32. Do OAB symptoms predict DO?
 Unselected population of 4,500 women with LUTS
Only 54% of women with OAB had DO
32% of women without OAB still had DO
Digesu et al, 2003
 Multivariate regression of factors predicting DO in cohort or 551
women
Cardinal symptoms of OAB namely urgency, frequency and
UUI were not found to be statistically significantly associated
with DO
Aschkenazi, Sand et al, IUGA 2007

33. Do OAB symptoms predict DO?
 Combination of urgency, urge
incontinence and frequency
strongly predicts DO
 Correlation is greater in men
than women
 Perhaps because stress
incontinence is more common
in women
 Perform UDS only when it will
change management
Hashim and Abrams, 2006
n =
1809
Prevalence of DO
Men Women
OAB
dry 69% 44%
OAB
wet 90% 58%

34. Therapy for OAB
1) Behavioral modification/ lifestyle
changes
2) Pelvic floor muscle therapy
3) Oral pharmacologic agent
4) Intravesical agent -
1) Capsaicin
2) Resiniferatoxin
3) Botulinum toxin - A
5) Sacral Neuromodulation
6) surgical therapy

35. Conservative management
 Behavioral modification
Dietary modification
Bladder training
Fluid management
 Pelvic floor muscle therapy (PFMT)

36. Management
 OAB – often can not be cured
 Sympathetic approach
 Reasonable expectation
 Goal – minimize effect on quality of life

37. Behavioral Modification
pa
Patient
Education
Voiding diary
Urge
inhibition
Timed
voiding
Fluid and Diet
Management
Pelvic floor
exercises

38. Patient education
 What is normal voiding?
 What’s wrong with them?
 Normal anatomy and function of PFMs.

39. Bladder training / timed voiding
 Most commonly used technique for UUI and OAB
 What is bladder training ?
 What is timed voiding ?
 Goal is 2-4 hrs void interval
between voids with continence.

40. Urge
inhibition
 Devolopment of
dysfunctonal behavior
Break the cycle
 PFM contraction –
quick flicks
distraction until
urgency goes.
-
Stop rushing to the toilet

41. Life style modification
 Fluid management-
 ALPP- volume dependent
 OAB – volume driven, slower filling better compliance
 Normal fluid intake rather than restriction recommended
 Avoid caffeinated beverages, acidic juices, and alcohal
 Avoid evening fluid
 Caffeine – scant level 1 evidence
 Smoking cessation – no evidence
 Obesity /weight reduction – level 2 evidence ( scant level 1
evidence )
 Avoid constipation

42. Pelvic floor muscle training
(PFMT)
 PFM contraction is taught to the patient
 Taught by a health care professional.
 Rational – repeated exercise will improve
responsiveness
 Bulk is not important
 Fifteen RCT – PFMT Vs no intervention, sham, control
have showed effectiveness in all type of incontinence.
(Grade A recommendation as first line therapy)

43. Risk factor for failure OF PFMT
 More than 2 leaks per day
 Presence of leak at 1st
cough
 Use of antidepressant and anxiolytic medication.

44. PFMT – clinical practice
 Most intensive PFMT supervision possible should be
applied.
 Representative program( C. Payne in Campbell’s
urology, 9thedition)
Sets of 10 – 12 near max contraction
Each contraction held 6 – 6 secs with equivalent rest
period
3-5 times a week

45. Three groups
1. No or minimal ability to contract the levator muscle
2. Can isolate the correct muscle with poor strength
3. Good PFM strength and isolation

46. Behavioral Modification
Burgio, et al
 197 women with urge incontinence
 Modified crossover design
 Initially on monotherapy of either
Behavioral therapy
Drug therapy (oxy 2.5-15 mg/d)
 Combined therapy offered after 8 weeks if not content
with monotherapy alone
Burgio et al. JAGS. 2000;48:370-
374

47. Behavioral Modification
 Behavioral therapy
57.5% reduction in incontinence
8 pts crossed over
88.5% reduction in incontinence when meds added (p=0.034)
 Medical therapy
72.7% reduction in incontinence
27 pts crossed over
84.3% reduction in incontinence when meds added (p=0.001)
 Conclusion: combining drug & behavioral therapy in a stepped
program can produce added benefit for patients with UUI
Burgio et al. JAGS. 2000;48:370-374

48. Biofeed back
 Method of training to control body function.
 Palpation only
 Vaginal cone
 Vaginal cone better than no treatment, not superior to
PFMT

49. Electrical and magnetic
stimulation
 Passive treatment – not motivated patients to do PFMT
 No evidence to define specific role
 Grade C recommendation

50. Pharmacologic Therapy for the
Treatment of OAB
 Antimuscarinic agents are the mainstay for treating
OAB
 OAB symptoms relieved by
Increased bladder volume for first involuntary
contraction
inhibition of involuntary bladder contractions
increased bladder capacity
 Treatment can be limited by side effects such as dry
mouth, GI effects (eg, constipation), and CNS effects

51. Drugs Used in the Treatment of Detrusor Overactivity (International
Consultation on Incontinence Assessments, 2004: Oxford Guidelines)

52. Abrams P, Wein AJ. The Overactive Bladder— A Widespread and Treatable
Condition. 1998.
Muscarinic Receptor Distribution
Bladder (detrusor muscle)
Salivary
glands
Dry mouth
Colon Constipation
Heart
Stomach and
esophagus
Dyspepsia
Iris/ciliary body
Lacrimal gland
Blurred vision
Dry eyes
Tachycardia
• Dizziness
• Somnolenc
e
• Impaired
memory
and
cognition
CNS

53. Anticholinergics
A Delicate Balance
Efficacy
• Less frequency
• Less UUI
• Increased voided volume
Adverse effects
• Dry mouth
• Constipation
• CNS

54. Antimuscarinic
 Tertiary amine (higher lipophilicity, less molecular
charges )
1. Atropine
2. Tolterodine
3. Oxybutinine
4. Propiverine
5. Derifenacine
6. Solifenacine
 Quartenary amine
1. Propantheline
2. Trospium

55. Tolterodine(2mg, 4mg)
 Tertiary amine, rapidly absorbed, extensively
metabolised(CYP2D6), lipophilic
 Active metabolite –5- hydroxy methyl metabolite ( half
life = 2-3 hrs)
 Bladder effect – long lasting
 Nonselective antimuscarinic
 Bladder selectivity over salivary gland
 Available as IR and EL tablets
 Grade – A recommendation

56. Trospium
 Quartenary amine, less lipophilic, 10% GI absorption
 Half life – 20 hrs
 Not metabolized, excreted unchanged
 Nonselective
 Less CNS side effects
 Efficacy and tolerability proved in many RCTs
 Grade – A recommendation

57. Derifenacine
 Tertiary amine, moderate lipophilicity, well absorbed,
extensively metabolized(CYP3A4 & CYP2D6).
 Relatively selective M3 antimuscarinic.
 Efficacy proved in many RCTs .
 MC s/e- mild to mod. - Dry mouth and constipation
 No effect on cognitive function in elderly (Lipton et al,
2005)
 Daily single dose – 7.5mg, 15 mg
 Grade A – recommendation
 Very few discontinuation

58. Derifenacine increases warning
time for urgency
 Multicenter , double blind RCT
 To assess effect of derifenacine on the warning time
associated with urgency
 Derifenacine 30 mg daily vs placebo
 First sensation of urgency to voluntary micturition or
incontinence recorded by electronic event recorder.
 Significant increase in mean warning time , median
increase – 4.5 minutes

59. Solifenacine
 Tertiary amine, well absorbed (90%), significant
hepatic metabolism(CYP3A4).
 Half life – 50 hrs
 Relatively bladder selective
 Mid to moderate dry mouth
 Availabe as 5 mg and 10 mg
 Efficacy proved in many RCTs
 Grade A recommendation
 More efficacious than tolterodine (4mg ER) in flexible
dosing regimen

60. Oxybutinine
 Tertiary amine , well absorbre, extensive first pass
metabolism
 Major metabolite N – des-ethyl oxybutinine, cause dry
mouth
 Plasma half life = 2 hrs
 Available as IR( 5mg tid or qid), ER, transdermal( 3.9
mg twice weekly )
 Can be given intravesical
 Antimuscarinic and local anesthetic property
 Dry moth 80% with IR

61. Which antimuscarinic to use?
 All have Level 1 evidence; Grade A recommendation14
 Choice depends on cost, availability, efficacy, tolerability, side
effects
 Extended release versions of oxybutynin and tolterodine are
marginally more efficacious than the immediate release but have
fewer adverse events
 Trospium, theoretically, does not cross the blood-brain barrier
and thus is advantageous in the elderly and those who operate
machinery
 Oxybutynin patch is transdermal and is advantageous in those on
oral polypharmacy or those who do not like taking tablets or
cannot tolerate them
 Solifenacin and darifenacin have the advantage of dose
escalation

62. Intravesical capsaicin and Resiniferatoxin
– promising approach
 Mechanism – initial excitation followed by long lasting
blockade
 Not approved for clinical use
 Have been tried in neurogenic DO
 de seze, 2004
 Double blind RCT capsaicin vs. RTX
39 spinal cord injury patients
Clinical and urodynamic improvement in 78% & 80%
in capsaicin group, 80% & 60% in RTX group
Well tolerated

63. Botulinus Toxin
 One gram of crystalline toxin will kill one million
people.
 Four distinct bacteria produce 7 toxins A – G
 A, B and E are implicated in human cases of botulism
Botox
Dysport
Neuronox

64. Administration of BTX A into the
detrusor
 Rigid or flexible
cystoscopy
 Williams flexible
cystoscopic injection
needle (23 G)
 200 units BTX made up
20mls saline
 20 x 1 mls injections into
the detrusor, sparing the
trigone.

65. Meta- analysis – OAB – idiopathic DO
641 patients / 29 single injection studies
 Efficacy rates for BoNTA varied (range: 36.4– 89.0%; mean:
69%) due to different definitions of efficacy and assessment
tools used.
 Complete continence was achieved in a mean of 58% of
patients (range: 32–86%);
 all studies reported significant reductions in incontinence
episodes (mean: 65%).
 The mean benefit from a single treatment was 6mo (range: 4–
10 mo).
 The range of duration of effect depended on the dosage, site,
and depth of injections(LoE 2b).
 There is no full paper on the efficacy of repeat injections in
non-neurogenic OAB/DO.
 There is LoE 1b that BoNTB is also effective but of short
duration
european urology 55 ( 2 0 0 9 ) 100–120

66. EAU recommendation,2009

67. Sacral nerve neuromodulation - InterStim
Therapy
 Second line
treatment of OAB
 Over 30,000
patients implanted
worldwide
 FDA approval –
2002

68. Sacral nerve modulation –
mechanism
Normal guarding reflex Sacral nerve stimulation

69. Test Stimulation (stage 1)
A test is done to determine the respond to
the stimulus.
Performed in the office (20 minutes).
A lead is placed under the skin 9 cms above
the coccyx and 1- 2 lateral to midline.
Lead is connected to an external
device (size of a pager).
Permanent device if >50%
improvement in urgency
frequency symptoms for
2- 4 weeks .

70. Procedure done in
operating room using a light
anesthesia on a same day
surgery basis.
Stimulator is usually placed
in upper buttock
The entire InterStim System
will reside under the skin
Entire procedure takes less
than one hour

71. How effective is this therapy?
 Schmidt et al 1999,
76 patients randomized to active or delayed SNS
16/38 dry at 6 month in active arm, 10(29%) >50%
improvement
 Hassouna et al 2000
 51 patients randomized to 2 groups
 Imrovement seen in all the patients
 Symptoms reappered after IPG turned off.

72. Potential Risks with InterStim Therapy
As with other surgical procedures, there are risks:
Pain
Infection
Transient electrical shock
Lead migration