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Diagnosis and Management of Overactive Bladder

(Published March 2011)

Introduction to Overactive Bladder

Overview

  • Overactive bladder (OAB) is a term first used in the 1990s to describe a constellation of lower urinary tract symptoms (LUTS).
  • OAB is prevalent and significantly affects patients' quality of life.

Definitions

  • OAB is urinary urgency (with or without urinary incontinence), urinary frequency, and nocturia, in the absence of proven infection or other obvious pathology.1
  • Urinary urgency is a compelling urge to urinate that is difficult to defer.2
  • Urinary frequency is defined as voiding more than eight times in 24 hours.3,4
  • Nocturia is defined as awakening more than one time per night to void.5

Pathophysiology

  • The symptoms of OAB are suggestive of urodynamically demonstrable detrusor overactivity, although they can be due to other forms of urethro-vesical dysfunction.1
  • OAB is also thought to result from changes in the afferent nerve endings in the bladder that increase bladder sensation.6

Prevalence

  • Approximately 17 percent of adults more than 18 years old have OAB.7-9
  • The prevalence of OAB increases with age among both men and women.
  • One third of patients with OAB have incontinence.8
  • As many as 45 percent of women will have urinary incontinence in their lifetime.10

Types of urinary incontinence

  • Urge urinary incontinence (UUI) is incontinence characterized by a compelling need to urinate
  • Stress urinary incontinence (SUI) is incontinence during sudden increases in intra-abdominal pressure (cough, sneeze)
  • Mixed urinary incontinence is a combination of stress and urge incontinence

 Prevalence of OAB comorbiditiesComorbid conditions

  • Several conditions are significantly more frequent among patients with OAB than among control subjects; the most prevalent comorbidities are urinary tract infections (UTIs), falls, and fractures.11
  • In one study:12
    • Of women more than 65 years old who had urge incontinence at least once per week, 19 to 42 percent sustained falls.
    • Fractures occurred in 4 to 9 percent of these falls.
    • Frequent urge incontinence was an independent risk factor for falling (OR = 1.26).

Impact of incontinence

  • Impact on patients:
    • Psychological—People with OAB may become depressed because of their symptoms, and some feel guilty. The embarrassment of leaking or smelling of urine can lead to a loss of self-respect and dignity.
    • Social—OAB sufferers might restrict social activity outside the home for fear of leaking urine or because of the frequent need to use a toilet.
    • Domestic—Some individuals with OAB use specialized undergarments and bedding materials for incontinence. These items can be costly and are not always covered by medical insurance.
    • Occupational—Overactive bladder may lead to decreased productivity in the workplace. Some patients may avoid going to work for fear of leaking urine.
    • Sexual—Women with OAB have reported avoiding dating and sexual intimacy because of overactive bladder symptoms and fear of leaking urine.
    • Physical—Some physical activities like exercising might be limited because of the frequent need to urinate or fear of leaking urine.
  • Impact on society:
    • Cost—$12.6 billion was spent on therapy for OAB in 2000 ($9.1 billion spent for community residents and $3.5 billion for institutional residents).13
  • Missed opportunities for treatment
  • More than 50 percent of patients who seek treatment for OAB wait more than a year before seeing a health care provider.14,15
  • Despite the widespread prevalence of OAB, its impact on quality of life, and its overall morbidity, this condition remains undiagnosed and undertreated for many patients.
    • Patient-related causes:7,16,17
      • Embarrassment
      • Failure to see symptoms as abnormal
      • Belief that symptoms are self-limited
      • Perception of lack of treatment efficacy
      • Fear of procedure
  • Fear of cost of treatment
    • Clinician-related causes: 7,16,17
      • Misperception that symptoms are not important to the patient (perhaps because the patient does not volunteer information or complaints)
      • Misperception that OAB is a natural part of aging
      • Misperception that treatment is ineffective
      • Lack of awareness of the differential diagnosis
      • Lack of appreciation for the impact on quality of life
      • Failure to consider potential complications, including:
      • Depression
      • Skin infections
      • Falls and fractures

Differential diagnosis in women

  • There are a limited number of ways the bladder can express its pathology.
  • Thus, the symptoms seen with OAB can have a number of different underlying causes, including:18
    • Uro-gynecologic conditions
  • Bladder cancer
      • Neurogenic bladder
      • Interstitial cystitis
      • Pelvic organ prolapse
      • Postsurgical complication
      • Stress incontinence
      • Urethral diverticulum
      • Urinary tract infection
    • General medical conditions
      • Polyuria/polydipsia
      • Diabetes
      • Congestive heart failure
      • Medications
Symptoms OAB SUI UTI
Urgency Yes No Yes
Frequency Yes No Yes
Leaking duringphysical activity Sometimes Yes No
Amount of leakage Variable Variable Small
Urge incontinence 1/3 No Sometimes
Nocturia Usually Sometimes Usually
Urinalysis & culture Normal Normal Abnormal
  • A simple symptom assessment can help differentiate among OAB, stress incontinence, and urinary tract infection.
  • Both OAB and UTI are accompanied by urinary urgency, frequency, and urge incontinence, but most patients with UTI also have dysuria, and all have pyuria or hematuria and a positive urine culture.
  • Stress incontinence is not a symptom of OAB, but about one third of patients with SUI also have urge incontinence.19

References

  1. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167-78.
  2. Chapple C. Classification of mixed incontinence. Eur Urol. 2006;5(16)837-41.
  3. Fitzgerald MP, Brubaker L. Variability of 24-hour voiding diary variables among asymptomatic women. J Urol. 2003;169(1):207-9.
  4. Fitzgerald MP, Stablein U, Brubaker L. Urinary habits among asymptomatic women. Am J Obstet Gynecol. 2002;187(5):1384-8.
  5. van Kerrebroeck P, Abrams P, Chaikin D, et al. The standardisation of terminology in nocturia: report from the standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21:179–83.
  6. Yoshida M, Masunaga K, Nagata T, et al. The forefront for novel therapeutic agents based on the pathophysiology of lower urinary tract dysfunction: pathophysiology and pharmacotherapy of overactive bladder. J Pharmacol Sci. 2010;112(2):128-34.
  7. Milsom I, Abrams P, Cardozo L, et al. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int. 2001;87(9):760–6.
  8. Stewart W, Herzog R, Wein A. The prevalence and impact of overactive bladder in the U.S.: results from the NOBLE program. Neurourol Urodyn. 2001;20:406-8.
  9. Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20(6):327-36.
  10. Buckley BS, Lapitan MC; Epidemiology Committee of the Fourth International Consultation on Incontinence, Paris, 2008. Prevalence of urinary incontinence in men, women, and children—current evidence: findings of the Fourth International Consultation on Incontinence. Urology. 2010;76(2):265-70.
  11. Darkow T, Fontes CL, Williamson TE. Costs associated with the management of overactive bladder and related comorbidities. Pharmacotherapy. 2005;25(4):511-9.
  12. Brown JS, Vittinghoff E, Wyman JF, et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc. 2000;48(7):721-5.
  13. Hu TW, Wagner TH, Bentkover JD, et al. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology. 2004;63(3):461-5.
  14. Harris Interactive. Harris Interactive survey examines a not-so-talked-about health issue affecting intimacy for many. Health Care News. June 7, 2001; 1(18).
  15. Dmochowski RR, Newman DK. Impact of overactive bladder on women in the United States: results of a national survey. Curr Med Res Opin. 2007;23(1):65-76.
  16. Milsom I, Stewart W, Thüroff J.  The prevalence of overactive bladder. Am J Manag Care. 2000;6(11 Suppl):S565-73.
  17. Ricci JA, Baggish JS, Hunt TL, et al. Coping strategies and health care-seeking behavior in a US national sample of adults with symptoms suggestive of overactive bladder. Clin Ther. 2001;23(8):1245-59.
  18. Rosenberg MT, Newman DK, Tallman CT, Page SA. Overactive bladder: recognition requires vigilance for symptoms. Cleve Clin J Med. 2007;74(Suppl 3):S21-9.
  19. Abrams P, Wein AJ. The Overactive Bladder: A Widespread and Treatable Condition. Stockholm, Sweden: Erik Sparre Medical AB; 1998.