OVERACTIVE BLADDER (OAB)

Kadek Budi Santosa

Department of Urology, Medical faculty of Udayana
University, PROF IGNG NGOERAH Hospital
What is overactive bladder?
 Symptoms of overactive bladder1

• International Continence Society (ICS): Symptoms

comprising overactive bladder1

1. Abrams P et al. Neurourol Urodyn 2010;29:213–40. 2. Abrams P et al. BJU Int 2005;96(Supp 1):1–3. 3. Cardozo L et al. BJU Int 2008;102:1120–7.
Overactive bladder: Myth or fact?

Q. Overactive bladder is a normal part of ageing

Q. The prevalence of overactive bladder is similar

between men and women

Q. The key defining symptom of overactive bladder

is ‘urgency’

Q. Patients with overactive bladder should

restrict their water intake

Q. Patients with overactive bladder should always

be referred to a specialist for evaluation prior to
treatment
Prevalence in Indonesia

• The overall urinary incontinence

prevalence was 13%
• The prevalence of urinary
incontinence is nearly similiar to
other Asian countries
• It increase with Age and is not
affected by gender
• Urinary incontinence impact daily
life and behavior
 Overactive bladder is highly prevalent1

• Reported prevalence of OAB varies from 12% to 17%1-3*^†

– Prevalence is similar in men & women, but generally develops later in life in
men1,2*^
– Up to ~55% of women and ~16% of men with OAB have urge urinary
incontinence1*
• Overactive bladder symptoms are reported in:3†
– 22% of men and women aged 70–74 years
– 31% of females and 42% of males aged  75 years

Although prevalence increases with age, overactive bladder is

treatable and should not be considered a normal part of ageing4

*Data from the US National Overactive Bladder Evaluation (NOBLE) Program involving 5204 adults aged  18 years and representative of
the US population by sex, age and geographical region.1
^Data from a cross-sectional survey of 19,165 individuals in Canada, Germany, Italy, Sweden and UK. 2
†Data from a random sample of 16,776 subjects aged  40 years from six European countries.3

1. Stewart WF et al. World J Urol 2003;20:327–36.

2. Irwin DE et al. Eur Urology 2006;50:1306-15.
3. Milsom I et al. BJU Int 2001;87:760–6. 4. Larocque P. CME Bulletin 2010;9:1–6.
 Costs of Urinary Incontinence

• Total costs in 1995 > US $ 26 Billion

• $3600 Annually per person aged > 65 years
 Overactive bladder:
Substantial impact on quality of life1

Emotional Embarrassment, loss of self-respect, dignity and confidence,

depression

Occupational May lead to decreased productivity, work absence

Sexual Avoiding sexual intimacy because of fear of leaking urine

Physical May limit physical activities (e.g. exercising) due to fear of

urine frequency/leaking urine

Incontinence pads, special underwear/bedding, increased

Financial
laundry. Comorbidities (UTIs, falls, fractures)

1. Association of Reproductive Health Professionals, 2011. Available at: www.arhp.org/Publications-and-

Resources/Quick-Reference-Guide-for-Clinicians/OAB/Introduction. Accessed June 2015.
 Pathophysiology and aetiology
of overactive bladder are multifactorial1
CNS centres involved in control
• While the exact causes are unknown, of lower urinary tract function3
symptoms are usually associated with:2
– Detrusor muscle overactivity, which
may be the result of upregulation of
bladder muscarinic receptors OR
– Decreased CNS control of the
bladder

We have come a long way from

thinking overactive bladder is
a psychosomatic condition!

Reproduced from Gulur & Drake, 2010.3

1. Ellsworth P. Overactive Bladder – Etiology, Diagnosis, and Impact. MedScape, 2011.

Available at: http://emedicine.medscape.com/article/459502-overview#aw2aab6b4.
Accessed January 2012.
2. Larocque P. CME Bulletin 2010;9:1–6. 3. Gulur DM & Drake MJ. Nat Rev Urol 2010;7:572–82.
The pathophysiology of overactive bladder

Decreased inhibition
of efferent activity

Decreased capacity to handle

afferent activity

Stretch Response
Neurotransmitters
released

Increased afferent activity Increased sensitivity to efferent signalling

URGENCY URINARY INCONTINENCE

URGENCY URINARY INCONTINENCE URGENCY URINARY INCONTINENCE
FREQUENCY

Adapted from: Andersson KE, et al. Pharmacological treatment of urinary incontinence. 3rd International Consultation on Incontinence.
Monaco, June 26–29, 2004
Why discuss overactive bladder
with your patients?
 Overactive bladder remains underdiagnosed1-3

• About 4 out of 10 patients with symptoms of overactive bladder

may not seek medical help2*

*Data from a population-based telephone survey involving 16,776 interviews in six European
countries2

1. Sussman DO. J Am Osteopath Assoc 2007;107:379–85. 2. Milsom I et al. BJU Int 2001;87:760–6.
3. Rosenberg MT et al. Cleve Clin J Med 2007;74 Suppl 3:S21–29.
 Reasons patients don’t seek medical help1,2

• Embarrassment
• Stigma surrounding bladder problems
• Belief symptoms are a normal part of
ageing
• Perception it is not a valid medical
condition
• Perception that nothing can be done to
alleviate symptoms

Patients want their primary care provider to raise and discuss the
issue,
yet there appears to be a communication gap2

1. Sussman DO. J Am Osteopath Assoc 2007;107:379–85. 2. Rosenberg MT et al. Cleve Clin J Med 2007; 74 Suppl 3:S21–29.
 OAB is undertreated1

Only about 25% of patients diagnosed Percentage of

with OAB receive treatment1* OAB patients
receiving
treatment1*
• Of those treated, only 1 in 4 were male1* 24.4%
receiving
treatment
*Data from 7,244,501 patients >45 years with an OAB
diagnosis from the USA IMS Health Dataset (published 75.6%
2010)1 not
receiving
treatment

1. Helfand BT et al. Eur Urol 2010;57:586–91.

What to consider in clinical practice

How often do you discuss overactive bladder symptoms

with your patients?

How could you improve your communication with patients to

make them feel more comfortable at disclosing any problems?

What systems could you put in place to improve the identification

of overactive bladder in your practice?
How do you diagnose
overactive bladder?
 Process to assist in diagnosing
patients with overactive bladder1

Symptoms suggestive of overactive bladder

Obtain patient history, including past

genitourinary disorders

Perform physical examination to exclude obvious pathologies

Obtain urinalysis and exclude other associated conditions (e.g. UTIs)

In the absence of proven infection or other pathology,

the symptoms should be treated as overactive bladder

Adapted from 1. Sussman DO. J Am Osteopath Assoc 2007;107:379–85.

Neurogenic causes or contributors
to overactive bladder1,2

Cause Presentation
Factors affecting the brain: • Usually more sudden onset
•Tumours (except dementia states)
•MS • Look for neurological
•Stroke symptoms/signs
•Parkinson’s
•Dementia
Factors affecting the spinal cord: • Usually obvious
•Spinal cord injury • Abnormality of function will
•Spina bifida (usually occulta in depend on level of injury
adults)
•Cauda equina
Trauma • Childbirth
• Surgery 1. Ouslander JG. N Engl J Med 2004;350:786–99.
2. Information provided by the Steering Committee.

20
Local bladder causes or contributors
of overactive bladder1,2
Cause Presentation
• Tumours • Change in severity
• Polyps • Sudden onset
• Stones • Haematuria
• Infections • Positive culture for UTI
• Positive cytology for tumours
• Obviously requires referral!

1. Ouslander JG. N Engl J Med 2004;350:786–99.

2. Information provided by Professor Ian Tucker.
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Systemic conditions that may
contribute to overactive bladder1
Cause
Congestive heart failure,
venous insufficiency
Diabetes mellitus
Sleep disorders (sleep
apnoea, periodic leg
movements)
Abnormalities of arginine
vasopressin
1. Ouslander JG. N Engl J Med 2004;350:786-99.
Mechanism of effect
Volume overload can contribute to
urinary frequency and nocturia when
patient is supine
Poor blood glucose control can
contribute to osmotic diuresis and
polyuria
Sleep disorders can contribute to
nocturia
Impaired secretion or action of
vasopressin may cause polyuria and
nocturia
22
Functional and behavioural conditions
that may contribute to overactive bladder1
Cause
Excess intake of caffeine,
alcohol; polydipsia
Poor bowel habits and
constipation
Impaired mobility (e.g. in
patients with degenerative
joint disease, Parkinson’s
disease, severe osteoporosis,
or muscle weakness)
Psychological conditions
1. Ouslander JG. N Engl J Med 2004;350:786-99.
Mechanism of effect
Polyuria and urinary frequency
can result
Faecal impaction can contribute
to symptoms
Impaired mobility can interfere
with toileting ability and
precipitate urge incontinence
Chronic anxiety and learned
voiding dysfunction can cause
symptoms of overactive bladder
23
Drugs implicated in overactive bladder1

Medication class Mechanisms or effect

Diuretics (especially Cause a rapid increase in bladder
rapid-acting agents) volume, which may precipitate urgency
and detrusor overactivity
Anticholinergic agents, These agents decrease bladder
narcotics, calcium- contractility and may cause urinary
channel blockers retention, with a decreased functional
bladder capacity
Cholinesterase inhibitors These agents could theoretically
contribute to detrusor overactivity by
increasing acetylcholine levels

1. Ouslander JG. N Engl J Med 2004;350:786-99.

24
 Diagnostic measures to consider1

• Physical examination
• Urinalysis
• Urine culture
• Post-void residual assessment
• Patient history

Further work-up for complicated*/refractory overactive bladder may

include:
• Cystoscopy
• Renal and bladder ultrasound
• Urodynamics
*Presence of other conditions that impact bladder function

1. Gormley AE et al. J Urol 2012;188: Suppl 2455–63.

 Differential diagnosis of ‘idiopathic’overactive
bladder: Main conditions to be excluded1,2

1. Urogenital infections
– Bacterial cystitis, prostatitis, urethritis
2. Extravesical abnormalities
– Endometriosis
3. Bladder abnormalities
– Bladder cancer, bladder calculus, interstitial cystitis
4. Prostate or urethral abnormalities
– Prostate cancer, benign prostatic hyperplasia, urethral calculus
5. Other
– Urinary retention, polyuria, psychogenic urinary frequency,
constipation

Adapted from 1. Yamaguchi O et al. Int J Urol 2009;16:126–42. 2. Gormley AE et al. J Urol 2012;188:2455–63.
 Diagnostic pathway1

*May include bladder abnormalities, pericystic abnormalities (e.g. endometriosis), prostate or urethral
abnormalities, and polyuria (not intended to be a complete list).
Adapted from 1. Yamaguchi O et al. Int J Urol 2009;16:126–42.
How is OAB Treated?

• FIRST LINE TREATMENT

1. Behavioral therapy
2. Medication
3. Combined therapy

• SECOND LINE TREATMENT for REFRACTORY CONDITION

1. Minimally invasive procedure

2. Surgery
Spectrum of treatment: Overview1

- Neuromodulation
- Reconstructive
Pharmacotherapy surgery
- Botulinum
Pharmacotherapy: toxin injections
- Anticholinergics
Behavioural - β3-adrenoceptor
therapy: agonist
- Lifestyle advice
- Bladder training
- Pelvic floor
muscle training

Adapted from 1. Arnold J et al. AFP 2012;41:878–883.

INVASIVENESS
‹#›
ANTIMUSKARINIK
BETA3 ADRENOCEPTOR AGONIS
BOTOX injection-maps FOR OVERACTIVE BLADDER
Can we achieve the optimal balance?

Efficacy Tolerability

Relieves symptoms of OAB Minimal side effects

Optimal Balance
Adherence/
Persistency

Duration of therapy

BET/13/0136/EU
THANK YOU