The Overactive BladderThe Overactive Bladder

Raji Gill, D.O., M.Sc.Raji Gill, D.O., M.Sc.

Clinical Assistant Professor of SurgeryClinical Assistant Professor of Surgery

Division of UrologyDivision of Urology

Tulsa Regional Medical CenterTulsa Regional Medical Center

&&

Cancer Treatment Centers of AmericaCancer Treatment Centers of America

2002 ICS Terminology: 2002 ICS Terminology: Overactive BladderOveractive Bladder

OAB defined based on symptomsOAB defined based on symptoms Urgency, with or without urge incontinence, Urgency, with or without urge incontinence,

usually with frequency and nocturiausually with frequency and nocturia In the absence of pathologic or In the absence of pathologic or

metabolic conditions that might metabolic conditions that might explain these symptomsexplain these symptoms

ICS = International Continence Society (www.icsoffice.org)

Urge IncontinenceUrge Incontinence

• Sudden & involuntary Sudden & involuntary loss of urineloss of urine

Urge IncontinenceUrge Incontinence

• Sudden & involuntary Sudden & involuntary loss of urineloss of urine

FrequencyFrequency

• 8 or more visits to the toilet per 24 hours8 or more visits to the toilet per 24 hours

Urination at nightUrination at night

• • 2 or more visits to toilet2 or more visits to toilet during sleeping hours during sleeping hours

FrequencyFrequency

• 8 or more visits to the toilet per 24 hours8 or more visits to the toilet per 24 hours

Urination at nightUrination at night

• • 2 or more visits to toilet2 or more visits to toilet during sleeping hours during sleeping hours

OABOABOABOAB

OAB SymptomsOAB Symptoms

UrgencyUrgency

• Sudden, strong Sudden, strong desire to urinatedesire to urinate

UrgencyUrgency

• Sudden, strong Sudden, strong desire to urinatedesire to urinate

Types of Urinary Incontinence Types of Urinary Incontinence Mixed symptomsMixed symptoms

– combination of stress combination of stress and urge and urge incontinenceincontinence

Urgeurine loss accompanied by urgency resulting from abnormal bladder contractions

Stressurine loss resulting from sudden increased intra-abdominal pressure (eg, laugh, cough, sneeze)

Sudden increasein intra-abdominalpressure

Uninhibited detrusorcontractionsUrethral pressure

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.

SymptomsSymptoms Overactive Overactive bladderbladder

Stress incontinenceStress 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

Estimated Prevalence of OAB in Comparison Estimated Prevalence of OAB in Comparison With Other Selected Chronic Conditions: 1990s With Other Selected Chronic Conditions: 1990s

DataData

Payne CK. Campbell’s Urology Updates. 1999;1:1-20. Evans DA et al. Milbank Q. 1990;68:267-289. Bureau of the Census, Population Estimate Data, 1995.National Institutes of Health. Osteoporosis and Related Bone DiseasesNational Resource Center. Osteoporosis Overview.National Center for Health Statistics. Vital Health Stat. 10(199):1998.

Alzheimer’s Disease

Diabetes

Osteoporosis

Asthma

OAB

Heart Conditions*

Arthritis

Chronic Sinusitis

Condition Millions of Americans

5

9

10

15

17

21

33

37

Excludes hypertension*

Prevalence of OAB in the USPrevalence of OAB in the US

Age (years)

0

5

10

15

20

25

30

35

40

18–24 25–34 35–44 45–54 55–64 65–74 75+

Pre

vale

nce

(%

)

Men

Women• Overall, 16.6% had symptoms of OAB

• Prevalence of OAB increased with age

Adapted from Stewart W et al. WHO/ICI 2001. Poster.

Prevalence of OAB: Prevalence of OAB: Wet versus DryWet 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)

OAB

Adapted from Stewart W et al. WHO/ICI 2001. Poster.

Diagnosis of OABDiagnosis of OAB

A presumptive diagnosis of OAB can be A presumptive diagnosis of OAB can be based on based on – patient history, symptom assessmentpatient history, symptom assessment– physical examinationphysical examination– urinalysisurinalysis

Initiation of noninvasive treatment may not Initiation of noninvasive treatment may not require an extensive further workuprequire 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.

* Survey conducted by Gallup Group (European Study).

A Hidden Condition*A Hidden Condition*

Many patients self-manage by voiding Many patients self-manage by voiding frequently, reducing fluid intake, and frequently, reducing fluid intake, and wearing padswearing pads

Nearly two-thirds of patients are Nearly two-thirds of patients are symptomatic for 2 years before seeking symptomatic for 2 years before seeking treatmenttreatment

30% of patients who seek treatment receive 30% of patients who seek treatment receive no assessmentno assessment

Nearly 80% are not examinedNearly 80% are not examined

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”

Screening andScreening andDiagnosing OABDiagnosing OAB

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

OAB Screening Can Help Diagnose OAB Screening Can Help Diagnose Other Causes of Bladder SymptomsOther Causes of Bladder Symptoms

Local pathologyLocal pathology– infectioninfection

– bladder stonesbladder stones

– bladder tumorsbladder tumors

– interstitial cystitisinterstitial cystitis

– outlet obstructionoutlet obstruction

Metabolic factorsMetabolic factors– diabetesdiabetes

– polydipsiapolydipsia

MedicationsMedications– diureticsdiuretics

– antidepressantsantidepressants

– antihypertensivesantihypertensives

– hypnotics & sedativeshypnotics & sedatives

– narcotics & analgesicsnarcotics & analgesics

Other factorsOther factors– pregnancypregnancy

– psychological issuespsychological issues

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.

Differential Diagnosis:Differential Diagnosis:Physical ExaminationPhysical Examination

Perform general, abdominal (including Perform general, abdominal (including bladder palpation), and neurologic examsbladder palpation), and neurologic exams

Perform pelvic and/or rectal exam in Perform pelvic and/or rectal exam in females and rectal exam in malesfemales and rectal exam in males

Observe for urine loss with vigorous coughObserve for urine loss with vigorous cough

Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; January 1996. AHCPR publication 96-0686.

Differential Diagnosis: Differential Diagnosis: Laboratory TestsLaboratory Tests

UrinalysisUrinalysis– to rule out hematuria, pyuria, bacteriuria, to rule out hematuria, pyuria, bacteriuria,

glucosuria, proteinuriaglucosuria, proteinuria Blood work if compromised renal function Blood work if compromised renal function

is suspected or if polyuria (in the absence of is suspected or if polyuria (in the absence of diuretics) is presentdiuretics) is present

Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; January 1996. AHCPR publication 96-0686.

Care PathwayCare Pathway

Working diagnosis? Yes OAB? Yes

No

Treat if:

Frequency and urgency, with or without urge incontinence, and

normal urinalysis

>8 weeks tx Failed

Consider referral to specialist

Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.

Suggested Reasons for ReferralSuggested Reasons for Referral

Symptoms do not respond to Symptoms do not respond to initial treatment within 2 to 3 initial treatment within 2 to 3 monthsmonths

Hematuria without infection Hematuria without infection on urinalysison urinalysis

Recurrent symptomatic UTIRecurrent symptomatic UTI Symptoms suggestive of poor Symptoms suggestive of poor

bladder emptyingbladder emptying Pelvic bladder, vaginal, or Pelvic bladder, vaginal, or

urethral painurethral pain

Evidence of complicated Evidence of complicated neurologic or metabolic neurologic or metabolic diseasedisease

Failed previous incontinence Failed previous incontinence surgerysurgery

Elevated PVR volumeElevated PVR volume Radical pelvic surgeryRadical pelvic surgery Symptomatic prolapseSymptomatic prolapse Prostate problemsProstate problems Surgery planned (2Surgery planned (2ndnd opinion) opinion)

Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.

Treatment OptionsTreatment Options

Behavioral therapyBehavioral therapy MedicationMedication Combined therapy: behavioral and Combined therapy: behavioral and

pharmacologic therapypharmacologic therapy Minimally invasive therapiesMinimally invasive therapies

– Botulinum A-toxinBotulinum A-toxin– NeuromodulationNeuromodulation

Surgery Surgery

So when the Drug Rep. visits, So when the Drug Rep. visits, which drug do I use?which drug do I use?

PharmacotherapyPharmacotherapy

Anticholinergic AgentsAnticholinergic Agents– Oxybutynin (Ditropan)Oxybutynin (Ditropan)– Oxybutynin transdermal (Oxytrol)Oxybutynin transdermal (Oxytrol)– Tolterodine (Detrol)Tolterodine (Detrol)– Solifenacin (Vesicare)Solifenacin (Vesicare)– Trospium chloride (Sanctura)Trospium chloride (Sanctura)– Darifenacin (Enablex)Darifenacin (Enablex)

Oxybutynin (Ditropan)Oxybutynin (Ditropan)

Immediate and long acting formImmediate and long acting form Immediate – TID dosingImmediate – TID dosing Long acting XL – once a day, 5 or 10 mg.Long acting XL – once a day, 5 or 10 mg. Side effects – dry mouth, constipation, Side effects – dry mouth, constipation,

headacheheadache Approved for pediatric use (age 6 or older)Approved for pediatric use (age 6 or older)

Oxybutynin Transdermal Oxybutynin 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 but Side effects – less dry mouth but

erythema/pruitiserythema/pruitis

Tolterodine (Detrol)Tolterodine (Detrol)

Immediate 2 mg. and long acting LA 4 mg Immediate 2 mg. and long acting LA 4 mg dosingdosing

Side effects profile similar to oxybutyninSide effects profile similar to oxybutynin

Solifenacin (Vesicare)Solifenacin (Vesicare)

5 – 10 mg daily dose5 – 10 mg daily dose Side effects – dry mouth, constipationSide effects – dry mouth, constipation

Trospium Chloride (Sanctura)Trospium Chloride (Sanctura)

Quaternary amine as opposed to tertiary Quaternary amine as opposed to tertiary amineamine

20 mg BID dose20 mg BID dose Theoretically harder to pass through Theoretically harder to pass through

blood/brain barrier with less side effectsblood/brain barrier with less side effects Not metabolized by liverNot metabolized by liver 60% excreted in the urine unchanged60% excreted in the urine unchanged

Darifenacin (Enablex)Darifenacin (Enablex)

MM33 selective anticholinergic selective anticholinergic

7.5 mg or 15 mg once a day7.5 mg or 15 mg once a day Side effects – constipation and dry mouthSide effects – constipation and dry mouth