Overactive bladder

Overactive bladder (OAB) is a common condition where there is a frequent feeling of needing to urinate to a degree that it negatively affects a person's life.[1] The frequent need to urinate may occur during the day, at night, or both.[5] Loss of bladder control (urge incontinence) may occur with this condition.[3] Overactive bladder affects approximately 11% of the population and more than 40% of people with overactive bladder have incontinence.[2][6] Conversely, about 40% to 70% of urinary incontinence is due to overactive bladder.[7] Overactive bladder is not life-threatening,[3] but most people with the condition have problems for years.[3]

Overactive bladder
Other namesOveractive bladder syndrome
SpecialtyUrology
SymptomsFrequent feeling of needing to urinate, incontinence[1][2]
Usual onsetMore common with age[3]
DurationOften years[3]
CausesUnknown[3]
Risk factorsObesity, caffeine, constipation[2]
Diagnostic methodBased on symptoms after ruling out other possible causes[1][3]
Differential diagnosisUrinary tract infections, neurological conditions[1][3]
TreatmentPelvic floor exercises, bladder training, drinking moderate fluids, weight loss[4]
PrognosisNot life-threatening[3]
Frequency~15% men, 25% women[3]

The cause of overactive bladder is unknown.[3] Risk factors include obesity, caffeine, and constipation.[2] Poorly controlled diabetes, poor functional mobility, and chronic pelvic pain may worsen the symptoms.[3] People often have the symptoms for a long time before seeking treatment and the condition is sometimes identified by caregivers.[3] Diagnosis is based on a person's signs and symptoms and requires other problems such as urinary tract infections or neurological conditions to be excluded.[1][3] The amount of urine passed during each urination is relatively small.[3] Pain while urinating suggests that there is a problem other than overactive bladder.[3]

Specific treatment is not always required.[3] If treatment is desired pelvic floor exercises, bladder training, and other behavioral methods are initially recommended.[4] Weight loss in those who are overweight, decreasing caffeine consumption, and drinking moderate fluids, can also have benefits.[4] Medications, typically of the anti-muscarinic type, are only recommended if other measures are not effective.[4] They are no more effective than behavioral methods; however, they are associated with side effects, particularly in older people.[4][8] Some non-invasive electrical stimulation methods appear effective while they are in use.[9] Injections of botulinum toxin into the bladder is another option.[4] Urinary catheters or surgery are generally not recommended.[4] A diary to track problems can help determine whether treatments are working.[4]

Overactive bladder is estimated to occur in 7–27% of men and 9–43% of women.[3] It becomes more common with age.[3] Some studies suggest that the condition is more common in women, especially when associated with loss of bladder control.[3] Economic costs of overactive bladder were estimated in the United States at US$12.6 billion and 4.2 billion Euro in 2000.[10]

Signs and symptoms

Overactive bladder is characterized by a group of four symptoms: urgency, urinary frequency, nocturia, and urge incontinence. Urge incontinence is not present in the "dry" classification.[11]

Urgency is considered the hallmark symptom of OAB, but there are no clear criteria for what constitutes urgency and studies often use other criteria.[3] Urgency is currently defined by the International Continence Society (ICS), as of 2002, as "Sudden, compelling desire to pass urine that is difficult to defer." The previous definition was "Strong desire to void accompanied by fear of leakage or pain."[12] The definition does not address the immediacy of the urge to void and has been criticized as subjective.[12]

Urinary frequency is considered abnormal if the person urinates more than eight times in a day. This frequency is usually monitored by having the person keep a voiding diary where they record urination episodes.[3] The number of episodes varies depending on sleep, fluid intake, medications, and up to seven is considered normal if consistent with the other factors.

Nocturia is a symptom where the person complains of interrupted sleep because of an urge to void and, like the urinary frequency component, is affected by similar lifestyle and medical factors. Individual waking events are not considered abnormal, one study in Finland established two or more voids per night as affecting quality of life.[13]

Urge incontinence is a form of urinary incontinence characterized by the involuntary loss of urine occurring for no apparent reason while feeling urinary urgency as discussed above. Like frequency, the person can track incontinence in a diary to assist with diagnosis and management of symptoms. Urge incontinence can also be measured with pad tests, and these are often used for research purposes. Some people with urge incontinence also have stress incontinence and this can complicate clinical studies.[3]

It is important that the clinician and the person with overactive bladder both reach a consensus on the term, 'urgency.' Some common phrases used to describe OAB include, 'When I've got to go, I've got to go,' or 'When I have to go, I have to rush, because I think I will wet myself.' Hence the term, 'fear of leakage,' is an important concept to people.[14]

Causes

The cause of OAB is unclear, and indeed there may be multiple causes.[15] It is often associated with overactivity of the detrusor urinae muscle, a pattern of bladder muscle contraction observed during urodynamics.[16] It is also possible that the increased contractile nature originates from within the urothelium and lamina propria, and abnormal contractions in this tissue could stimulate dysfunction in the detrusor or whole bladder.[17]

If bladder spasms occur or there is no urine in the drainage bag when a catheter is in place, the catheter may be blocked by blood, thick sediment, or a kink in the catheter or drainage tubing. Sometimes spasms are caused by the catheter irritating the bladder, prostate or penis. Such spasms can be controlled with medication such as butylscopolamine, although most people eventually adjust to the irritation and the spasms go away.[18]

Diagnosis

Diagnosis of OAB is made primarily on the person's signs and symptoms and by ruling out other possible causes such as an infection.[3] Urodynamics, a bladder scope, and ultrasound are generally not needed.[3][19] Additionally, urine culture may be done to rule out infection. The frequency/volume chart may be maintained and cystourethroscopy may be done to exclude tumor and kidney stones. If there is an underlying metabolic or pathologic condition that explains the symptoms, the symptoms may be considered part of that disease and not OAB.

Psychometrically robust self-completion questionnaires are generally recognized as a valid way of measuring a person's signs and symptoms, but there does not exist a single ideal questionnaire.[20] These surveys can be divided into two groups: general surveys of lower urinary tract symptoms and surveys specific to overactive bladder. General questionnaires include: American Urological Association Symptom Index (AUASI), Urogenital Distress Inventory (UDI),[21] Incontinence Impact Questionnaire (IIQ),[21] and Bristol Female Lower Urinary Tract Symptoms (BFLUTS). Overactive bladder questionnaires include: Overactive Bladder Questionnaire (OAB-q),[22] Urgency Questionnaire (UQ), Primary OAB Symptom Questionnaire (POSQ), and the International Consultation on Incontinence Questionnaire (ICIQ).

OAB causes similar symptoms to some other conditions such as urinary tract infection (UTI), bladder cancer, and benign prostatic hyperplasia (BPH). Urinary tract infections often involve pain and hematuria (blood in the urine) which are typically absent in OAB. Bladder cancer usually includes hematuria and can include pain, both not associated with OAB, and the common symptoms of OAB (urgency, frequency, and nocturia) may be absent. BPH frequently includes symptoms at the time of voiding as well as sometimes including pain or hematuria, and all of these are not usually present in OAB.[12] Diabetes insipidus, which causes high frequency and volume, though not necessarily urgency.

Classification

There is some controversy about the classification and diagnosis of OAB.[3][23] Some sources classify overactive bladder into two different variants: "wet" (i.e., an urgent need to urinate with involuntary leakage) or "dry" (i.e., an urgent need to urinate but no involuntary leakage). Wet variants are more common than dry variants.[24] The distinction is not absolute; one study suggested that many classified as "dry" were actually "wet" and that people with no history of any leakage may have had other syndromes.[25]

OAB is distinct from stress urinary incontinence, but when they occur together, the condition is usually known as mixed incontinence.

Management
Main article: Treatments for overactive bladder

The usual first suggested treatment for a person with overactive bladder is a combination of lifestyle changes, exercises to strengthen the person's pelvic floor, and manage how much the person drinks and when during the day ("fluid management"). There are also some medications that may be helpful if these three first approaches are not effective at relieving the symptoms. Finally, if medications and the non-invasive bahavioural/lifestyle and strengthening approaches do not work, a surgical intervention or procedures may be suggested.[6]

Lifestyle and behavioural therapy

Nonpharmacologic methods such as lifestyle modification (fluid restriction, avoidance of caffeine), bladder retraining, and pelvic floor muscle (PFM) exercise are often suggested as the first line therapy for people with overactive bladder syndrome.

Bladder training involves teaching sessions where the person learns how to gradually increase the time between urinating in a safe way.[26] The person is often encouraged to keep track of their progress using a chart. 50% of people with overactive bladder may see improvements with bladder training alone, however, the certainty of this evidence is not strong.[27] There are fewer side side effects associated with bladder training compared to using medications such as treatment with anticholonergics.[26] Timed voiding is a form of bladder training that uses biofeedback to reduce the frequency of accidents resulting from poor bladder control. This method is aimed at improving the person's control over the time, place and frequency of urination. Timed voiding programs involve establishing a schedule for urination. To do this, a person fills in a chart of voiding and leaking. From the patterns that appear in the chart, the person can plan to empty his or her bladder before he or she would otherwise leak. Some individuals find it helpful to use a vibrating reminder watch to help them remember to use the bathroom. Vibrating watches can be set to go off at certain intervals or at specific times throughout the day, depending on the watch.[28] Through this bladder training exercise, the person can alter their bladder's schedule for storing and emptying urine.[29]

Pelvic floor muscle training usually consist of exercises suggested by physiotherapists that are meant to improve the person's control of their pelvic floor muscles in order to decrease the overactive bladder symptoms. This approach is thought to be more highly recommended for people with stress urinary incontinence rather than for treating overactive bladder symptoms.[27]

Behavioural therapy typically involves a combination of training exercises such as bladder training exercises combined with biofeedback pelvic floor muscle training. A 2019 systematic review of studies related to urinary incontinence in women found that behavioral therapy, alone or combined with other treatments, is generally more effective than any other single treatment alone.[30] Behavioral therapy as a treatment has been used to improve or cure urgency urinary incontinence, including improving patient satisfaction.[31]


This review focused on the effect of bladder training to treat OAB. However, most of the evidence was low or very‐low certainty. Based on the low‐ or very low‐certainty evidence, bladder training may cure or improve OAB compared to no treatment. Bladder training may be more effective to cure or improve OAB than anticholinergics, and there may be fewer adverse events. There may be no difference in efficacy or safety between bladder training and PFMT. More well‐designed trials are needed to reach a firm conclusion.


Medications

Medications are a common treatment option for people with overactive bladder syndrome. A number of antimuscarinic drugs (e.g., darifenacin, hyoscyamine, oxybutynin, tolterodine, solifenacin, trospium, fesoterodine) are frequently used to treat overactive bladder.[16] Long term use, however, has been linked to dementia.[32] β3 adrenergic receptor agonists (e.g., mirabegron, vibegron),[33] may be used, as well. However, both antimuscarinic drugs and β3 adrenergic receptor agonists constitute a second-line treatment due to the risk of side effects.[3]

Few people get complete relief with medications and all medications are no more than moderately effective.[34]

A typical person with overactive bladder may urinate 12 times per day.[34] Medication may reduce this number by 2-3 and reduce urinary incontinence events by 1-2 per day.[34]

Surgery

If non-invasive and pharmacological approaches are not helpful, some people may be eligible for a surgical procedure to treat overactive bladder.[35] Surgical options may include urinary diversion, sacral neuromodulation, or augmentation cystoplasty.[35]

One surgical intervention involves the enlargement of the bladder using bowel tissues, although generally used as a last resort. This procedure can greatly enlarge urine volume in the bladder.

Procedures

Botulinum toxin A (Botox) is approved by the Food and Drug Administration in adults with neurological conditions, including multiple sclerosis and spinal cord injury.[36] Botulinum Toxin A injections into the bladder wall can suppress involuntary bladder contractions by blocking nerve signals and may be effective for up to 9 months.[37][38] The growing knowledge of pathophysiology of overactive bladder fuelled a huge amount of basic and clinical research in this field of pharmacotherapy.[39][40][41]

OAB may be treated with electrical stimulation, which aims to reduce the contractions of the muscle that tenses around the bladder and causes urine to pass out of it. There are invasive and non-invasive electrical stimulation options. Non-invasive options include the introduction of a probe into the vagina or anus, or the insertion of an electrical probe into a nerve near the ankle with a fine needle. These non-invasive options appear to reduce symptoms while they are in use, and are better than no treatment, or treatment with drugs, or pelvic floor muscle treatment, but the quality of evidence is low. It is unknown which electrical stimulation option works best. Also, it is unknown whether the benefits last after treatment stops.[9]

Alternative medicine

There is very low-quality evidence that acupuncture may offer a very small improvement in a person's symptoms when compared to a person who does not seek treatment for this condition.[6]

Prognosis

Many people with OAB symptoms had those symptoms subside within a year, with estimates as high as 39%, but most have symptoms for several years.[3]

Epidemiology

Earlier reports estimated that about one in six adults in the United States and Europe had OAB.[42][43] The number of people affected with OAB increases with age,[42][43] thus it is expected that OAB will become more common in the future as the average age of people living in the developed world is increasing. However, a recent Finnish population-based survey[44] suggested that the number of people affected had been largely overestimated due to methodological shortcomings regarding age distribution and low participation (in earlier reports). It is suspected, then, that OAB affects approximately half the number of individuals as earlier reported.[44]

The American Urological Association reports studies showing rates as low as 7% to as high as 27% in men and rates as low as 9% to 43% in women.[3] Urge incontinence was reported as higher in women.[3] Older people are more likely to be affected, and the number of symptoms increases with age.[3]

See also

References
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