Disease: Overactive Bladder (OAB)

    Overactive bladder (OAB) facts

    • Overactive bladder is an involuntary and sudden contraction of the muscle in the wall of the urinary bladder.
    • Overactive bladder can also result in urinary incontinence, otherwise termed urge incontinence (wet OAB).
    • Overactive bladder is not a normal part of aging.
    • OAB affects both men and women and can significantly impact the quality of life.
    • Many treatments are available for overactive bladder, including pelvic-muscle strengthening, behavioral therapies, medications, neuromodulation, and surgery.

    What is an overactive bladder?

    Overactive bladder (OAB) is a condition that is characterized by sudden, involuntary contraction of the muscle in the wall of the urinary bladder. This results in a sudden and unstoppable need to urinate (urinary urgency), even though the bladder may only contain a small amount of urine. Key features are the sudden urge to void along with urinary frequency (voiding < 2 hour intervals). Irritating fluids, such as caffeinated beverages (coffee, tea), spicy foods, and alcohol can worsen the symptoms. It is common for those affected to compensate for OAB by toilet mapping, fluid restriction, and timed voiding. There is no pain, burning, or blood in the urine with OAB.

    Overactive bladder coupled with urinary leakage (inability to suppress the urge to void) is also referred to as urge incontinence and is a form of urinary incontinence (unintentional loss of urine). Another common type of urinary incontinence is called stress incontinence, which is caused by anatomic weakness in the structures that prevent the bladder from leaking. Such patients will leak with coughing, straining, jumping, or other physical activity that contracts the abdominal muscles. Treatment for stress incontinence is very different than urge incontinence. Stress incontinence is treated with methods that support the weakened support structures, including Kegel exercises, urethral bulking agents, and urethral mesh surgery to strengthen the pelvic floor muscles. In some, there can be a combination of urge and stress incontinence (mixed incontinence). In general, urinary incontinence is more common in women compared to men.

    SymptomsOABStress Urinary IncontinenceUrgency (Strong, Sudden Desire to Void)YesNoFrequency With Urgency (≥ 8 Times/24 Hours)YesNoLeaking During Physical Activity (For Example, Coughing, Sneezing, Lifting)NoYesAmounts of Urinary Leakage With Each Episode of IncontinenceLarge (If Present)SmallAbility to Reach the Toilet in Time Following Urge to VoidOften NoYesNocturia (Waking to Pass Urine at Night)UsuallySeldom

    The overall prevalence of overactive bladder is 13.9%, affecting men and women with equal frequency. Although it can happen at any age, overactive bladder is especially common in older adults. Overactive bladder should not be considered a normal part of aging. The prevalence under the age of 50 is < 10%. After age 60, the prevalence increases to 20%-30%. It is estimated that 60% of patients have dry OAB (no leakage) while 40% have wet OAB.

    What are the causes of overactive bladder?

    Overactive bladder is typically caused by early, uncontrolled contraction (spasms) of the bladder muscle (detrusor muscle), resulting in an urge to urinate. Overactive bladder is primarily a problem of the nerves and muscles of the bladder that allow for early contraction during the normal relaxation phase of bladder filling. The bladder's contraction in response to filling with urine is one the steps in the normal process of urination. The contraction and relaxation of the detrusor muscle is regulated by the nervous system. Approximately 300 cc of urine in the bladder can signal the nervous to trigger muscles of the bladder to coordinate urination. Voluntary control of the sphincter muscles at the opening of the bladder can hold the urine in the bladder for longer. Up to 600 cc of urine can be contained in a normal adult bladder. For those with OAB, the bladder capacity is typically low (< 200cc).

    Overactive bladder typically results from inappropriate contraction of the detrusor muscle regardless of the amount of urine. This could result from problems of the nervous system or other causes.

    The common abnormalities of the nervous system that cause overactive bladder are

    • spinal cord injury,
    • back problems (disc hernia, degenerative disc disease),
    • strokes,
    • Parkinson's disease,
    • dementia,
    • multiple sclerosis,
    • diabetic neuropathy.

    Other causes include urinary tract infection, bladder stones, urethral strictures, benign prostatic enlargement (BPH), or bladder tumors.

    Frequently, no apparent cause of overactive bladder can be determined (idiopathic overactive bladder).

    Are there any risk factors for overactive bladder?

    Some of the common risk factors for overactive bladder include

    • advanced age,
    • injury to the nervous system,
      • stroke,
      • spinal cord injury,
      • dementia,
      • Parkinson's disease,
      • multiple sclerosis,
    • diabetes mellitus,
    • prostate enlargement,
    • prostate surgery,
    • multiple pregnancies,
    • previous pelvic surgery,
    • previous radiotherapy of the pelvis.

    Race is not a risk factor for overactive bladder as it can affect people of all races.

    What are overactive bladder symptoms?

    The symptoms of an overactive bladder include frequent urination, urgency of urination, and nocturia (urinating in the middle of the night), with or without urge incontinence. Overactive bladder may cause significant social, psychological, occupational, domestic, physical, and sexual problems. Again, these symptoms should not be considered a normal part of aging.

    How is overactive bladder diagnosed?

    Careful medical history and diligent review of symptoms related to overactive bladder are very important. Getting up to urinate at least three times in the middle of the night, increased urinary frequency (urinating at least eight times daily), urinary urgency, and urinary incontinence are all important clues in evaluating someone suspected of having overactive bladder.

    In addition to a general physical examination, a pelvic exam in women (to assess for dryness, atrophy, inflammation, and/or infection) and a prostate examination in men (to assess for size, tenderness, texture, and/or masses) are helpful in excluding other contributing conditions.

    Urine analysis (UA) to assess for infections and occasionally urine cytology (to look for cancer cells in the bladder) are sometimes advised in individuals undergoing evaluation of urinary incontinence and overactive bladder. Ultrasound measurement of the amount of urine left in the bladder after urination (called post-void residual) may also provide additional information about the cause of urinary incontinence (obstruction to urine flow or weak bladder muscle).

    What are the treatments for an overactive bladder?

    The treatment for overactive bladder depends on the capabilities of the patient. Generally, treatment can be behavioral retraining, pharmacological (medications), and surgical.

    Here are commonly recommended treatments.

    Pelvic muscle rehabilitation to improve pelvic muscle tone and prevent leakage
    • Kegel exercises: Regular, daily exercising of pelvic muscles can improve, and even prevent, urinary incontinence. This is particularly helpful for younger women. These exercises should be performed 30-80 times daily for at least eight weeks. These exercises are thought to strengthen the muscles of the pelvis and urethra, which can support the opening to the bladder to prevent incontinence. Their success depends on practicing the proper technique and the recommended frequency.
    • Biofeedback: Used in conjunction with Kegel exercises, biofeedback helps people gain awareness and control of their pelvic muscles.
    • Vaginal weight training: Small weights are held within the vagina by tightening the vaginal muscles. These exercises should be performed for 15 minutes, twice daily, for four to six weeks.
    • Pelvic-floor electrical stimulation: Mild electrical pulses stimulate muscle contractions. This should be done in conjunction with Kegel exercises.
    Behavioral therapies to help people regain control of their bladder
    • Bladder training teaches people to resist the urge to void and gradually expand the intervals between voiding.
    • Toileting assistance uses routine or scheduled toileting, habit-training schedules, and prompted voiding to empty the bladder regularly to prevent leaking.

    What is the role of medications in treating overactive bladder?

    There are several medications recommended for the treatment of overactive bladder. Using these medications in conjunction with behavioral therapies has shown to increase the success rate for the treatment of overactive bladder.

    The main goals of OAB treatment are to

    1. reduce urinary urgency and frequency,
    2. increase voided volume (bladder capacity),
    3. decrease urge incontinence (reduce leakage episodes).

    Typically, the medications for overactive bladder start to work within one to two weeks, and optimal relief of OAB symptoms is achieved by 12 weeks. The most common medications (anticholinergics) target to decrease the overactivity of the detrusor muscle. Anticholinergics should be used under the direction of the physician prescribing them. They may have some common side effects, including dry mouth, constipation, blurry vision, and confusion (in the elderly). Here is a list of the most commonly recommended medications for overactive bladder.

    Anticholinergic class
    • Oxybutynin (Ditropan) prevents urge incontinence by relaxing the detrusor muscle. This is typically taken two to three times a day (Ditropan XL is extended release, taken once a day). This medication was the first-generation therapy available, and its main side effects include dry mouth (60%) and constipation. Ditropan patch (Oxytrol) is also available with fewer side effects, but it releases a smaller dose than the oral form. The patch is placed on the skin once to twice weekly, and it may cause some local skin irritation.
    • Tolterodine (Detrol, Detrol LA) is indicated for the treatment of an overactive bladder with symptoms of urinary frequency, urgency, or urge incontinence. This medication affects the salivary glands less than oxybutynin, thus, it is better tolerated with fewer side effects (dry mouth). Detrol is usually prescribed twice a day, whereas the long-acting type (Detrol LA) is taken only once a day.
    • Solifenacin (Vesicare) is a relatively newer medication in this group. It is generally similar to tolterodine, but it has a longer half-life and needs to be taken once a day.
    • Darifenacin (Enablex) is also a newer anticholinergic medicine for treating overactive bladder with fewer side effects, such as confusion. Therefore, it may be more helpful in the elderly with underlying dementia. This medication is also typically taken once a day.
    • Fesoterodine fumarate (Toviaz) is indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency. The medication is taken once daily. Common side effects include constipation and dry mouth.

    Learn more about: Ditropan | Ditropan XL | Oxytrol | Detrol | Detrol LA | Vesicare | Enablex | Toviaz

    B3-Agonist class
    • Mirabegron (Myrbetriq) is a new type of medication to treat overactive bladder that is not an anticholinergic and can be used alone or with anticholinergic medications. The side effects include increased blood pressure, incomplete bladder emptying, sinus irritation, constipation and dry mouth (< 2%-3%).

    Learn more about: Myrbetriq

    Botox injection class
    • OnabotulinumtoxinA (Botox) is injected directly into the bladder muscle with a cystoscope and may be repeated every four to six months. Serious side effects are unusual but may include difficulty breathing, difficulty swallowing, difficulty talking, muscle weakness, urinary tract infection, and urinary retention.
    • Estrogen, either oral or vaginal, may be helpful in conjunction with other treatments for postmenopausal women with urinary incontinence.

    Neuromodulation is a newer method of treating overactive bladder with electrical stimulation that results in reorganization of the spinal reflexes involved in bladder control. There are two types of neuromodulation available: percutaneous tibial nerve stimulation (PTNS) and sacral neuromodulation (Interstim).

    Surgery is rarely necessary in treating overactive bladder unless symptoms are debilitating and unresponsive to other treatments. Reconstructive bladder surgery (cystoplasty) is the most common surgical procedure. This surgery involves enlarging the size of the bladder by using part of the intestine.

    What are treatments for the chronically incontinent?

    Although many people will improve their continence through medications, pelvic-muscle exercises, and bladder training, some will never achieve complete dryness. Sometimes treatment failures are due to concurrent use of other necessary medications, such as diuretics (water pills that increase urination), that actually can cause incontinence. Others may have dementia or other physical impairments that keep them from being able to perform pelvic-muscle exercises or retrain their bladders. Many will be cared for in long-term care facilities or at home. The following recommendations can help keep the chronically incontinent drier and reduce their cost of care:

    • Scheduled toileting (timed voiding): Take people to the toilet every two to four hours or according to their toilet habits.
    • Prompted voiding: Check for dryness and encourage use of the toilet.
    • Improved access to toilets: Use equipment such as canes, walkers, wheelchairs, and devices that raise the seating level of toilets to make toileting easier.
    • Managing fluids and diet: Behavioral modifications can directly impact symptoms of OAB. These include eliminating dietary caffeine, alcohol, and spicy foods (for those with urge incontinence) and encourage adequate fiber in the diet.
    • Disposable absorbent garments: Use these to keep people dry.

    What measures can be taken at home to prevent overactive bladder symptoms?

    There are simple steps that can reduce symptoms of overactive bladder. For example, caffeine may exacerbate urinary urgency and it is potentially an irritant to the bladder. Eliminating caffeine intake can diminish some of the symptoms of overactive bladder.

    Some experts suggest that avoidance of certain foods, such as chocolate, spicy foods, alcohol, carbonated beverages, and nuts, can be beneficial in preventing symptoms of overactive bladder. Others encourage increasing the amount of dietary fiber for people with overactive bladder. Limiting fluid intake can also help to reduce urinary frequency.

    Excess weight can put more pressure on the bladder, causing urinary incontinence. Therefore, weight loss can also help with urinary incontinence in general.

    Are there any risk factors for overactive bladder?

    Some of the common risk factors for overactive bladder include

    • advanced age,
    • injury to the nervous system,
      • stroke,
      • spinal cord injury,
      • dementia,
      • Parkinson's disease,
      • multiple sclerosis,
    • diabetes mellitus,
    • prostate enlargement,
    • prostate surgery,
    • multiple pregnancies,
    • previous pelvic surgery,
    • previous radiotherapy of the pelvis.

    Race is not a risk factor for overactive bladder as it can affect people of all races.

    What are overactive bladder symptoms?

    The symptoms of an overactive bladder include frequent urination, urgency of urination, and nocturia (urinating in the middle of the night), with or without urge incontinence. Overactive bladder may cause significant social, psychological, occupational, domestic, physical, and sexual problems. Again, these symptoms should not be considered a normal part of aging.

    How is overactive bladder diagnosed?

    Careful medical history and diligent review of symptoms related to overactive bladder are very important. Getting up to urinate at least three times in the middle of the night, increased urinary frequency (urinating at least eight times daily), urinary urgency, and urinary incontinence are all important clues in evaluating someone suspected of having overactive bladder.

    In addition to a general physical examination, a pelvic exam in women (to assess for dryness, atrophy, inflammation, and/or infection) and a prostate examination in men (to assess for size, tenderness, texture, and/or masses) are helpful in excluding other contributing conditions.

    Urine analysis (UA) to assess for infections and occasionally urine cytology (to look for cancer cells in the bladder) are sometimes advised in individuals undergoing evaluation of urinary incontinence and overactive bladder. Ultrasound measurement of the amount of urine left in the bladder after urination (called post-void residual) may also provide additional information about the cause of urinary incontinence (obstruction to urine flow or weak bladder muscle).

    What are the treatments for an overactive bladder?

    The treatment for overactive bladder depends on the capabilities of the patient. Generally, treatment can be behavioral retraining, pharmacological (medications), and surgical.

    Here are commonly recommended treatments.

    Pelvic muscle rehabilitation to improve pelvic muscle tone and prevent leakage
    • Kegel exercises: Regular, daily exercising of pelvic muscles can improve, and even prevent, urinary incontinence. This is particularly helpful for younger women. These exercises should be performed 30-80 times daily for at least eight weeks. These exercises are thought to strengthen the muscles of the pelvis and urethra, which can support the opening to the bladder to prevent incontinence. Their success depends on practicing the proper technique and the recommended frequency.
    • Biofeedback: Used in conjunction with Kegel exercises, biofeedback helps people gain awareness and control of their pelvic muscles.
    • Vaginal weight training: Small weights are held within the vagina by tightening the vaginal muscles. These exercises should be performed for 15 minutes, twice daily, for four to six weeks.
    • Pelvic-floor electrical stimulation: Mild electrical pulses stimulate muscle contractions. This should be done in conjunction with Kegel exercises.
    Behavioral therapies to help people regain control of their bladder
    • Bladder training teaches people to resist the urge to void and gradually expand the intervals between voiding.
    • Toileting assistance uses routine or scheduled toileting, habit-training schedules, and prompted voiding to empty the bladder regularly to prevent leaking.

    What is the role of medications in treating overactive bladder?

    There are several medications recommended for the treatment of overactive bladder. Using these medications in conjunction with behavioral therapies has shown to increase the success rate for the treatment of overactive bladder.

    The main goals of OAB treatment are to

    1. reduce urinary urgency and frequency,
    2. increase voided volume (bladder capacity),
    3. decrease urge incontinence (reduce leakage episodes).

    Typically, the medications for overactive bladder start to work within one to two weeks, and optimal relief of OAB symptoms is achieved by 12 weeks. The most common medications (anticholinergics) target to decrease the overactivity of the detrusor muscle. Anticholinergics should be used under the direction of the physician prescribing them. They may have some common side effects, including dry mouth, constipation, blurry vision, and confusion (in the elderly). Here is a list of the most commonly recommended medications for overactive bladder.

    Anticholinergic class
    • Oxybutynin (Ditropan) prevents urge incontinence by relaxing the detrusor muscle. This is typically taken two to three times a day (Ditropan XL is extended release, taken once a day). This medication was the first-generation therapy available, and its main side effects include dry mouth (60%) and constipation. Ditropan patch (Oxytrol) is also available with fewer side effects, but it releases a smaller dose than the oral form. The patch is placed on the skin once to twice weekly, and it may cause some local skin irritation.
    • Tolterodine (Detrol, Detrol LA) is indicated for the treatment of an overactive bladder with symptoms of urinary frequency, urgency, or urge incontinence. This medication affects the salivary glands less than oxybutynin, thus, it is better tolerated with fewer side effects (dry mouth). Detrol is usually prescribed twice a day, whereas the long-acting type (Detrol LA) is taken only once a day.
    • Solifenacin (Vesicare) is a relatively newer medication in this group. It is generally similar to tolterodine, but it has a longer half-life and needs to be taken once a day.
    • Darifenacin (Enablex) is also a newer anticholinergic medicine for treating overactive bladder with fewer side effects, such as confusion. Therefore, it may be more helpful in the elderly with underlying dementia. This medication is also typically taken once a day.
    • Fesoterodine fumarate (Toviaz) is indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency. The medication is taken once daily. Common side effects include constipation and dry mouth.

    Learn more about: Ditropan | Ditropan XL | Oxytrol | Detrol | Detrol LA | Vesicare | Enablex | Toviaz

    B3-Agonist class
    • Mirabegron (Myrbetriq) is a new type of medication to treat overactive bladder that is not an anticholinergic and can be used alone or with anticholinergic medications. The side effects include increased blood pressure, incomplete bladder emptying, sinus irritation, constipation and dry mouth (< 2%-3%).

    Learn more about: Myrbetriq

    Botox injection class
    • OnabotulinumtoxinA (Botox) is injected directly into the bladder muscle with a cystoscope and may be repeated every four to six months. Serious side effects are unusual but may include difficulty breathing, difficulty swallowing, difficulty talking, muscle weakness, urinary tract infection, and urinary retention.
    • Estrogen, either oral or vaginal, may be helpful in conjunction with other treatments for postmenopausal women with urinary incontinence.

    Neuromodulation is a newer method of treating overactive bladder with electrical stimulation that results in reorganization of the spinal reflexes involved in bladder control. There are two types of neuromodulation available: percutaneous tibial nerve stimulation (PTNS) and sacral neuromodulation (Interstim).

    Surgery is rarely necessary in treating overactive bladder unless symptoms are debilitating and unresponsive to other treatments. Reconstructive bladder surgery (cystoplasty) is the most common surgical procedure. This surgery involves enlarging the size of the bladder by using part of the intestine.

    What are treatments for the chronically incontinent?

    Although many people will improve their continence through medications, pelvic-muscle exercises, and bladder training, some will never achieve complete dryness. Sometimes treatment failures are due to concurrent use of other necessary medications, such as diuretics (water pills that increase urination), that actually can cause incontinence. Others may have dementia or other physical impairments that keep them from being able to perform pelvic-muscle exercises or retrain their bladders. Many will be cared for in long-term care facilities or at home. The following recommendations can help keep the chronically incontinent drier and reduce their cost of care:

    • Scheduled toileting (timed voiding): Take people to the toilet every two to four hours or according to their toilet habits.
    • Prompted voiding: Check for dryness and encourage use of the toilet.
    • Improved access to toilets: Use equipment such as canes, walkers, wheelchairs, and devices that raise the seating level of toilets to make toileting easier.
    • Managing fluids and diet: Behavioral modifications can directly impact symptoms of OAB. These include eliminating dietary caffeine, alcohol, and spicy foods (for those with urge incontinence) and encourage adequate fiber in the diet.
    • Disposable absorbent garments: Use these to keep people dry.

    What measures can be taken at home to prevent overactive bladder symptoms?

    There are simple steps that can reduce symptoms of overactive bladder. For example, caffeine may exacerbate urinary urgency and it is potentially an irritant to the bladder. Eliminating caffeine intake can diminish some of the symptoms of overactive bladder.

    Some experts suggest that avoidance of certain foods, such as chocolate, spicy foods, alcohol, carbonated beverages, and nuts, can be beneficial in preventing symptoms of overactive bladder. Others encourage increasing the amount of dietary fiber for people with overactive bladder. Limiting fluid intake can also help to reduce urinary frequency.

    Excess weight can put more pressure on the bladder, causing urinary incontinence. Therefore, weight loss can also help with urinary incontinence in general.

    Source: http://www.rxlist.com

    Overactive bladder is typically caused by early, uncontrolled contraction (spasms) of the bladder muscle (detrusor muscle), resulting in an urge to urinate. Overactive bladder is primarily a problem of the nerves and muscles of the bladder that allow for early contraction during the normal relaxation phase of bladder filling. The bladder's contraction in response to filling with urine is one the steps in the normal process of urination. The contraction and relaxation of the detrusor muscle is regulated by the nervous system. Approximately 300 cc of urine in the bladder can signal the nervous to trigger muscles of the bladder to coordinate urination. Voluntary control of the sphincter muscles at the opening of the bladder can hold the urine in the bladder for longer. Up to 600 cc of urine can be contained in a normal adult bladder. For those with OAB, the bladder capacity is typically low (< 200cc).

    Overactive bladder typically results from inappropriate contraction of the detrusor muscle regardless of the amount of urine. This could result from problems of the nervous system or other causes.

    The common abnormalities of the nervous system that cause overactive bladder are

    • spinal cord injury,
    • back problems (disc hernia, degenerative disc disease),
    • strokes,
    • Parkinson's disease,
    • dementia,
    • multiple sclerosis,
    • diabetic neuropathy.

    Other causes include urinary tract infection, bladder stones, urethral strictures, benign prostatic enlargement (BPH), or bladder tumors.

    Frequently, no apparent cause of overactive bladder can be determined (idiopathic overactive bladder).

    Source: http://www.rxlist.com

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