Management of Overactive BladderFor Gynecologist

Prof Aboubakr ElnasharBenha university Hospital, EgyptAboubakr Elnashar

Definition2002 ICS

OAB defined based on symptoms Urgency, with or without urge

incontinence, usually with frequency and nocturia

In the absence of pathologic or metabolic conditions that might explain these symptoms

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

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/24 h8 or more visits to the toilet/24 h

Nocturia 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/24 h8 or more visits to the toilet/24 h

Nocturia Urination at nightUrination at night

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

OABOABOABOAB

SymptomsSymptoms

UrgencyUrgency

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

UrgencyUrgency

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

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Epidemiology Adult:

1 out of 11

i.e. >osteoporosis or Alzheimer’s disease

All ages

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Impact on HRQoLImpact on HRQoL significantly impaired significantly impaired

SocialSocial– Reduction in social interaction/increased social Reduction in social interaction/increased social

isolationisolation– Cessation of some hobbiesCessation of some hobbies

PhysicalPhysical– Limitations or cessation of physical activitiesLimitations or cessation of physical activities

SexualSexual– Avoidance of sexual contactAvoidance of sexual contact

PsychologicalPsychological– Guilt/depressionGuilt/depression– Fear of:Fear of:

» Being a burden Or Having urine odorBeing a burden Or Having urine odor OccupationalOccupational Aboubakr Elnashar

Physical ProblemsPhysical Problems

Limitations or cessation of physical activities

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Psychological ProblemsPsychological Problems

Guilt/depressionFear of:

Being a burden Or Having urine odor

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Social ProblemsSocial Problems

Reduction in social interaction/increased social isolationCessation of some hobbies

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Sexual ProblemsSexual Problems

• Avoidance of sexual contact

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Occupational/Financial Occupational/Financial ProblemsProblems

• Absence from work

• Job loss

• Change of job

• Poor relationship with employers/ employee

• Financial loss

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Vicious Circle of Vicious Circle of Bladder Control ProblemsBladder Control Problems

Isolation Guilt

Social, domestic, physical, sexual and psychologicalproblems

Absence from work

DepressionAboubakr Elnashar

Causes

• Majority: Idiopathic unknownunknown.

• Some: ±neurologicalneurological deficit.

• Multiple sclerosis• Stroke• Parkinson’s Disease• Spina Bifida• Spinal cord damage

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Screening and DiagnosisScreening and Diagnosis

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* Survey conducted by Gallup Group (European Study).

A Hidden Condition*A Hidden Condition*

Many:Many: Self-manage: Self-manage: voiding frequently, reducing fluid intake, wearing voiding frequently, reducing fluid intake, wearing

padspads Two-thirds:Two-thirds: symptomatic for 2 ys before seeking treatmentsymptomatic for 2 ys before seeking treatment 30% who seek treatment:30% who seek treatment: receive no assessmentreceive no assessment 80%80%not examinednot examined

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ScreeningScreening

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

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DiagnosisDiagnosis

A presumptive diagnosis based on A presumptive diagnosis based on – HistoryHistory– Physical examinationPhysical examination– UrinalysisUrinalysis

Initiation of noninvasive treatment may Initiation of noninvasive treatment may not require an extensive further workupnot require 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.Aboubakr Elnashar

Medications That May Medications That May Cause IncontinenceCause Incontinence

DiureticsDiuretics

AntidepressantsAntidepressants

AntihypertensivesAntihypertensives

AnalgesicsAnalgesics

Narcotics

Sedatives

Hypnotics

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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.

Symptoms Overactive bladder

Stress 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

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ManagementManagement

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Who Manages Patients?Who Manages Patients?

• General practitioners

• Gynecologists

•Geriatricians

• Urologists

• Others E.g.

•pediatricians, neurologists, physiotherapists and psychologists

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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”

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Care PathwayCare Pathway

Screening OAB? Yes

Treat if:

Urgency and Frequency, with or without urge incontinence, and

normal urinalysis

>8-12 w TT Failed

Referral to specialist

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

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ReferralReferral

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

Hematuria without infection Hematuria without infection on urinalysison urinalysis

Symptoms suggestive of Symptoms suggestive of poor bladder emptyingpoor bladder 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 Failed previous incontinence surgeryincontinence surgery

Elevated PVR volumeElevated PVR volume Radical pelvic surgeryRadical pelvic surgery Symptomatic prolapseSymptomatic prolapse

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

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Treatment OptionsTreatment Options

I.I. Life style changesLife style changes

II.II. Behavioral therapyBehavioral therapy

III.III. MedicationMedication

IV.IV. Minimally invasive therapiesMinimally invasive therapiesBotulinum A-toxinBotulinum A-toxin

NeuromodulationNeuromodulation

I.I. Surgery Surgery

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I. Lifestyle changesI. Lifestyle changes

Moderate fluid intake

Reduce or eliminate caffeine

Avoid fluids before bed

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II. Behavioral Therapy Bladder education/retraining

Pelvic floor muscle exercises

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Bladder Training:Bladder Training:• Helps patients regain control of their bladder by Helps patients regain control of their bladder by

teaching them to resist the urge to pass urineteaching them to resist the urge to pass urine• Helps to increase bladder capacity and reduce Helps to increase bladder capacity and reduce

the number of episodes of incontinence.the number of episodes of incontinence.- delayed/timed voidingdelayed/timed voiding

- urge suppression exercisesurge suppression exercises

• Effective but requires a high degree of Effective but requires a high degree of motivation and commitment from patients.motivation and commitment from patients.

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Pelvic Floor ExercisesPelvic Floor Exercises

Repeat, as recommended

by physician

1. Locate pelvic floor muscles

Squeeze pelvic floor muscles as tightly as possible for a few seconds (maximum of 10 sec)

Relax completely for at least 10 seconds

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III. MedicationsIII. Medications

Anticholinergic AgentsAnticholinergic Agents1.1. Trospium chloride (Spasmex)Trospium chloride (Spasmex)

2.2. Oxybutynin (Ditropan)Oxybutynin (Ditropan)

Oxybutynin transdermal (Oxytrol)Oxybutynin transdermal (Oxytrol)

3. Tolterodine (Detrol)3. Tolterodine (Detrol)

4. Solifenacin (Vesicare)4. Solifenacin (Vesicare)

5. Darifenacin (Enablex)5. Darifenacin (Enablex)

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Spasmex

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Onset of actionOnset of actionTrospium chlpride has looked to onset of action in the first Trospium chlpride has looked to onset of action in the first weekweek

Rudy D. BJU International. 2006;97:540-546.

Week 2 Week 4 Week 6 Week 8 Week 10 Week 12Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

TROSPIUMTROSPIUM

OXYBUTININ VS. TOLTERODINE OXYBUTININ VS. TOLTERODINE

SOLIFENACIN

TOLDERODINE

DARIFENACIN

TROSPIUM

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Side EffectsSide Effects

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1. Trospium Chloride 1. Trospium Chloride ((SpasmexSpasmex)) Quaternary amine as opposed to Quaternary amine as opposed to

tertiary aminetertiary amine 20 mg BID dose20 mg BID dose No pass through blood/brain barrier No pass through blood/brain barrier

with less side effectswith less side effects Rapid onsetRapid onset Not metabolized by liverNot metabolized by liver 60% excreted in the urine unchanged60% excreted in the urine unchanged

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2. Oxybutynin (Ditropan)2. Oxybutynin (Ditropan) Previous standard of treatment for urge Previous standard of treatment for urge

incontinenceincontinence

Effectively reduces symptomsEffectively reduces symptoms

High incidence of dry mouth severe enough to High incidence of dry mouth severe enough to cause discontinuationcause discontinuation

Reported to cause CNS adverse events and Reported to cause CNS adverse events and cognitive dysfunctioncognitive dysfunction

Katz IR et al. Am J Geriatr Soc. 1998;46:8-13.Donnellon CA et al. BMJ. 1997;315:1363-1364.

Yarker YE et al. Drugs and Aging. 1995;6:243-262.Aboubakr Elnashar

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

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3. Tolterodine (Detrol. Detrusitol) 3. Tolterodine (Detrol. Detrusitol)

Immediate: 2 mg. Immediate: 2 mg.

long acting LA 4 mg dosinglong acting LA 4 mg dosing Side effects: similar to oxybutyninSide effects: similar to oxybutynin Develop a potent and pure muscarinic Develop a potent and pure muscarinic

receptor antagonistreceptor antagonist Equipotent to oxybutynin on the bladderEquipotent to oxybutynin on the bladder Less potent than oxybutynin on Less potent than oxybutynin on

glands/salivationglands/salivation

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4. Solifenacin (Vesicare)4. Solifenacin (Vesicare)

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

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5. Darifenacin (Enablex)5. Darifenacin (Enablex)

MM33 selective anticholinergic selective anticholinergic

7.5 mg or 15 mg once a day7.5 mg or 15 mg once a day

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IV. Minimally invasive therapies

1. Botox® injection• 100 units diluted in 10ml saline in 30 injection sites,

sparing the trigone• Under local anesthesia (xylocaine 2% in 20ml, 20

minutes)

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2. Sacral NeuromodulationImplantation of programmable stimulator SC which delivers low amplitude electrical stimulation via a lead to the sacral nerve, usually accessed via the S3 foramen. FDA has approved InterStim Therapy, by Medtronic, as a safe sacral nerve stimulator for treatment of Urinary Urge Incontinence, Urinary Frequency, and Urinary Retention.

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V. SurgeryV. Surgery

All measures: failedfailed. CystoplastyCystoplasty a portion of the bowel is attached to the bladder to increase its capacity

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Conclusion

1. Definition• Urgency• Frequency ± Urge incontinence

1. Screening and Assessment• History, Physical

1. Management Approach• Lifestyle, Behavioural, Pharmacological

1. Safety of Pharmacologic agents in the Elderly• Use agents which don’t cross the BBB

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Thank YouThank YouAboubakr ElnasharAboubakr Elnashar

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