5.5: The Management of Overactive bladder

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Incontinence occurs in approximately a third of people presenting clinically with OAB, and approximately a third of them have a mixed picture of combined sphincteric weakness and detrusor overactivity. The prevalence of OAB is higher among the elderly population (age 64 and above); it is estimated to be approximately 30 – 40% among persons older that 75 years, and this may have additional ramifications as both urinary urgency, associated incontinence and noctuira have been shown to be associated with an increased incidence of falls and fractures among elderly.

The intensity of urinary urgency has a significant association with other symptoms of OAB. Urgency is the ‘driving’ symptom in OAB, those experiencing OAB frequently experience urgency at inconvenient and unpredictable times and consequently, often lose control before reaching the toilet. This adversely affects their physical and psychological state by limiting daily activities, intimacy, compromising sexual function and worsening self – esteem. It is no surprise therefore that improvements in urgency are often stated by people to be the most noticeable response to therapy.

Urgency is a sensory symptom and as such is difficult to define, to communicate to both patients and colleagues alike and the measure and quantify. Despite the difficulties, urgency and the other symptoms of OAB result in a significant deterioration in HRQL. To date, patient diaries have been shown to be a reliable way to collect various OAB symptoms, including urgency episodes, and diary entry remains the most accurate and sensitive method for evaluating changes in urgency with pharmacotherapy. Data obtained on the basis of 3 – or 4 – day diaries suggest that short – duration diaries are just as reliable as those recorded for 7 days, and because they impart less patient burden, may be an acceptable method of assessing the symptoms of OAB. Apart from increases in cystometric capacity, invasive pressure flow studies have failed to show positive results with existing antimuscarinic therapy.

Initial assessment must include a thorough history and physical examination. A complete pelvic and neurological exam is mandatory, to exclude other conditions that may mimic OAB symptoms. Urine analysis, and microscopy and culture will exclude urinary infections. Further special investigations are not required.

Treatment for all forms of incontinence should commence with conservative methods before progressing to more complex surgical procedures if these do not work. A multidisciplinary approach is important in its management. In addition to urologists and gynaecologists, continence nurse specialists, physiotherapists and healthcare professionals in community based primary care services play a pivotal role in the management of incontinent patients.
Behavioural therapy and pharmacotherapy are the mainstay of treatment, and there is continuing search for more effective and selective drugs with minimal adverse effects (AEs). About 50% of people gain satisfactory benefit from pharmacotherapy. The role of physiotherapy in the treatment of urge incontinence remains unclear as evidenced by systematic review of clinical trials.

Treatment of OAB is multifaceted. Effective treatment modalities include lifestyle modifications, medications, bladder retraining, and exercises to strengthen the pelvic floor (Kegel Exercises)

1. Lifestyle modifications

The patient should limit intake of foods and drinks that may irritate the bladder or stimulate the production of urine e.g alcohol, caffeine, coffee, tea and fizzy drinks, and aspartate sweeteners.
Drink 25ml / kg / day of fluids
Maintain healthy bowel actions. Eat high fibre foods such as wholewheat bread and pastas.

2. Bladder retaining
The patient should

Gradually increase the time between voids
Increase the time intervals by 15 minutes until she reaches an optimal time which is comfortable for her.

3. Pelvic floor muscle exercises (Kegel Exercises) (See elsewhere)

Surgical options (some still experimental) have been added in recent years and these include, neuromodulation and botulinum toxin injection therapy, but these interventions are reserved for cases where medical therapy fails.