Updates on Overactive Bladder. By Professor Hassan Abdellatif Abolella, Assiut University,Egypt.

1. OVERACTIVE BLADDER
Updates

2. Agenda
Definition
Prevalence.
Bladder Anatomy and Physiology.
Risk factors for OAB .
Clinical evaluation of OAB.
Treatment of OAB.

3. Definition of OAB
The ICS defines OAB as:
• Urinary urgency, usually accompanied by frequency
and nocturia, with or without urgency urinary
incontinence, in the absence of pathologic conditions
that might explain these symptoms.
• While detrusor overactivity (DO) is a urodynamic
observation, characterized by involuntary detrusor
contractions during the filling phase.
Abrams et al, 2002

4. Sudden compelling desire to pass urine that is
difficult to defer
urgency
Patient considers that he/she voids too often by day
Normal is < 8 times per 24 hours
Frequency
Waking to void during sleep hours considered a
clinical problem if frequency is greater than twice a
night
Nocturia
Involuntary leakage accompanied by or immediately
preceded by urgency
Urgency
urinary
incontinence
(UUI)
OAB with UUIOAB “wet”
OAB without UUIOAB “dry”
Terminology

5. • Overall OAB prevalence is 16.9% in women and
16.2% in men and increased with age.
• OAB wet is more prevalent in women and OAB
dry is more prevalent in men.
• OAB wet common in women due to the relative
weakness of the bladder neck and urethral
sphincteric mechanism .
Milsom et al, 2001
PREVALENCE

6. L1
L2
L3
Sympathetic nerve supply
Sympathetic
chain
Hypogastric
ganglion
Hypogastric
nerve Urethra
External sphincter
Parasympathetic nerve supply
S2
S3
S4
S2
S3
S4
Pelvic nerve
Pudendal nerve
Somatic nerve supply
Bladder Anatomy and Physiology

8. Patterns of LUT dysfunction following
neurological disease

9. Risk factors for OAB
• Bladder inflammation.
• Bladder outlet obstruction.
• Central nervous system disorders .
• Pregnancy .
• Vaginal delivery .
• Post-menopausal status .
• Older age (risk increase with age) .
• Although the most common cause is idiopathic.
Anderson et al ,2009

10. Clinical Evaluation
Diagnosis of OAB is symptom based and involves:
Careful history.
physical exam.
Urinalysis.
Frequency volume chart (FVC).
Post-void residue (PVR).

11. Clinical Evaluation ( cont . )
History should cover the following:
1.Presence or absence, severity, and effect of OAB on
quality of life .
2.Other LUTS should also be assessed.
3.Presence or absence of dysuria and hematuria.
4. Nature and volume of fluid intake.
5.Neurologic disease.
6. Obstetric and gynecologic history, previous surgery/
radiotherapy .
7. Closed-angle glaucoma and cognitive impairment .
8. Drug history diuretics, alpha agonists
Abrams et al, 2009

12. Clinical Evaluation ( cont . )
Physical examination
• Abdominal examination:
– Vaginal examination.
– Rectal examination DRE.
– Bimanual examination will rule out pelvic masses.

13. Clinical Evaluation ( cont . )
Frequency volume chart (FVC) :
• Bladder diary done for a minimum of 3 days.
• A record of how much fluid intake , how much urine
output.
• How often patient empty his bladder on a daily basis as
well as any leakage occurs.
• Number and degree of wetness of pads.

14. Frequency volume chart

15. Investigations
• Urinalysis
• Post void residue: calculated by Ellipsoid formula
= (0.52 x width x height x depth) Roehrborn, et al 1988

16. Investigations (Cont.)
Urodynamic study (UDS) , when indicated ?
1) When conservative and drug therapy fail
adequately to manage OAB.
2) Refractory cases of OAB.
3) Patient with diabetes and neurological diseases.
4) Before invasive surgery.
Abrams et al, 2006

17. Treatment
First line Treatments :
• Behavioral therapy.
Second line Treatments :
• Pharmacologic therapy (antimuscarinics or beta 3
agonist).
• Combined therapy: behavioral and pharmacologic
therapy .
Third line Treatments :
• Botulinum A-toxin.
• Neuromodulation : peripheral tibial nerve stimulation
(PTNS) , sacral neuromodulation (SNS) .
• Augmentation cystoplasty.
• Urinary diversion.

18. I- Behavioral Modifications
Dietary Changes and fluid Management .
Timed voiding .
Bladder training .
 Pelvic floor muscle training.
Labrie et al, 2013

19. Behavioral Modifications
1. Dietary Changes and fluid Management:
EUA 2019

20. Behavioral Modifications (Cont.)
Food and drink should avoided in OAB :
1. Spicy foods
2. Coffee
3.Tomatoes (acidic)
4. Soda
5.Orange juice
6. Alcohol

21. Behavioral Modifications (cont.)
7. Cranberry juice (acidic).
8. Chinese Flavor
(Mono- sodium Glutamate )
9. Too much or too little fluid
intake (6-8 glasses of water
per day is acceptable).
10. Added sugar and artificial
sweeteners.

22. Behavioral Modifications (cont.)
2. Timed voiding:
• Voiding with constant interval every 2 -3 hours .
• To empty the bladder before incontinence and
decrease urgency and frequency.
Ostaszkiewicz , et al , 2004

23. Behavioral Modifications (cont.)
3. Bladder training :
A- Modification of voiding interval by gradual
increase of voiding interval by 15- 60 min every 1-2
week until an acceptable voiding interval is
achieved without incontinence.
B- Urge control (bladder inhibition)
After the urge subside don't urinate until the next
scheduled void.
Wallace SA ,et al , 2004
.

24. Behavioral Modifications (Cont.)
4. Pelvic floor muscle exercises :
• Kegel exercises :simply squeeze the muscle of
pelvic floor.
• Holding each squeeze for 3 seconds.
• Gradually build up to 3 sets of 10 repetitions
every day.

25. Tertiary amines
Oxybutynin
Oxybutynin transdermal
Tolterodine
Solifenacin
Darifenacin
Propiverine hydrochloride
II - Pharmacotherapy
A) Antimuscarinic Agents
Quaternary amines
Trospium
propantheline
B) 3 adrenoreceptor agonist
 Mirabegron

26. A. Antimuscarinic Agents
 Mechanism of action
Act by competitive inhibition of the muscarinic receptor
in bladder wall Reduce detrusor overactivity.
 Side effects:
Inhibition of muscarinic receptors outside the bladder :
1.Eye Blurry vision
2.Salivary glands Dry mouth
3.Intestine Constipation
4.Heart Tachycardia
5.Brain Impairs cognition and memory
(more with tertiary amines)

27. A. Antimuscarinic Agents (cont.)
 Contraindications :
1.Urinary retention .
2.Intestinal hypo motility.
3.Narrow angle glaucoma.
4.Myasthenia gravis .
 Duration of treatment :
It improve symptoms within 1 week but maximum
benefit is achieved by 3 months.
Over 5o% of patients stop it within 3 months due to
Ineffectiveness, side effect, or cost.
Rai BP, et al, 2012

28. B. Beta 3 adrenoreceptor agonist
Mirabegron
• FDA approved in 2012
• Mechanism of action
Directly cause detrusor relaxation during the storage phase of micturition
cycle and increase bladder capacity with no change in micturition
pressure and residual volume.
• Adult dose
50 mg per day
25 mg per day for patients with renal and hepatic impairment
• Contraindications
In patient severe uncontrolled hypertension

29. Adverse effects (cont.)
Most frequent adverse effects (TAURUS trial)
Chapple et al., 2012
Adverse event Mirabegron
50 mg
Tolterodine SR
4 mg
Hypertension 9.2% 9.6%
Headache 4.1% 2.5%
Tachycardia 1% 3.1%
dry mouth 2.8% 8.6%

31. EAU Guidelines 2020

32. EAU Guidelines 2020

33. III - Third line treatments
1) Botulinum A-toxin Intradetrusal injection.
Inhibit detrusor contraction by inhibit release of Ach at
neuromuscular Junction.
FDA approved in ttt of OAB refractory to Antimuscarinic
medications.
Side effects
Increase risk of UTI and Urinary retention that required
catheterization.
Contraindications
UTI, Pregnancy , myasthenia gravis.

34. Intradetrusor botulinum toxin-A in 20-30 injection
sites .

35. EAU Guidelines 2020

36. Third line treatment (cont.)
2. Posterior tibial nerve stimulation (PTNS) :
 Electric Stimulation of tibial nerve transmitted to
S3 to modify voiding reflex.
 Weekly sessions for 12 weeks (30 minutes each)
using Urgent system.
 Efficacy
Frequency , urgency , and UUI improves in 60% of
patients.
 FDA approved since 2006 .
Van Balken ,et al, 2001

37. •
Posterior tibial nerve stimulation (PTNS)

38. EAU Guidelines 2020

39. Third line treatment (cont.)
3. Sacral Neuromodulation (InterStim)
 Modifies voiding reflex by direct electric stimulation of S3
afferent nerve.
 Stimulation of the sacral roots has effectively suppressed the
hyperactivity of the detrusor muscle.
 Indicated in pt. who fail or cannot tolerate conservative ttt.
 It consists of Two stage:
1. Percutaneous nerve evaluation (PNE) which determine if the
patient is candidate for SNM, done as outpatient procedure.
2. Permanent implantation done if patient shows 50% or greater
improvement of symptoms after 3-5 days of PNE.

40. Third line treatment (cont.)
Sacral Neuromodulation (InterStim)
 Complications
Infection, lead migration and change in bowel function.
 Contraindications
Pregnancy and MRI imaging.
Short wave diathermy in patient with permanent
implant.
 Efficacy
•50% symptom improvement in more than 60% of patients
for urgency/frequency and urgency urinary incontinence.
Siegel SW , et al ,2000

41. Sacral Neuromodulation (cont.)

42. Third line treatment (cont.)
4. Surgical treatment :
Indications :
-OAB refractory to less invasive treatment.
-Urinary incontinence due to reduce bladder capacity.
Types :
•Augmentation Enterocystoplasty
•Autoaugmentation
•Urinary diversion .
Mechanism :
Increase bladder capacity and lower intravesical pressure.
Efficacy :
•80% become dry however 10-40% requires CIC.

43. EAU Guidelines 2020