DR. R. M.

SARAOGI
MD, FCPS, FICOG, DGO

Honorary Professor, Seth G. S. Medical College

Honorary , Dr. R. N. Cooper Hospital
Senior Consultant & Unit Head, Nanavati Hospital
Director, Saraogi Group of Hospitals
Recipient of FOGSI Corion Award for Meshplasty
Recipient of FOGSI Dutta Prize for Best Publication
Recipient of Lifetime Achievement Award, MMA
DEFINITION
 A bladder that squeezes without its owners
permission
 It is a condition that results from sudden,
involuntary contraction of muscle within the
wall of the urinary bladder
 There is a sudden, unstoppable need to
urinate, regardless of the amount of urine.
URGENCY
A strong and sudden desire to urinate
 2002 ICS TERMINOLOGY:
OVERACTIVE BLADDER

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)

INCIDENCE

 Prevalence is 12 % in both men and women

 Advancing age - 20 % above 70 years
INCIDENCE UNDERREPORTED

 “Tip of the iceberg”

 Increasing
incidence in an
aging population
OVERACTIVE BLADDER

Urgency Urge
Frequency
incontinence

OVERACTIVE BLADDER
SYMPTOMS

 Urgency : strong and sudden desire to void

 Precipitancy : need to run to the bathroom
 Frequency : more than 8 voids per day
 Nocturia : 2 or more voids per night
 Urgency Incontinence : leakage, usually
high volume, occuring after the strong and
sudden desire to void
FREQUENCY
Going to the toilet often (more than eight
times in a 24-hour period)
TRIGGERING FACTORS
 Running tap water (sight and sound)
 Key-in-the-door phenomenon (when a
person gets closer to the bathroom)
 Standing up from a sitting position (getting
out of a car)
 Cold, damp weather (even the freezer
section of the supermarket)
CAUSES
 Idiopathic
 Irritation :
UTI
Cystitis
 Obstruction :
Bladder calculi
Tumor
Prostate enlargement
 Bladder compression :
Multiple pregnancies
Big fibroid on anterior wall of uterus
 Neurological problems :
Spinal cord injury
Strokes
Parkinson’s Disease
Multiple Sclerosis
 Dementia
Diabetic Neuropathy
 TYPES OF URINARY INCONTINENCE
Urge Mixed symptoms
 combination of
urine loss stress and urge
accompanied by incontinence
urgency resulting
from abnormal
bladder contractions

Stress Sudden increase in

urine loss resulting from intra-abdominal
sudden pressure
increased intra-abdominal Uninhibited detrusor
pressure (eg, laugh, cough, contractions
sneeze) Urethral pressure
 DIFFERENTIAL DIAGNOSIS:
OAB AND STRESS INCONTINENCE Medical History and Physical Examination

Symptom Assessment
Symptoms Overactive Stress incontinence
bladder
Urgency (strong, sudden desire to Yes No
void)
Frequency with urgency Yes No
(>8 times/24 h)
Leaking during physical activity; No Yes
eg, coughing, sneezing, lifting
Amount of urinary leakage with Large Small
each episode of incontinence (if present)
Ability to reach the toilet in time Often no Yes
following an urge to void
Waking to pass urine at night Usually Seldom
Abrams P, Wein AJ. The Overactive Bladder:
A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.
 DIAGNOSIS OF OAB

 A presumptive diagnosis of OAB can be

based on
patient history, symptom assessment
physical examination
urinalysis
 Ultrasound for post – void residual urine

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.
HISTORY
 Urologic : infections, stone
 Ob/Gyn
 Neurologic
 Medical/surgical : diabetes, etc.
 Social/psych
 Radiation
 Pelvic trauma
 Drugs : diuretics, antidepressants,
antihypertensives, sedatives
PHYSICAL EXAM WOMEN

 Systematic vaginal and pelvic exam

• condition of mucosa
• urethral mobility (Q tip test)
• demonstration of continence (CST)
• vaginal prolapse (anterior wall, posterior wall,
apical)
• bimanual exam
PHYSICAL EXAMINATION
 Atrophic vaginitis
 Estrogen deficiency
 Pelvic floor dysfunction
 Pelvic organ prolapse
 Potentially serious pathologic conditions
Conditions Associated With
Signs of Hypoestrogenation
Vaginal Relaxation
Prominent
caruncle
• Cystocele
• Rectocele
• Enterocele
• Uterine prolapse
Agglutination of
labia minora
PHYSICAL EXAMINATION contd.

 Neurologic exam
• mental status
• mobility
• lumbar and sacral sensory and motor
eg, BC reflex, anal wink, knee and ankle DTR’s
ANCILLARY TESTS

 Voiding and intake diary

• Extremely important especially in cases of
overactive bladder
 Incontinence diary
 Urine analysis
• urine culture and cytology when indicated
 Post void residual
 Pad test
ROLE OF CYSTOMETRY

 Defining underlying pathophysiology

• bladder filling
• involuntary detrusor contractions
• low bladder compliance
• urethral obstruction
• impaired detrusor contractility
 Directing treatment
LABORATORY TESTS
 Urinalysis
 Dipstick
 Culture
 Microscopic examination
 Look for hematuria, pyuria, bacteriuria,
glucosuria,
proteinuria
 Appropriate blood work
Glucose
Electrolytes
Prostate specific antigen (PSA) in men
Fantl JA, et al. Agency for Healthcare Policy and Research;
1996. AHCPR publication 96-0686.
IMPACT OF URINARY INCONTINENCE ON
QUALITY OF LIFE

Physical Psychological
• Limitations or cessation of • Guilt/depression
physical activities • Loss of self-respect and dignity
Sexual • Fear of:
- being a burden
• Avoidance of sexual - lack of bladder control
contact and intimacy - urine odor
• Apathy/denial
Quality of Life
Occupational
• Absence from work
• Decreased productivity
Social
• Reduction in social interaction
Domestic • Alteration of travel plans
• Requirements for specialized • Increased risk of institutionalization
underwear, bedding of frail older persons
• Special precautions with clothing
CASE STUDY
“My boyfriend and I don’t go
out very often because of my
problem. If we do go out,
let’s say to a departmental
store, the first thing that I
look for is the toilet. If I can’t
find one, I leave the store.
That’s how serious the
problem is.”
Devi, 27 years old
PHYSICAL PROBLEMS
• Limitation or stopping of physical activities
• Discomfort due to dampness
• Unpleasant odour
• Skin rashes/ ulcers
• Confinement in nursing homes
• Falls
• Insomnia
• Dehydration
PSYCHOLOGICAL PROBLEMS
• Loss of independence - feels tied to home
• Fear of embarrassment
• Loss of dignity & self esteem
• Depression
• Feeling of being a burden
• Suicide
• Affects career
SOCIAL PROBLEMS
• Reduction in social
interaction/ increased
social isolation
• Alteration of travel plans
(e.g. plan around
availability of toilets)
• Cessation of some
hobbies
SEXUAL PROBLEMS

• Avoidance of
sexual contact
OCCUPATIONAL / FINANCIAL
PROBLEMS
• Absence from work
• Job loss
• Change of job
• Poor relationship with
employers/ employee
• Financial loss
VICIOUS CIRCLE OF
BLADDER CONTROL PROBLEMS
Isolation Guilt

Social, domestic,
Absence physical, sexual
from work and psychological
problems

Depression
MANAGEMENT : BEHAVIORAL AND DIET
MODIFICATION
 Avoid food/beverages irritating to the bladder
(coffee, caffeine, etc.)
 Manage fluid intake
 Stop evening fluids
 Avoid constipation
 Minimize food and hidden
water content
 Stop smoking
BLADDER TRAINING
 Modify bladder
function
 Methods
 bladder diary
 gradually increase void
interval
 teach coping strategies
 Strengthen pelvic floor
muscles and improving
bladder stability
BLADDER TRAINING contd.

 Kiegel’s exercise
 Vaginal weight training
 Pelvic floor electrical stimulation
PHARMACOLOGIC TREATMENT

 Decrease detrusor activity

• abolish involuntary detrusor contractions
• increase volume at which they occur
• Increase compliance
 Increase bladder capacity
 Commonly used agents focus on inhibition
at the end organ level
PHARMACOLOGIC AGENTS

 Antimuscarinics
 Muscle relaxants
 Mixed action drugs
 Tricyclic antidepressants
 Alpha blockers
 Beta agonists
 Vasopressin analogues
Muscarinic Receptor Distribution
Iris/ciliary body Blurred vision
CNS Lacrimal gland Dry eyes
Salivary
Dry mouth
glands
• Dizziness
• Somnolence
• Impaired
Heart Tachycardia
memory and
cognition
Stomach and Dyspepsia
esophagus

Colon Constipation

Bladder (detrusor muscle)

Abrams P, Wein AJ. The Overactive Bladder— A
Widespread and Treatable Condition. 1998.
Ideal Muscarinic Receptor
Antagonist (Anticholinergic)
 Efficacious
 inhibits involuntary bladder contractions
 does not adversely affect volitional detrusor activity
 Organ selective
 preferentially affects the bladder over other organs
 results in minimal side effects and improved tolerability
 Durable effects
 improves compliance and/or persistency
 Provides clinical effectiveness
 the optimal balance of efficacy, tolerability, and
compliance/persistency
ANTICHOLINERGICS :
A Delicate Balance

Adverse effects
Efficacy
• Dry mouth
• Less frequency
• Constipation
• Less UUI
• CNS : confusion, blurring
• Increased voided volume
of vision
PHARMACOTHERAPY
 Anticholinergic Agents
Oxybutynin (Ditropan)
Oxybutynin transdermal (Oxytrol)
Tolterodine (Detrol)
Solifenacin (Vesicare)
Trospium chloride (Sanctura)
Darifenacin (Enablex)
Oxybutynin (Ditropan)
 Immediate and long acting form
 Immediate – TID dosing, 2.5 or 5 mg
 Long acting XL – once a day, 5, 10 or 20 mg.
 Side effects – dry mouth, constipation,
headache, blurring of vision
 Approved for pediatric use (age 6 or older)
Oxybutynin Transdermal (Oxytrol)
 Patch, twice weekly, releases 3.9 mg of drug
daily and is applied on stomach / thigh /
buttocks
 Side effects – less dry mouth but
erythema/pruritis , skin irritation, itching
and redness
 Fewer side effects because first pass
metabolism is avoided
Tolterodine (Detrol)

 Immediate 2 mg. and long acting (LA) 4 mg

dosing
 Side effects (similar to oxybutynin) – dry
mouth, dry eyes, headache, constipation,
abdominal pain
Solifenacin (Vesicare)
 5 – 10 mg daily dose
 Side effects – dry mouth, constipation,
blurring of vision, dyspepsia
 Most cost-effective amongst all
 Fewer side effects
Trospium Chloride (Sanctura)
 Quaternary amine as opposed to tertiary
amine
 20 mg BID dose (taken before meals or 2hrs
after meals)
 Theoretically harder to pass through
blood/brain barrier with less side effects
 Not metabolized by liver
 60% excreted in the urine unchanged
 Side effects- dry mouth, constipation,
headache
Darifenacin (Enablex)
 M3 selective anticholinergic
 7.5 mg or 15 mg once a day
 Side effects – constipation and dry mouth,
indigestion, blurring of vision, heat
prostration
 Side effects are mild to moderate and occur
during first 2 weeks of treatment
Imipramine
 Prominent systemic anticholinergic effects
 Weak antimuscarinic effects on the bladder
 Strong direct inhibitory effect on bladder smooth
muscle which is not anticholinergic or adrenergic
 Decreases contractility/increases outlet resistance
 Effects on lower urinary tract are additive to those
of atropine-like agents; useful in combo with other
anticholinergics
 Most common side effects
 anticholinergic effects, weakness, fatigue, sedation
ROLE OF OESTROGEN
In 2003, Cochrare Meta-analysis on oestrogens
and urinary incompetence considered 28
randomized trials. The author reported a
significantly higher rate of subjective
improvement or cure rate with high use of
oestrogens.
OTHER TREATMENTS
Botulinum Toxin A :

 Injected in small doses into tissues-

paralyses muscle
 Temporary reaction
 Can be used as day care treatment to bridge
the gap between medication and surgery
 Not approved by FDA
NEUROMODULATION
Sacral Nerve Stimulation

 Thin wire is placed close to sacral nerves

(near tail bone)
 Electrical impulses are send to the bladder
via sacral nerves (similar to pacemaker in
the heart)
IMPLANTATION OF THE INTERSTIM
SYSTEM
 Procedure done in operating
room using a light anesthesia
on a same day surgery basis.

 Stimulator is usually placed in

upper buttock

 The entire InterStim System

will reside under the skin

 Entire procedure takes less

than one hour
POTENTIAL RISKS WITH INTERSTIM
THERAPY
 As with other surgical procedures, there are
risks:
Pain
Infection
Transient electrical shock
Lead migration
 These complications were generally
resolvable in the clinical study
ALTERNATIVE MEDICINE : Biofeedback

In this, the patient is connected to electrical

sensors that receive information from the
body and teach the patient how to make
subtle changes in the body, such as
contracting pelvic muscles in response to
urge.
ALTERNATIVE MEDICINE : Acupuncture

A small study suggests it might help to ease

sympotms.
THANK YOU