Lesson 7: Overactive Bladder / Urge Incontinence

Question 1

Pathology

Answer 1

• Urgency, frequency and nocturnal in absence of UTI
• Wet OAB = urgency + frequency with leakage
• Dry OAB = urgency + frequency with no leakage
• Bladder contracts inappropriately at low levels
• Pt unable to consistently delay voiding

Question 2

Etiology

Answer 2

Neurogenic
- Cerebrocortical lesions
- CVS
- Parkinson’s
- MS

Sensory Dysfunctions
- Abnormal signaling
- Increased excitability/contractility of detrusor muscle

Question 3

Presentation

Answer 3

• Sudden and intense urgency
• Frequency (>8 voids/24 hrs)
• Low voided volumes
• Nocturia
• “Key in lock” syndrome
• Leakage during intercourse
• Toilet mapping
• Detrusor hyperactivity impaired contractility

Question 4

Diagnostics

Answer 4

• Presumptive diagnosis based on clinical presentation
  — Need to rule out pathological conditions
  — UTI, bladder CA, hyperglycemia
• Rule out voiding dysfunction

Questions
- Feelings of incomplete emptying?
- Risk factors for retention?
- Indicators of bladder distension?
- Uroflow/description of urinary stream?

Definitive diagnosis = flow cystometrogram to document inapplicable detrusor contraction

Question 5

Management - Lifestyle

Answer 5

• Weight loss
• Nicotine elimination
• Elimination of dietary irritants
• Constipation management

Pelvic muscle exercises
- Contraction activates feedback loop between pelvic floor and bladder
- Strong pelvic floor = improved ability to inhibit urge/prevent leakage

Question 6

Management - Bladder Retraining

Answer 6

Designed to re-establish normal bladder capacity + voiding interval

1) Teach bladder control + urge inhibition
2) Tracking voiding intervals

Alternative
- Urge suppression strategies
- Use suppression to delay voiding until urgency is controlled
-Instruct patient to gradually lengthen delay period

Question 7

Management - Pharmacologic

Answer 7

Anticholinergics
- Block cholinergic receptor sites that control detrusor contractility
- Reduction in urgency and frequency
- Adverse effects
— Constipation
— Dry mouth
— Heat intolerance
— Confusion
- Oxybutynin
— Least expensive but more side effects

Antimuscarinics
- Anticholinergic drugs that target receptors controlling bladder contractility
- Fewer side effects but expensive
Ie. trospium, tolterodine

Beta-3 adrenergic agonists
- Causes relaxation of detrusor through effects on sympathetic receptors in bladder wall
- Ie. mirabegron

Question 8

Management - Neuromodulation

Answer 8

• Low level electrical stimulation can modulate function of nerves controlling bladder + sphincter function
• Only for refractory OAB

Sacral nerve stimulation
- Perc placement of lead wires that terminate adjacent to sacral nerve

Percutaneous trivial nerve stimulation
- 34g needle inserted above ankle adjacent to tibial nerve + surface electrode placed on arch of foot
- Stimulation of tibial nerve inhibits detrusor activity

Question 9

Management - Surgical Intervention

Answer 9

Augmentation Cystoplasty
- Indicated for patients with low capacity high pressure bladder
- Bladder is augmented with segment of detubularized bowel
— Converts bladder to high capacity low pressure
- Procedure creates minimally contractile bladder
— Most patients require clean intermittent catheterization