Overactive Bladder (Non-Neurogenic) in Adults Flashcards
Diagnosis of OAB: Minimum requirements for diagnosis
The clinician should engage in a diagnostic process to document symptoms and signs that characterize OAB and exclude other disorders that could be the cause of the patient’s symptoms
The minimum requirements for this process are
- A careful history
- Physical exam
- Urinalysis
OAB Diagnosis: Tests done at the clinician’s discretion
In some patients, additional procedures and measures may be necessary to validate an OAB diagnosis, exclude other disorders and fully inform the treatment plan.
At the clinician’s discretion:
- A urine culture
- And/or post-void residual assessment
- Information from bladder diaries and/or symptom questionnaires may be obtained
What should NOT be part of the initial workup of the uncomplicated OAB patient?
Urodynamics
Cystoscopy
Diagnostic renal and bladder ultrasound
Is OAB a disease?
OAB is not a disease; it is a symptom complex that generally is not a life- threatening condition.
After assessment has been performed to exclude conditions requiring treatment and counseling, no treatment is an acceptable choice made by some patients and caregivers.
Education for OAB Patients
Clinicians should provide education to patients regarding normal lower urinary tract function, what is known about OAB, the benefits versus risks/burdens of the available treatment alternatives and the fact that acceptable symptom control may require trials of multiple therapeutic options before it is achieved.
First line treatment for OAB
Clinicians should offer behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, fluid management) as first line therapy to all patients with OAB.
- Bladder training
- Bladder control strategies
- Pelvic floor muscle training
- Fluid management
Recommendation: Behavioral therapies may be combined with pharmacologic management.
Second line treatment for OAB
Pharmacologic treatment
What second line treatment should be offered to patients with OAB?
Clinicians should offer oral anti-muscarinics or oral β3-adrenoceptor agonists as second-line therapy.
- If an immediate release (IR) and an extended release (ER) formulation are available, then ER formulations should preferentially be prescribed over IR formulations because of lower rates of dry mouth.
- Transdermal (TDS) oxybutynin (patch or gel) may be offered.
If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti- muscarinic medication, then a dose modification or a different anti-muscarinic medication or a β3-adrenoceptor agonist may be tried.
Clinicians may consider combination therapy with an anti-muscarinic and β3-adrenoceptor agonist for patients refractory to monotherapy with either anti-muscarinics or β3-adrenoceptor agonists.
What are contraindications for anti-muscarinics in patients with OAB?
Clinicians should not use anti-muscarinics in patients with narrow-angle glaucoma unless approved by the treating ophthalmologist and should use anti-muscarinics with extreme caution in patients with impaired gastric emptying or a history of urinary retention.
- Narrow angle glaucoma
- Impaired gastric emptying
- History of urinary retention
Clinicians must use caution in prescribing anti-muscarinics in patients who are using other medications with anti- cholinergic properties.
If a patient gets constipation or dry mouth from an anti-muscarinic, what is the next step if the patient has OAB?
Clinicians should manage constipation and dry mouth before abandoning effective anti-muscarinic therapy. Management may include bowel management, fluid management, dose modification or alternative anti- muscarinics.
What should you watch out for in a frail OAB patient?
Clinicians should use caution in prescribing anti-muscarinics or β3-adrenoceptor agonists in the frail OAB patient.
What happens if an OAB patient is refractory to behavioral and pharmacologic therapy?
Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy.
What are third line treatments for OAB?
Botox, PTNS and Neuromodulation
Of note, the OAB addendum says about PTNS: “n other words, the lines of therapy, while representing a successive increase in risk or invasiveness, are not intended to represent a strict algorithm. This is specifically relevant with regard to PTNS, as it is the opinion of the Panel that, given the minimally invasive and reversible nature of this therapy, juxtaposed with the potential side effects and cost of medications, PTNS can be considered in drug-naïve patients who opt to forego pharmacotherapy.”
Botox Dosing and Counseling in OAB
This is a third line treatment.
Clinicians may offer intradetrusor onabotulinumtoxinA (100U) as third-line treatment in the carefully-selected and thoroughly-counseled patient who has been refractory to first- and second-line OAB treatments. The patient must be able and willing to return for frequent post-void residual evaluation and able and willing to perform self- catheterization if necessary.
100!!!!
Be willing to self-cath (and able)
PTNS in OAB
Clinicians may offer peripheral tibial nerve stimulation (PTNS) as third-line treatment in a carefully selected patient population.
THIRD LINE treatment
