Overactive Bladder

What is Overactive Bladder?

Overactive bladder (OAB) is a condition characterized by a sudden, uncomfortable need to urinate with or without urine leakage usually with daytime and nighttime frequency. OAB occurs when the smooth muscle of the detrusor muscle of the bladder squeezes or contracts more often than normal and at inappropriate times. Instead of staying at rest as urine fills the bladder, the detrusor contracts while the bladder is filling with urine.

What Causes OAB?

By definition, the cause of OAB is unknown. However, identifiable underlying causes can include: drug side effects, nerve damage or neurological disease (e.g., multiple sclerosis, Parkinson’s disease, etc.) or stroke. There are also conditions that are associated with urgency and frequency – including bladder cancer, urinary tract infections and benign prostatic hyperplasia (BPH) – that must be excluded during an examination. Some experts believe that some individuals are predisposed to OAB. Circumstantial evidence suggests that individuals with depression, anxiety, and attention deficit disorder may experience symptoms of OAB more often than the general population. Some investigators suggest that depression, anxiety, feeding disturbances, pain, irritable bowel syndrome, fibromyalgia and changes in urination are associated with disturbances in brain circuits using specific chemical messengers between nerves known as neurotransmitters, in particular, serotonin 5-hydroxytryptamine (5-HT). Fibromyalgia and irritable bowel syndrome are conditions seen more often in patients with OAB and interstitial cystitis (IC) than the general population. These conditions are associated with an overactive bladder and possibly with depression, which provides a potential link with 5-HT metabolism and OAB.

What are Some Risk Factors for OAB?

Risk factors related to OAB happen around the childbearing ages, when the process of pregnancy and a vaginal delivery can affect bladder control. However, this problem usually goes away in the majority of patients with OAB during pregnancy or immediately after childbirth. The next series of events in life affecting OAB are around the time of menopause for women, and enlargement of the prostate in the fifth and sixth decades of life in men. Enlargement of the prostate gland occurs in the majority of the men living in the western society and may affect bladder function. Menopause can also affect bladder function. The other independent event affecting bladder function is aging and the changes that occur within the tissues of the lower urinary tract and the bladder itself. Given that the above risk factors could affect almost everyone living in the society, it is estimated that up to 50 percent of women and 30 percent of men will have bladder control problems during their lifetime.

How is Overactive Bladder Diagnosed?

One of the first steps toward diagnosing OAB is to keep a urination diary. Documenting symptoms – including urgency – can help your urologist make the proper diagnosis.A urinalysis (UA) must be performed to rule out infection and to look for glucose (sugar), blood, white cells or difficulty concentrating the urine (specific gravity). After urination, residual urine is also checked using an ultrasound or catheterization. In some patients, a urine cytology or endoscopy (cystoscopy) of the bladder is warranted. It is sometimes useful to perform bladder pressure testing using cystometry (CMG) to document bladder (detrusor) overactivity during filling and exclude obstruction. Imaging of the urinary tract with cystogram, computerized tomography (CT) scan or magnetic resonance imaging (MRI) is rarely needed.

How is Overactive Bladder Treated?

Behavioral Therapies
Behavioral regimens have been shown to reduce incontinence and urinary frequency. These regimens range from simple maneuvers such as timed or prompted urination and fluid management to biofeedback.

• Timed voids – this helps to train your bladder, and to control the urge that may occur frequently. We recommend voiding every 2-3 hours while awake. For patients who get up several times during the night to urinate, we recommend no fluid intake (even water) two hours prior to sleeping, especially alcohol or caffeine. Also make sure to empty your bladder before going to bed.
• Pelvic muscle exercises – (Kegel exercises) are beneficial in appeasing urge incontinence, and can be done alone or in combination with antimuscarinic drugs. Please see our section on Kegels for specific instructions on these exercises. While you may be able to do them on your own, if your symptoms are severe or not improving, we suggest seeing a specialized physical therapist who will teach you in-depth ways of exercising these muscles. The therapist with also utilize certain techniques and devices to help gather information of muscle activity; this is referred to as biofeedback therapy.
• Diet – Certain foods, drinks, and dietary habits can cause or worsen your OAB symptoms. Decrease or moderate the amount of caffeine, acidic foods, alcohol, artificial sweeteners, energy drinks. Reducing smoking and weight loss are other habits that help relieve symptoms long-term.

Drugs

• Antimuscarinics – Agents that relax the detrusor or prevent a bladder contraction are effective for OAB and urge incontinence. Acetylcholine is a chemical released from nerves supplying the bladder that acts at muscarinic receptors to trigger a bladder muscle contraction, thereby producing urination. The detrusor expresses muscarinic (acetylcholine binding) M3 and M2 receptor subtypes. Antimuscarinics are used to treat OAB and urge incontinence and they include: Vesicare, Toviaz, oxybutynin, Detrol (tolterodine), and trospium. Although these pharmacologic agents are used as first line treatment options, side effects limit long term compliance. Typical side effects include dry mouth, dry eyes, and constipation.
• Beta-3 Agonist (Myrbetriq) – This is an OAB medication that has recently come out. It works on different receptors in the bladder (called beta-3 receptors) to help the bladder fill properly before it gets the urge to contract. The bladder muscle is able to relax which allows the bladder to store urine. As with other OAB medications, it can take up 3-4 weeks to notice improvement. The advantage to Myrbetriq over antimuscarinics is that it does not have the side effects of dry mouth, dry eyes, and constipation. One side effect that has been noted is elevation in blood pressure. Please contact us if this occurs.
• Vaginal estrogen – The body uses estrogen to keep the vaginal and urethral tissue strong and healthy. As women go through menopause (or if the ovaries have been removed), the vagina and urethral opening can atrophy, which may contribute to urgency and frequency with urination. By using vaginal estrogen, either in the form of a tablet or cream, the tissue becomes health and restored and OAB symptoms should decreased.
• Botox for bladder – Botox, while most commonly associated for cosmetic purpose, has several other medical uses as well. It has recently been approved to treat overactive bladder. It works to relax the bladder muscle, thereby reducing symptoms of frequency, urgency, and leakage. This is a quick procedure that may be done in the clinic or operating room under light sedation. Side effects can include urinary retention, UTI, and burning with urination. Many of our patients have noticed relief with Botox after failing numerous oral medications.

Neuromodulation
Additional options exist when drugs and behavioral therapies fail to improve symptoms in patients with OAB and urge incontinence. Electrical stimulation of nerves or regions of the skin, vagina or rectum innervated by the lower spinal cord can reduce OAB and urge incontinence. The two stage sacral nerve stimulation technique using the Axonics neuromodulation device has been reported to be effective in many patients refractory to medical therapy.

Surgery
In some women with OAB and urinary incontinence, who also exhibit vaginal prolapse (e.g., cystocele, enterocele) and urinary incontinence, correction of these conditions can improve the overactive bladder.

Bladder Control Problems Questionnaire

If you would like to know whether you have OAB, answer our questionnaire. If you answer “yes” to two or more questions, you may have OAB, and should seek medical attention.

• Do you urinate eight times or more during a 24 hour period?
• Do you often have strong, sudden urges to urinate?
• Do you have accidents before getting to the bathroom?
• Do you get up two or more times at night to urinate?
• Do you use pads because of leaking you don’t notice?
• Do you wear pads because you are not able to get to the bathroom in time?
• Do you leak urine when you cough, laugh or lift something?
• If you checked three or more of the above questions, do you ever feel upset about these matters?
• Do you urinate eight times or more during a 24 hour period?
• Do you often have strong, sudden urges to urinate?
• Do you have accidents before getting to the bathroom?
• Do you get up two or more times at night to urinate?
• Do you use pads because of leaking you don’t notice?
• Do you wear pads because you are not able to get to the bathroom in time?
• Do you leak urine when you cough, laugh or lift something?
• If you checked three or more of the above questions, do you ever feel upset about these matters?